Management of aortic aneurysm: History in the making

by James H. Thomas, MD, RVT, Former Chair of Surgery, and Philip L. Johnson, MD, Chair of Radiology

The University of Kansas Hospital has a long history of excellence and innovation when it comes to aortic aneurysm repair. We currently perform open surgery, endovascular repair and a combination of the two (debranching), and we are continually evaluating emerging technologies to better care for our patients.

Creighton Hardin, MD

In 1951, at the University of Kansas, Dr. Hardin revolutionized the field of vascular surgery when he became one of the first three surgeons in the world to successfully reconstruct an abdominal aneurysm.

Early discovery

The treatment of aneurysms has been recognized as a daunting medical issue since antiquity. Aneurysms were first described in Ebers Papyrus circa 2000 BC. By the 2nd century AD, Greek surgeon Antyllus recommended proximal and distal ligation of peripheral aneurysms with evacuation of the contents. He advised caution due to the risk of exsanguination. Advancements in the vascular field were negligible until the 16th century when physician Andreas Vesalius first identified aneurysm of the thoracic and abdominal aorta, and he considered them untreatable.

Vascular pioneers

No intervention was possible for aortic aneurysm until 1817 when Sir Astley Cooper first ligated the abdominal aorta transperitoneally for the treatment of an iliac artery aneurysm. The next leap was made in 1888, when Dr. Rudolph Matas introduced a reconstructive method for brachial artery aneurysm by resecting the diseased portion and creating a tunnel through the remaining portion. Then in 1912, Alexis Carrel received the Nobel Prize for demonstrating that arterial suturing and reconstruction with xenografts was feasible.

1951, a watershed year

After hundreds of years of sporadic progress, the vascular field was on the brink of a major breakthrough. Three independent surgeons, Charles Dubost, MD, in Paris, Norman Freeman, MD, in San Francisco, and Creighton Hardin, MD, in Kansas City, built on the pioneering work of their predecessors and did the unthinkable. Within just one month’s time, they each performed a successful abdominal aortic aneurysm reconstruction.

Pictured above are reproductions of original pathologic specimen photographs taken after the surgery.

The University of Kansas

Creighton Hardin, MD, professor of surgery at the University of Kansas, evaluated a patient whose plain film of the abdomen demonstrated a 10-centimeter aneurysm. The patient had been advised by a prominent physician at another hospital to return to his home and prepare to die.

Hardin recommended surgery instead. He performed an inlay graft using a cryopreserved aortic allograft, leaving the aneurysmal back wall intact. The patient survived.

Hardin’s procedure remained the recommended method for the next 40 years, although synthetic allografts replaced aortic allografts by the late 1950s.

Another revolutionary shift

Two physicians are often given credit for the next dramatic change in the management of aortic aneurysms. In 1987, Nikolay Volodos, MD, and in 1991, Juan Parodi, MD, simplified aortic aneurysm repair by inserting preloaded Dacron aortic grafts attached to Palmas® stents through the femoral arteries. This procedure is better known today as endovascular aneurysm repair, or EVAR. These physicians gained international acclaim for their minimally invasive treatment of both thoracic and abdominal aortic aneurysms. Since that time the technique has been used extensively and far outnumbers open aneurysm repair.

Current portfolio

At The University of Kansas Hospital, we offer state-of-the-art aneurysm management including open surgical, endovascular repair and a combination technique called debranching. 

Open – This traditional approach to abdominal and thoracic aortic aneurysm repair is still an effective option for patients who are in good health or whose anatomical situation makes endovascular surgery impossible. 

Endovascular – EVAR emerged in the early 1990s as an alternative treatment for aortic aneurysm repair. Advantages include reduced hospital length of stay, reduced blood loss, fewer major complications and more rapid recovery. The most common problem has been a high incidence of type II endoleaks with the majority being managed conservatively.

Debranching – This hybrid procedure combines endovascular repair and open surgery. It is reserved for patients with aneurysms that are dangerously close to branching arteries to the kidneys, small bowel or liver. An endovascular stent graft is manually placed to exclude the aneurysm during an open operation. Arteries blocked by the stent graft are rerouted around the organs to preserve arterial flow.

Emerging technologies

The next generation of endovascular devices will likely expand the role of endovascular aortic aneurysm repair in the near future. At The University of Kansas Hospital, we look forward to providing these solutions and more to our patients as soon as their safety and efficacy are proven.

Fenestrated stent grafts feature custom designed openings so an aneurysm can be repaired to maintain the patency of certain important blood vessels. This fenestrated endovascular aneurysm repair, or FEVAR, is highly promising for patients with complex abdominal aortic aneurysms near the renal arteries.

Advantages of endovascular aneurysm repair, or EVAR
  • Requires only a small incision in the patient’s thigh
  • Takes about two hours for the internal procedure
  • Allows most patients to leave the hospital the next day
  • Allows patients to resume normal activities in a week or two
  • Reduces blood loss by 80% compared to traditional surgery, and typically leads to fewer post-operative complications
Advantages of open and debranching techniques
  • Effective solution for complex anatomical cases
  • Minimal post-operative follow-up
  • Fewer re-interventions
  • Proven approach

One patient at a time

We take a multidisciplinary approach and carefully tailor management to each individual patient. Current recommendations for repair include:
  • Abdominal aortic aneurysm diameter of 5.5 cm or greater
  • Thoracic aortic aneurysm diameter of 6.0 cm or greater
  • Aneurysm enlargement greater than 1 cm per year
  • Onset of symptoms

The future is now

Our medical understanding of aortic aneurysms progressed slowly but surely for thousands of years. In the past 60 years, there has been a virtual explosion of technological advancements.

We must continue to study treatment options and follow-up procedures to ensure the best interests of our aneurysm patients. Perhaps the greatest transformation since the beginning of time is just around the corner.

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