The Hands of a Surgeon

My partner, Lee Kirksey, Vice-Chair of Vascular Surgery, just got a paper on-line (link) about the curiously increasing volume of open surgical repairs we were experiencing from 2010-2014 at the Cleveland campus of the Cleveland Clinic. When I joined in 2012, my impressions at that time were mostly the paucity of straightforward EVAR cases that I had seen in private practice, and the high prevalence of stent graft explantation, infected aortic grafts, and open aortic aneurysm repairs (OAR) for juxtarenal and thoracoabdominal aortic aneurysms for nominally high risk patients. My TAAA muscles had atrophied during my years out of fellowship and I eagerly took the opportunity to recruit the help of my partners and scrub in on these cases with Pat O’Hara, Jean Kang, Dan Clair, Ezequiel Parodi, and Lee Kirksey. It is without any shame that I sought out not just extra expert hands, but interrogated these experts for different ideas and approaches, and absorbed feedback. At the time, I was ten years removed from graduation, a full-fledged vascular surgeon who thought he could do any operation put before him. I cannot imagine the thoughts churning through the head of a recent graduate faced with the choice of taking on an open aortic operation with only 5 cases under their belt, referring the case on to the regional tertiary center, or trying to McGyver an endovascular solution. I contributed probably about 35-50 cases to this paper, but the outcomes were a collective effort. Even today, I will run cases by Sean Lyden, Christopher Smolock, or Lee, if only for the company and gossip.

“We explain this distribution of cases as a function of several factors: a unique, broad regional quaternary referral practice whereby patients with complex aneurysmal disease are referred to our institution; an institutional practice evolution resulting from a critical analysis and understanding of EVAR failure modes that lead to explantation, thus generating a different perspective in the EVAR vs open decision-making process; a parallel high-risk IDE fenestrated graft study; a historical willingness to accept all physician and self-directed patient referrals (ie, a willingness to manage more complex cases); and a published expertise in the area of EVAR device explantation with an annually growing volume of commercial device removals” -from El-Arousy et al.

Reading through that paper, I have come to the conclusion that the increasing open aortic volumes at the Cleveland campus has as much to do with the ongoing retirement of experienced surgeons regionally as it does with the ability to attract these cases. Loss of these surgeons has a cascade effect like losing a species in an ecosystem. The operating rooms forget where the OMNI retractor is because nobody asks for it anymore. The ICU’s are no longer familiar with the ebb and flow of the postoperative open aortic operation. The floors lose institutional memory of the care of these vascular patients as the stent grafts and interventions go home within 48 hours, sometimes the same day.

If you were a vascular surgeon born before 1970, your approach to the scenario of the ruptured abdominal aortic aneurysm may differ substantially from that of surgeons born after the Carter administration. Most of my cohort, Gen-X and older, feel comfortable applying some betadine, opening the belly and placing a clamp. Those younger than us have told me they feel more comfortable putting up a large balloon and deploying a stent graft. In this generation, it is normal to call a general surgeon to decompress the abdominal compartment syndrome and manage the abdominal vacuum dressing. For our generation, the giant industrial robot arms and 80 inch monitors creates a barrier to the problem at hand, and gathering all the extra staff after hours and on weekends requires the logistical skills of a wedding planner.

We prefer an operating table, a willing anesthesiologist, a cooler full of O-neg blood, Prolene and a graft, strong suction, and an extra set of hands. The data suggests either method is equivalent in outcome, but I would argue that depending on the circumstance, there is an optimal method for that patient and you have to have the ability to do either open or endovascular or some hybrid combination. Unfortunately, it is clear that open vascular surgery is year over year diminishing, and and it might not be so great when we start rupturing our aneurysms.

The open approach is preferred because we got good at it by doing a lot of these cases. Your hands -it becomes natural to change the course of the disease and the fate of the patient with your hands. One of the things you lose with a wire based approach is the tactile feedback from the organ that you are treating. Yes, there is a subtle feedback from the flexible tip of a Glidewire, but that’s missing the point. The thing that is rarely considered with open surgery is the tactile aspects of operating.

Your fingers are your point of care ultrasound. As an intern, one of my earliest tasks was reaching in through a 2cm incision with my index finger, feeling for what I would describe as a rotten shrimp, and delivering it out by hooking my distal phalanx around its base. Adhesions were rubbed like money between finger and thumb to judge if you could bovie through it. If you felt a sliding sensation, it was mucosa to mucosa and you looked for another spot to cut. Into my fellowship which could be called the triple-redo, no-one else wants to do-, difficult vascular operations fellowship, the pulse or the plaque felt under the finger would guide me to carve away scar tissue from blood vessel, visualizing the feedback from the fingers. In a rupture, with the belly under a dark mire of blood, there is no seeing, only feeling. Your hands reach into the lesser sac or transverse mesocolon and strangle the aorta -your fingers while clamping, feel and avoid the caudate lobe, the NG tube in the esophagus, and split the crura of the diaphragm like a pick pocket. Once the pulse returns as anesthesia refills the tank, you scratch free the aorta with your thumb and forefinger, then slide the jaws of the aortic cross clamp over your fingers and against the spine and clamp. This takes about 60 to 90 seconds (link).

