Now NZ physicians are fixing aneurysms without even making an incision

Aneurysms – we’ve all heard of them. We may not know what they are but we all probably know someone who’s died from one.

Well, that’s all in the past, as far as aortic aneurysms are concerned. Thanks to the pioneering work being done by two New Zealand medical specialists and the leading edge technology that they use, aortic aneursyms are no longer a death sentence. In fact, far from it, they can now be completely repaired in an operation that, before too long, will be a convenient day-stay procedure in a hospital.

“A lot of people, even doctors, think it’s still a big deal to treat an aortic aneurysm,” says vascular surgeon Mr Andrew Hill who, with interventional radiologist Associate Professor Andrew Holden, leads the vascular surgery team at Auckland Hospital. “But we’ve seen rapid and ongoing progression of stent graft technology over the past 13 years to the point where we can now treat aneurysms without any incision at all.”

If that sounds astounding, it’s because it is to the lay person. These Auckland physicians have developed and honed their surgical techniques to the point where they can now introduce a stent graft device through a hole a few millimetres in size in the femoral artery in the groin and using wires, guided by x-ray, channel it up through a person’s aortic artery to the site of the problem.

An aneurysm, an abnormal swelling or bubble in the aortic wall caused by a weakness in the tissue, can be slow or fast to develop. Once it reaches a critical size – 5 cms in width – the risk of rupture increases. If this happens, death follows within 24 hours in nearly every case. For some reason, not yet understood, the aorta - the body’s largest artery that takes blood from the heart to the abdomen - is the most common site for an aneurysm.

The stent graft is introduced into the femoral artery inside a plastic sheath. When it is in position in the aorta, it is released from the sheath with the help of guide wires that are just 35/1000 of an inch in diameter. Its release allows it to expand to fill and reinforce the weakened blood vessel from the inside. The plastic sheath is then removed back through the needle entry in the groin. Metal struts secure the graft stent in position. The operation increases in complexity if multiple sections of stent graft are used to accommodate smaller arteries branching off the aorta around the site of the aneurysm.
Even ruptured aneurysms can be treated in the same way if reached within the critical 24-hour window post rupture.

Perversely, rupture is the first sign for many patients that anything is wrong. In most people with an aortic aneurysm there are no clear warning signs. A direct indication can be a pulsing sensation in the upper abdomen but other signs can be as vague as a fullness or discomfort after eating; stomach pain or pain from the lower back radiating down into the buttocks and thighs; a dull ache in the back, chest or shoulders; breathlessness; a dry cough or hoarseness.

John Salthouse, a retired boatbuilder living on Auckland’s North Shore, felt extraordinary tiredness over several weeks. He was 69 at the time. It took his GP to spot the tell-tale pulsating in his lower abdomen that hinted at an aortic aneurysm. Former Helensville farmer Eddie Reyland suffered stomach pain for about a week before he went to his doctor.

Both men had ultrasounds and CT scans to confirm their aneurysms – John Salthouse’s had reached a staggering 8cms in size, well above the 5cm size that is considered operable – and received stent grafts. Both men have also been back in for minor surgery since to repair small leaks in the grafts, which has required an overnight stay in hospital.

About 20,000 New Zealanders have an undiagnosed aneurysm at any one time and many of these are at risk of rupture. The problem is usually discovered, if at all, when a patient has routine checks for other health issues such as gall bladder and kidney problems.

In the United Kingdom and the United States there are aneurysm screening programmes in place. The state government in Western Australia has funded a screening programme there since the 1990s. Both Mr Hill and Professor Holden are hopeful that a screening programme may be introduced in New Zealand one day.

“The cost would be relatively low as it only requires an ultrasound to locate an aneurysm and could be done as part of regularly screening for other conditions,” says Mr Hill.

Some type of screening programme might have helped North Shore resident Reg Duffill who was unlucky enough to have his aneurysm rupture. He’d had no inkling at all that there was a bulge waiting to explode in his lower aortic tract.

A retired house painter and decorator, Reg suffered already from chronic obstructive pulmonary disease from a lifetime of exposure to white lead and asbestos, and he was a smoker. But the difficulty he had with that was a walk in the park compared to the searing pain he experienced when the wall of his aorta burst one evening.

“I thought the end of the world had come; it was this really severe pain at the bottom of my stomach, so bad that I was vomiting.”

Luckily, his wife, Gael, was on hand to drive him minutes down the road to North Shore Hospital. Three hours later, after x-rays and a scan had confirmed a ruptured aneurysm, he was wheeled into Auckland Hospital where an operating team was waiting for him.

“There were about 20 of them expecting me. Some of them had already worked a full shift and were about to go home. They stayed on to work on me,” recalls Reg.

A grim-faced Andrew Hill explained to Reg that he’d suffered a ruptured aneurysm. He didn’t explain, however, that most patients die within one day of a rupture if they are not operated on. Reg had the added complication of his age – he was 81 – and, as with all surgery, there were significant risks involved.

Gael could see that Mr Hill was very worried. Just two hours later though she was relieved to see the surgeon emerge from the operating theatre with a grin that stretched from ear to ear. Within two days, Reg was walking around and four days later he was discharged from Auckland Hospital. His pain was completely gone.