When a patient is bleeding out, this is the way to control the bleeding. In practice, no amount of rehearsing for getting a patient into a endovascular suite, getting airway and access, swinging in the industrial robot arm, and getting everyone into lead aprons, sending up wire, placing a 12F sheath and an aortic occlusion balloon, will be satisfactorily smoothly and efficiently as a STEMI or STROKE alert. The rAAA is for most hospitals, unless you are in Seattle, a once in a while occurence. Many more people can find a scalpel and an aortic clamp than they can find a 32 inch aortic balloon, a stiff exchange length wire, and a 12F sheath.

When a patient presents with a slowly bleeding, contained rupture, there is time to assemble the teams required for an endovascular repair, and for opening and decompressing the abdomen, for anesthesia to get IV’s, central lines, arterial lines, and order crossmatched blood. One has the time to get and review CT scans and choose grafts. One can even do things backwards, debranching after securing the leak (link) with a stent graft. The luxury of time should signal to you that the endovascular option is the preferable route, as all the advantages of minimally invasive repair are possible. Rural hospitals sending patients two hours by ambulance or arranging for a helicopter -this is the great filter through which those likely to survive make it into the endovascular suite. These patients do great with EVAR, because everything moves more or less like a routine elective EVAR.

The setting up the operating room for tackling rAAA is quite simple. Keep everything nearby. Nothing should ever be stored out of sight, retrievable only by arcane codes whispered in the ears of people down in the basement or across the street. Amazon gives itself a day to get that gadget to you, but the rupturing patient does not have the time to have a 28mm stent graft ordered by looking up a Lawson number, finding the materials person in the faraway room to find it, running it over a city block. The stuff has to be next to the OR. Every scenario is unique, and the best planning is assuming no one person knows where everything is but everything is close at hand -major vascular sets, retractors, C-arm, cell saver, stent grafts, open grafts, balloons, cardiopulmonary bypass -every gewgaw is few steps away. The inventory is what you see, because if you can’t grab it, it does not help the hemorrhaging patient.

If you are a vascular surgeon born after 1980, it is likely that you may have trained in a 0-5 residency and all the old people harumphing about the old ways seem biased. Rather than being rational about their awful upbringing, the old people seem to suffer from Stockholm Syndrome, turning from victims of a harsh and brutal system inherited from the original, Halsted, a cocaine addict, to willing collaborators now mooning about the good old days of every other day call and 120 hour work weeks.

There might be a growing suspicion about advocating for open surgery when fewer people can perform it. One of the truisms of surgery is if only one surgeon claims to be able to do a rare operation with great results when everyone else abandons it, like venous valve surgery or robot assisted mastectomies, it can mean that surgeon might be uniquely talented or shamelessly selling something. It is a shame that open vascular surgery is devolving into that category of arcana, like the Jedi. I have no doubt that the last open vascular surgeon will be a reclusive, bitter, wild eyed hermit like Luke Skywalker was in episode VIII, if we let it get that far.

Bald eagles were saved from extinction. The methods of species reclamation may be what is needed to save open vascular surgery. Financial metabolism drives behavior, and there must be recognition of the time and dedication required to perform good open vascular surgery in the form of increased RVUs and reimbursement. The surgeons retiring in their mid 60’s with straight backs and steady hands need to be incentivized to stay around and coach the next generation in the ways of the Jedi. Call it the master surgeon designation. Every 0-5 graduate needs to focus on getting 100 leg bypasses, 50 carotid emdarterectomy, and 25 open aortas within the first five years of practice with a master surgeon if they did not get this experience during training. Like dead Jedi, it would help even if they were just virtually present, shimmering on Facetime in their (bath)robes to go over planning and approaches, but being physically present and reimbursed for it would make the most sense.

There is always self service in any human activity. One mildly prominent vascular surgeon that I have come across is famous for saying he did not have a vascular fellowship because he did not want to train his competition. It is easy for the fifty somethings to sit and proffer their open skills and profit from its scarcity but it goes against decency to not pass on this collective body of hard won knowledge and skills. There must be stewardship of this great thing we do, this honorable and treasured endowment.

Of the concrete ways we are trying is creating a network of advanced open surgery capable surgeons regionally organized by Martin Maresch, capitalizing on social media and electronic communications. Here at CCAD we are in the organizing phase of a vascular residency, and I very fortunate to have Houssam Younes join us as he shares my interest in surgical education and open vascular surgery. We are contemplating a non-accredited fellowship. We have general surgery residents coming through our service as well as medical students.

One of my mentors told me, “I can train a monkey to do cardiac surgery,” as he was training me to do cardiac surgery. And he was right. The final comment I have is you have to demystify surgery, take away the Instagram perfection, the romance, and list in practical terms the toolkit of maneuvers that form the component parts of all operations and propagate it. Let us not kid ourselves. The technical skills of surgery can be taught to anyone. The Mayo brothers were performing surgery as teenagers before medical school. The knowledge and experience and judgement -that varies as much as people vary and we have a curriculum for that, but the physical acts of surgery need to be taught starting at the medical school level. Standardized drills and exercises need to be created so that proficiency can be metered.

“The individual per trainee OAR volume did not decrease during this period. In the training program, the use of “component separation” (separation of each
operation into discrete, instructionable steps that facilitates trainee mastery) is integral to instruction of open aortic aneurysm repair techniques and permits the
trainee to master all of the technical exposure and repair skills necessary to address and to manage both straightforward and complex aneurysm anatomy. Component
separation is essential to maximize trainee experience across all levels” –from reference 1

Here is my list of things a trainee must accomplish by the time they graduate from a vascular residency or fellowship.
1. Tying knots with gloves on with 6-0 Prolene inside a pickle jar without lifting or moving a 12 ounce lead fishing weight to which the suture is being tied, fast, one handed, two handed, left and right handed.
2. Holding forceps, needle holders, and clamps
3. Correct operation of the OMNI retractor, Weitlander retractor, Balfour retractor, Thompson retractor
4. Incise skin through dermis through correct depth and length with both #15 and #10 blade
5. Open the abdomen through midline and flank incisions and close these incisions
6. Harvest saphenous vein
7. Vascular anastomosis on a table, inside a pickle jar, inside a short Pringle’s can
8. Dissection of adhesions and scar tissue around blood vessels and organs
9. Dissect and expose the common femoral artery via vertical and oblique incisions and close these incisions
10. Dissect and expose the carotid bifurcation, left and right side, and close these incisions
11. Dissect and expose the tibial vessels in various parts of the leg and foot
12. Dissect out the brachial artery at the elbow
13. Dissect out the axillary artery and vein below the clavicle
14. Dissect out the axillary artery and vein from the axilla
15. Dissect out the subclavian artery, vein, and brachial plexus above the clavicle
16. Dissect out the arm veins
17. Dissect out the iliac artery via a lower quadrant pelvic retroperitoneal exposure
18. Dissect out the abdominal aorta via midline laparotomy
19. Dissect out the abdominal aorta via retroperitoneal approach
20. Dissect out the thoracoabdominal aorta via a thoracoabdominal exposure
21. Dissect out the popliteal artery via suprageniculate, infrageniculate incisions and prone position
22. Dissect out the inferior vena cava
23. Dissect out the iliac veins
24. Harvest deep femoral vein
25. Temporal artery biopsy
26. Endarterectomy of carotid, femoral artery, any artery with patch angioplasty
27. Exposure and control of supraceliac aorta, suprarenal aorta for clamping
28. Exposure and control of thoracic aorta
29. Exposure and control of the great vessels via sternotomy and supraclavicular incisions
30. Exposure and control of the vertebral artery
31. Safe removal of vascularized tumors
32. Amputations of digits, legs and arms up to pelvis and shoulder
33. Exposure and control of radial and ulnar arteries
34. Hand surgical techniques of exposing arteries, tendons, and nerves in forearm and hand
35. Plastic surgical techniques of skin grafting and basic rotational flaps
36. Fasciotomy of arms and legs, hands and feet.
37. Exposure and control of celiac axis
38. Exposure and control of superior mesenteric artery
39. Exposure and control of left renal vein
40. Exposure and control of hepatic veins, portal vein
41. Exposure and control of renal arteries
42. Exposure and control of profunda femoral arteries
43. Safe removal of spleen
44. Transabdominal retroperitoneal exposures of the abdominal aorta and inferior vena cava
45. All of the above in a reoperative field
46. All of the above with limited visualization and by sense of feel only
47. Laparoscopic and thoracoscopic techniques
48. Orthopaedic surgical techniques of myodesis, bone grafting, precision osteotomies, infection control, external fixation, spinal exposure
49. Safe resection and anastomosis of bowel
50. Drainage of infection
51. Intensive care of SIRS, MOFS, CHF, Septic shock, postoperative fluid shifts
52. Nonsurgical and surgical management of lymphedema, seromas, and edema
53. First rib resection
54. Spinal exposure
55. Organ harvest and transplantation
56. Planning of complex open, hybrid, and endovascular procedures

Every year, it is apparent that endovascular options suffer from some flaw when outcomes are studied beyond 2 years, but progress will march on in that sphere. It has to. The loss of open capable surgeons to early retirement is accompanied by overapplication of endovascular techniques at least partly due to the lack of knowledge of these open surgical options and achievable good results and partly due to financial incentives. The solution lies in redistribution of reimbursement to open procedures and creation of open surgical fellowships and identifying and empowering mentors who still walk among us.