Two months later, Reg says he feels “excellent”. The only evidence that anything has happened to him is a barely visible keyhole scar in his groin.

“I’m trying not to make any lifestyle changes,” Reg jokes, “but my wife is making me slow down a bit. But I’m still playing bowls, gardening and walking, no problems at all.

“I’m really grateful to the surgical team who saved my life.”

Intensive development of the pipes used in the stent grafts have seen their size dramatically reduced in the past decade. Whereas an incision had to be always made in the groin to insert the stent graft, now in 40 per cent of the operations performed today at Auckland Hospital the needle technique or “percutaneous” method is used with no incision at all.

“Stent grafts have become much smaller and at the same time more reliable and durable. The operation takes less than an hour and there is increasingly less need for repair procedures,” says Mr Hill.

He’s talking about the need to repair leaking stent grafts after the first procedure that both John Salthouse and Eddie Reyland required. If a person’s aneurysm is 5 cm in width, there’s a 5 to 10 per cent risk of rupture within the first post-operative year; the risk increases to between 20 and 30 per cent for a 7 cm aneurysm. Patients are followed up by regular scans for this reason and are given the “all clear” if there has been no further leaking five years after the stent graft procedure.

“Increasingly, we are looking to a time when we can operate more quickly with no requirement for followup at all. The rapid development of medical technology means patients will soon only require an overnight stay in hospital, instead of the three or four day stays a patient currently requires after receiving a stent graft,” says Professor Holden.

Before stent grafts came along, aortic aneurysms required a large incision to be made through the abdomen or chest. The aorta was then clamped above and below the aneurysm to stop blood flow and an artificial artery diversion was created to bypass the weakened artery wall. This “open” procedure is still undertaken in about 45 per cent of cases across New Zealand when a patient’s particular anatomy precludes the use of the newer , less invasive technology.

It requires about two weeks’ hospital stay and a further six or seven weeks for complete recovery.
“The way stent grafts are being developed, the open procedure will eventually become obsolete,” says Mr Hill. “We are already having stent grafts custom built to accommodate peculiarities of a person’s aorta such as size, length, shape and curve.”

Working with stent graft developers like US-based Cook Medical, the Auckland physicians are also collaborating on the design of stent grafts that can accommodate other smaller arteries that branch off the aorta while containing the aneurysm in the aorta.
“Sometimes we may use four, five or six stents sectioned together to fit around the branching renal arteries.

“Not only are the new devices we are using much less invasive, there is a significantly lower risk of mortality,” says Mr Hill. “Clearly, with any operation there is a risk of complications. With stent graft procedures the risk of dying at the time of the operation is 1.5 per cent compared with 4.5 per cent for the open procedure. We expect new studies will show that the benefit of stent grafts will be maintained in the years following an operation for a patient.”

It is not understood why some patients develop “hardening” or narrowing of the arteries with the build up of plaque and others develop ruptures of their artery walls. What is known is that aortic aneurysms are influenced by the usual cardiovascular risk factors like smoking, high blood pressure and family predisposition; that they usually – but not always - occur in people in their seventies and eighties; and they are more common in men. In fact, men are eight to nine times more likely than a woman to develop an aortic aneurysm for reasons that are still unclear.

The University of Otago is coordinating a research project that is attempting to unravel the underlying genetic influences on aneurysm disease. All patients treated in New Zealand are asked if they want to participate by providing a DNA sample.

In many cases, age is a determinator of treatment. Sometimes the quality of life for an aged patient may be too severely compromised by the after-effects of an invasive “open procedure” operation, and the decision may be taken to let the aneurysm run its course, with death the inevitable outcome.
Again, the increasingly low-invasiveness of stent graft technology is enabling the Auckland surgical team to override considerations of age in many cases.

When 93-year old Eddie Reyland collapsed with the pain of his bulging aneurysm in November last year, his doctor and children had to make the call for him.

“The doctors called us in to show us the scan and discuss the treatment options for Dad,” explains Eddie’s son, David Reyland. “The options were for him to have the operation or he would probably die over the weekend because the aneurysm was close to rupturing.

“We explained to the doctor at Auckland Hospital that Dad lived alone, did his own cooking, and drove himself around Helensville in his car. He’s been a member of the Helensville Bowling Club for over 50 years. He’s the patron now and he’s looking forward to celebrating the club’s centennial in 2013. When the doctor heard all this, he just said ‘okay, we’re going to operate right now’.”

Nearly a year down the track, Eddie is still managing in his own home, walking to the shops and enjoying a “couple of beers”. He’s still not sure if he will be bowling this season, but he bowled last season after receiving his stent graft and he’s looking forward to being the guest of honour at his club’s upcoming centennial.

David Reyland sent a letter to the team at Auckland Hospital, on behalf of Eddie’s family and friends at the Helensville Bowling Club, acknowledging the medicos’ role in what was a “touch and go” decision to operate.

“Thank you for keeping Dad alive,” David wrote.

For their part, the Auckland physicians and their team are stoked about what they can achieve for Eddie Reyland and their other patients.

“It’s intellectually very challenging to use the technology that we now have available to do very complex reconstructions in a minimally invasive way,” says Professor Holden. “Personally, it’s very satisfying to see people get better so quickly.”