When You Pay Your Own Way, You Chose Value

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The patient is an active man in his 60’s with a history of hypertension who had known about a right common iliac artery aneurysm for several years and had come for an opinion. He was asymptomatic of pain. He had a prior splenic artery aneurysm embolization about a decade prior to presentation.. CT scan showed a large eccentric aneurysm arising from a retrograde chronic dissection dilating the right common iliac artery to over 4cm. This is typically iatrogenic, but impossible to know for sure. The left common iliac artery was ectatic to 2cm as was the aorta to 3 cm and all were “wavy.” This sort of tortuosity is the result of remodeling in the axis of flow resulting in lengthening of the artery and is found in those with the substrate for aneurysmal degeneration (footnote). He did not smoke and he could climb stairs without dyspnea or chest pain.

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On examination, he was a fit middle aged man with a slight paunch. His abdomen was soft and his peripheral pulses were present and normal. Laboratory results were normal, including creatinine. EKG and echocardiogram were also normal.Treatment options were discussed in detail. The patient was paying for the operation himself and wanted to understand in detail the possible options. These included

1. Open aortobi-iliac bypass with a jump bypass to the right internal iliac artery
2. Open aortobi-iliac bypass with ligation of right internal iliac artery
3. EVAR with right external iliac extension after embolization of right internal iliac artery
4. EVAR with parallel grafts to right external and internal iliac artery (off label)
5. EVAR with iliac branched graft to right internal and external iliac artery (off label)

People are known to react with emotions and to decide typically for near term gain over far term benefits. The offer of an operation involving laparotomy and a possible weeklong hospitalization with all the attendant risks of death, heart attack, stroke, ileus, wound infection, pneumonia, organ failure and so on provides a stark contrast to the appeal of endovascular repair which can be done percutaneously, with local anesthesia, and with a short hospital stay. The lifelong CT scans are in the murky future compared to the present which is sharply in focus. This is why few people save for retirement, why profligate grasshoppers far outnumber industrious ants. In the same vein, the offer of an “advanced minimally invasive” solution plays to several cognitive biases that exists in the mind of not only the patient but the health-care provider. These include this preference for short term gain over long term gain, but also viewing all innovation as being necessarily better than what was available.

After going over the operation in great detail, the patient cut me off when I mentioned the need for lifelong followup CT scanning. Because he lives in several countries, typically, he has to pay for his healthcare out of pocket and he balked at the notion of paying for an annual CT scan. He was also disdainful of the possibility of reintervention (quoted at 10%) and having to pay for it. Also, the stent grafts, which he would have to pay for, end up being as costly as a new luxury sedan based on local pricing.

We chose open surgical repair via a midline laparotomy. An aortobi-iliac bypass was performed from proximal aorta to right internal iliac artery and left common iliac artery bifurcation with a jump bypass from the right graft branch to the right external iliac artery. Technically, this sequence was chosen for ease of access to the internal iliac artery with the external clear of graft. Operative time was 3 hours. He was in the ICU for one night. He went home after 10 days after contracting a UTI. In followup three weeks after discharge, because he had fevers, a CT scan was performed (figure). He was treated for an upper respiratory infection which cleared, and he has been doing well since. We are both happy that he will never need a followup CT scan.

Before and After

The literature supports this stance. The long term followup of the EVAR-1 Trial (Reference 1) is an example. This was the late followup of the prospective randomized study looking at open surgery versus EVAR in 1252 patients. The initial EVAR 1 findings are well known and put into question the long term benefits of EVAR as the initial mortality benefit of EVAR is lost within a few years of treatment. At a mean of 12.7 years of followup, there were more deaths from aortic aneurysm rupture and aneurysm related death in the EVAR group compared OPEN surgery (adjusted HR 5.82, p=.0064), with 13 AAA ruptures. I have mentioned before that the failure of a handful of pacemakers drove the Guidant company to recall over 20,000 of their devices. Plus, the cost of annual CT scans in the treatment group and cost of devices and cost of reintervention have driven the UK’s NICE Guidelines recommending against EVAR in elective AAA repair. The meta-analysis of EVAR-1, DREAM, OVER, and ACE trials comprising 2783 patients is confirmatory, that aneurysm related mortality was significantly higher after the initial mortality benefit of EVAR fades away, and that patients of marginal fitness gain no advantage from EVAR, particularly those with heart or renal disease, and those with PAD had lower mortality in the period of 6 months to 4 years (reference 2).

I post this case, because despite a complications, in this case UTI and URI, the patient did fine. So why is open aortic surgery considered a dying art? Why is there such pushback against the UK NICE Guidelines?During my residency in the 1990’s, in the heyday of open surgery, I observed a lot of mediocre vascular surgeons and a very few great ones. The average vascular surgeon would take 6-8 hours to perform open aortic surgery, and the patient would come out with a typical picture of oliguria, third spacing, SIRS, that would generate a 1-2 week stay that would even be described as the normal and expected course for AAA repair in surgical and critical care textbooks. The best surgeons back in the day did these operations under 3 hours with 100mL blood loss and the patients would spend a day in the ICU (often not needing it), and 3-7 days in the hospital, but they were the exception.A higher percentage of surgeons today can do EVAR well than surgeons 25 years ago could perform competent open aortic surgery. Most surgeons graduating from training rarely see or do open aortic surgery compared to the multitude of interventions. Capable open surgery basically is not available outside of a few centers, and most surgeons admit to not having equipoise to start a new trial with modern devices. Open aortic surgery is a lost art, like growing your own vegetables, dressing your own game, reading cursive script, and dialing a rotary telephone.

It is not for a lack of desire. I have several younger colleagues I have met or interacted with via social media who have an intense interest in gaining open vascular skills. They have organized open skills courses at major European vascular meetings, but I believe that is not enough.The need for exovascular fellowship, the running topic of conversation of older surgeons through the 2000’s, is never as critical as it is now as we see milennia of surgeon-years of experience retiring to golf courses and cottages. The recommendation for preferring open surgery in the younger and fitter patients is sadly out of reach for most patients and surgeons. The same passion in disseminating endovascular knowledge needs to be applied to repair the damage to vascular education by over-relying on and over-prescribing endovascular approaches.

Finally, and sadly, this patient is the exception. When given clear options and outcomes and costs, this patient made a rational decision, choosing value over convenience.

Reference
1. Lancet 2016;388: 2366-2374.
2. BJS 2017;104:166-178

Footnote:

Pearls for finding AAA:
1. Tortuosity of the internal carotid arteries including loops and hairpin turns found in patients particularly smokers implies the present of a AAA until proved otherwise
2. Palpating bounding popliteal or pedal pulses in an older smoker implies the presence of a AAA until proved otherwise. Especially if the medical student can feel these pulses.
3. African-American Females with Diabetes almost never get AAA.
4. Palpate their abdomen

A lot of people can put in a stent graft, unfortunately only a few can take them out.

 

IMG_8167
Drs. Roy Miler and Xiao Yi Teng performing anastomosis on open coversion of an aortic stent graft, now graduated and in practice. A significant part of their open aortic experience is in addressing failing stent grafts.

I recently had to remove a stent graft for infection and got to thinking about how the number of people who could comfortably and confidently manage that has thinned out in the world through the unintended consequence of the medical device market place. In every surgical specialty over the past twenty years, many open procedures were replaced with a minimally invasive option which generally involved adoption of new technology and large costs to the hospital. These newer procedures were touted as easier on the patient while being easier to perform for the average physician than the open procedure that they were replacing. That was the other selling point -that one could do several of these operations in the time it took one open procedure. In most cases, they were at best almost as good as the open procedure but at higher cost.

In the marketplace, minimally invasive always wins. In many specialties it became untenable to practice without marketing these “advanced minimally invasive” skills. Hence, the wide adoption of robotics in urology outside major academic centers -during those years of rapid adoption the surgeons would get flown to a course, work on an animal model, then for their first case a proctor would be flown out and voila -a minimally invasive specialist is born. The problem comes when learning these skills displaces the learning of traditional open surgical skills. In general surgery, it is not uncommon to hear of residents graduating without having ever having done an open cholecystectomy.  It is also the case that many vascular trainees graduate with but a few if any open aortic cases. What happens when minimally invasive options run out? Who will do my carotid endarterectomy or open AAA repair?

The first case is an elderly man with an enlarging AAA sac despite having had EVAR about seven years prior. No endoleak was demonstrated but the proximal seal was short on CT. Also, it was a first generation graft which is prone to “peek a boo” endoleaks from graft junctions and stent anchoring sutures. On that last point, I use the analogy of a patio umbrella -after seven seasons, they can leak where cloth is sewn to the metal struts. It is very hard to demonstrate leak of this kind on CTA or duplex ultrasound because they are small. The patient had his EVAR because he was considered high risk for open repair at the time of his operation -moderate COPD, mild cardiac dysfunction. His sac had enlarged to over 6cm in a short time, and therefore open conversion was undertaken. No clinical signs of infection were present. A retroperitoneal approach was undertaken. After clamps were positioned, the sac was opened.

IMG_8144

The picture does not show it, but a leak from the posterior proximal seal zone was seen with clamp off. The clamp was reapplied and the graft transected flush to the aortic neck. A bifurcated graft was sewn to this neck incorporating the main body stent graft and aortic neck in a generous running suture. The left iliac limb came out well and the new graft limb sewn to the iliac orifice, the right iliac limb was harder to clamp and therefore I clamped the stent graft and sewed the open graft to the stent graft.

IMG_8151

The patient recovered well and went home within the week. He was relieved at no longer needing annual CT scans.

Who needs annual CT scans? Patients with metastatic cancer in remission.

The second patient was an older man referred for enlarging AAA sac without visible endoleak. The aneurysm had grown over 7cm and was causing discomfort with bending forward. He too had been deemed high risk for open repair prior to his EVAR. If he had had an early generation Excluder graft, the possibility of ultrafiltration would be more likely and relining the graft would be reasonable (link). This was again a cloth and metal stent graft which can develop intermittent bleeding from graft to stent sutures, and I don’t think relining will help.

IMG_6528

The patient was taken for open repair (above), and on opening the AAA sac, bleeding could be seen coming from the flow divider. It stopped with pressure, but I replaced the graft in a limited fashion from the neck to the iliac limbs as in the first case. This patient did very well and was discharged home under a week.

The third patient was another fellow referred from outside who had an EVAR for a very short and angulated neck, and a secondary procedure with an aortic extension in an attempt to seal the leak had been done. This failed to seal the type Ia leak. This patient too was deemed too high risk for open surgery of what was basically a juxtarenal AAA with very tortuous anatomy.

The patient was taken for open repair, and the stent grafts slid out easily (below).

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A tube graft was sewn to the short aortic neck and distally anastomosed to the main body of the stent graft -with pledgets because of the thin PTFE graft material in this particular graft. This patient did well and went home within a week.

All three cases are patients who were deemed originally too high risk for open repair, who underwent EVAR, then underwent explantation of their failing stent graft. Only one involved a patient whose graft was placed off the IFU (short angled neck), but the rationale was that he was too high risk.

What is high risk? In non-ruptured, non-infected explantation of failing stent graft, the mortality is 3% (ref 2) from an earlier series from Cleveland Clinic.  With stent graft infection, the 30-day mortality of surgical management from a multi-institutional series was 11% (ref 3) when there was no rupture. From a Mayo Clinic series, stent graft resection for infection came with a 4% 30-day mortality (ref 4). These were nominally all high risk patients at the time of the original EVAR.

Real world risk is a range at the intersection of patient risk and the expertise of the operating room, critical care, and hospital floor teams. The constant factor is the surgeon.

Endografts for AAA disease (EVAR, endovascular aortic aneurysm repair), makes simple work of a traditionally complex operation, the open aortic aneurysm repair. The issue has been the cost and risks of long term followup as well as endograft failure and aneurysm rupture. The Instructions For Use on these devices recommend a preop, a followup 1 month, 6 month, and 12 month CTA (with contrast) and annual followup with CTA for life. These devices were meant to treat high risk patients but high risk patients with limited life spans do not benefit from EVAR (ref 1, EVAR-2 Trial). These have lead the NHS in the UK to propose that EVAR has no role in the elective repair of abdominal aortic aneurysms in their draft proposal for the NICE guidelines for management of AAA (link). While this is a critical discussion, it is a discussion that is coming at least ten years too late. A generation of surgeons have been brought up with endovascular repair, and to suddenly announce that they must become DeBakey’s, Wiley’s, Imperato’s, and Rutherford’s is wishful thinking at best or wilful rationing of services at worst.

In 2006, Guidant pacemakers were recalled because of a 1000 cases of possible capacitor failure out of 28,000 implants for a failure rate of 3.7% -there were 2 deaths for a fatality rate of 0.00007%. EVAR-1 Trial’s 8 year result (ref 5) reported 16 aneurysm related deaths out of 339 patients (1.3%) in the EVAR group compared to 3 aneurysm related deaths out of 333 patients (0.2%) in the OPEN group.

Academic medical centers, behemoths though they are, serve a critical function in that they are critical repositories of human capital. The elders of vascular surgery, that first and second generation of surgeons who trained and received  board certification, are still there and serving a vital role in preserving open aortic surgery. My generation -the ones who trained in both open and endovascular, are still here, but market forces have pushed many of my colleagues into becoming pure endovascularists. The younger generation recognizes this and last year, I sat in on an open surgical technique course at the ESVS meeting in Lyons organized by Dr. Fernando Gallardo and colleagues. It was fully attended and wonderfully proctored by master surgeons. This is of critical importance and not a trivial matter. As in the 2000’s when endovascular training was offered as a postgraduate fellowship in centers of excellence, there is no doubt in my mind that today, exovascular fellowships need to be considered and planned and that current training must reinvigorate and reincorporate their open surgical components.

References

  1. Lancet 2005;365:2187–92.
  2. J Vasc Surg. 2009 Mar;49(3):589-95.
  3. J Vasc Surg. 2016 Feb;63(2):332-40.
  4. J Vasc Surg. 2013 Aug;58(2):371-9.
  5. Lancet 2005;365:2179–86.

When both iliac systems are occluded below an abdominal aortic aneurysm: hybrid techniques on the cutting edge

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AAA with iliac arterial occlusion -arrows point to right external iliac and left common iliac arterial occlusions

The patient is an 70 year old man referred for evaluation of claudication that occurred at under a block of walking. He reported no rest pain or tissue loss. He smoked heavily up to a pack a day, with congestive heart failure with an ejection fraction of 40%, prior history of myocardial infarction treated with PTCA, and pacemaker, and moderate dyspnea on exertion.

On examination, patient had a flaccid abdomen through which the AAA could be palpated, and he had no palpable femoral artery pulse bilaterally, nor anything below. He had a cardiac murmur and moderate bilateral edema. Preoperative risk evaluation placed him in the high risk category because of his heart failure, coronary artery disease, and his mild to moderate pulmonary disease.
CTA (pictured above and below) showed a 5.1cm infrarenal AAA with an hourglass shaped neck with moderate atherosclerosis in the neck, an occluded left common iliac artery with external iliac artery reconstitution via internal iliac artery collaterals, and a right external iliac artery occlusion with common femoral artery reconstitution. There was calcified right common femoral artery plaque.

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Treatment options included open surgical aortobifemoral bypass with exclusion of the AAA, total endovascular repair with some form of endo-conduit revascularization of the occluded segments of iliac artery, or a hybrid repair.

Open aortic repair in patients with heart failure and moderate COPD can be performed safely (ref 1). Dr. Hollier et al, in the golden age of open repair, reported a 5.7% mortality rate operating on 106 patients with severe category of heart, lung, kidney, or liver disease.

Typically, the hybrid repair involves sewing in a conduit to deliver the main body of a bifurcated or unibody stent graft when endovascular access is not possible. Despite techniques to stay minimally invasive -largely by staying retroperitoneal, this is not a benign procedure (ref 2). Nzara et al reviewed 15,082 patients from the NSQIP database breaking out 1% of patients who had conduit or direct puncture access.

Matched analyses of comorbidities revealed that patients requiring [conduit or direct access] had higher perioperative mortality (6.8% vs. 2.3%, P = 0.008), cardiac (4.8% vs. 1%, P = 0.004), pulmonary (8.8% vs. 3.4%, P = 0.006), and bleeding complications (10.2% vs. 4.6%, P = 0.016).

Despite these risks, I have performed AUI-FEM-FEM with good results with the modification of deploying the terminus of the stent graft across an end to end anastomosis of the conduit graft to the iliac artery (below), resulting in seal and avoiding the problems of bleeding from the usually heavily diseased artery

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Aorto-uni-iliac stent graft across end to end conduit anastomosis to fem-fem bypass

The iliac limbs of some stent graft systems will have proximal flares and can be used in a telescoping manner to create an aorto-uni-iliac (AUI) configuration in occlusive disease. The Cook RENU converter has a 22mm tall sealing zone designed for deployment inside another stent graft and would conform poorly to this kind of neck as a primary  AUI endograft which this was not designed to act as. The Endurant II AUI converter has a suprarenal stent which I preferred to avoid in this patient as the juxtarenal neck likely was aneurysmal and might require future interventions

I chose to perform a right sided common femoral cutdown and from that exposure, perform an iliofemoral remote endarterectomy of the right external iliac to common femoral artery. This in my experience is a well tolerated and highly durable procedure (personal data). Kavanagh et al (ref 3) presented their experience with iliofemoral EndoRE and shared their techniques. This would create the lumenal diameter necessary to pass an 18F sheath to deliver an endograft. I chose the Gore Excluder which would achieve seal in the hourglass shaped neck and allow for future visceral segment intervention if necessary without having a suprarenal stent in the way. I planned on managing the left common iliac artery via a percutaneous recanalization.

The patient’s right common femoral artery was exposed in the usual manner. Wire access across the occluded external iliac artery was achieved from a puncture of the common femoral artery. Remote endarterectomy (EndoRE) was performed over a wire from the common femoral artery to the external iliac artery origin (pictures below).

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External iliac to common femoral artery plaque removed with Moll ring cutter (LeMaitre Vascular) over a wire

The 18F sheath went up with minimal resistance, and the EVAR was performed in the usual manner. The left common iliac artery occlusion was managed percutaneously from a left brachial access. The stent graft on the left was terminated above the iliac bifurcation and a self expanding stent was used to extend across the iliac bifurcation which had a persistent stenosis after recanalization.

The patient recovered well and was sent home several days postprocedure. He returned a month later with healed wounds and palpable peripheral pulses. He no longer had claudication and CTA showed the aneurysm sac to have no endoleak (figures below).

post CTA EVAR-ENDORE

postop centerline EVAR-ENDORE
Composite imaging showing normal appearing right iliofemoral segment (EIA + CFA) and patent left common iliac artery.

Discussion
I have previously posted on using EndoRE (remote endarterectomy) for both occlusive disease and as an adjunct in EVAR. Iliofemoral EndoRE has excellent patency in the short and midterm, and in my experience has superior patency compared to the femoropopliteal segment where EndoRE is traditionally used. This case illustrates both scenarios. While the common iliac artery occlusions can be expected to have acceptable patencies with percutaneous interventions, the external iliac lesions typically fail when managed percutaneously especially when the stents are extended across the inguinal ligament. The external iliac artery is quite mobile and biologically, in my opinon, behaves much as the popliteal artery and not like the common iliac. Also, the common femoral arterial plaque is contiguous with the external iliac plaque, making in my mind, imperative to clear out all the plaque rather than what can just be seen through a groin exposure.

On microscopy, the external iliac artery is restored to a normal patent artery -I have sent arterial biopsies several months after endarterectomy and the artery felt and sewed like a normal artery and had normal structure on pathology. This implies that the external iliac can be restored to a near normal status and patients that are turned down for living related donor transplantation of kidneys can become excellent recipients. In this case, this hybrid approach effectively treated his claudication but also sealed off his moderate sized AAA while not precluding future visceral segment surgery or intervention with a large suprarenal stent.

 

Reference

  1. Hollier LH et al. J Vasc Surg 1986; 3:712-7.
  2. Nzara R et al. Ann Vasc Surg. 2015 Nov;29(8):1548-53
  3. Kavanagh CM et al. J Vasc Surg 2016;64:1327-34

Avoiding Aortic Exoleaks: principles of the proximal aortic anastomosis

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The proximal anastomosis is the most critical portion of an open aortic aneurysm repair. Several concepts are central to creating an anastomosis that doesn’t bleed at unclamping: managing narrow spaces, overcoming distortion, and using just enough tackle.

Narrow Spaces

The transabdominal exposure is a narrow space. The work is done under the overhanging left renal vein, the transverse colonic mesentery, the liver, the rib cage. Extra lateral space can be made by eviscerating the bowel, but at the cost of higher rates of ileus, and doesn’t solve the first problem. The standard DeBakey aortic clamp and straight Fogarty clamps stand nearly straight up, limiting the space above the incision at the aortic neck. My goto clamp is the Cherry Supra Celiac Aortic Clamp, designed by my mentor Ken Cherry. 1606988_10203082426724504_324421715_n

It hugs the contour of the mesentery and liver overhang, and the handles stay out of the way above the wound. It will also tilt up the aorta because of the weight balance. The other option is to apply a transverse clamp, which I will discuss in a later post. The transverse clamp leaves the suprarenal space free of clamp, but can be difficult if not hazardous to apply. The clamp has to be hemostatic and this can be challenging with atherosclerotic plaque -preoperative planning must include planning for safe clamp sites. A suprarenal clamp may be limited by the presence of the terminal insertions of the diaphragmatic crurae. I have recently found that dividing these crurae with a Maryland tipped Ligasure, a laparoscopic instrument I use to dissect the retroperitoneum, makes short order of what can sometimes be an awkward exposure in this tight space. Finally, endarterectomy of the neck should be done carefully to let needles pass without difficulty.

Distortion

The proximal anastomosis is ideally just another end to end anastomosis -attaching a circle to a circle, but clamping narrows and distorts the circular aortic neck (top illustration). To envision this, imagine the aortic neck being a clock face:

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Lets say the suture should be applied at each of the hours and half hours. You get ready to sew your first aortic neck and after endarterectomizing some plaque, you get this:

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The important point is that you still have to apply the original plan of applying sutures evenly and at an appropriate frequency (about 3mm apart), to avoid gathers and gaps, especially on the posterior wall. One way is to apply outward tension with a Wheatlander retractor in the aortic sac.

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The posterior wall of the aorta should be distracted to avoid distortions that create uneven gaps between passes of the needle. 
The bites on the aorta should be generous, on the graft, less so. As long as the gaps between the sutures is the same on both aorta and graft, you shouldn’t get leaks.  The other principle to guide you is the needles should pass pointing to the center of the clock -this is challenging in the Dali clock, but if you pivot your shoulder, your suturing won’t be bullied by the distortions and the narrow space.

The Right Tackle

You don’t go after panfish with a deep sea tackle. Pictured below are a spinning lure for trolling with a large hook and a small dry fly with narrow guage hook for comparison.

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Which hook creates the larger hole in the fish’s mouth? In fact, both lures can be used to catch the same large trout, but in different situations.

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On a lake, large hook, on a stream, small hook for same fish.
One of the techniques which I have borrowed from our partners in cardiac surgery here at the clinic is using smaller guage monofilament and needles. I once co-scrubbed an aortic arch case with Eric Roselli, and was bemused to see him sew graft to the fearsome ascending aorta with 5-0 monofilament suture. Then I saw no needle hole bleeding and was sold. Up to then, I had switched from my 3-0 on SH needles to 2-0 on MH needles -basically the largest vascular needle, and saw posterior aortic wall break down from the needle trauma. Unfortunately, 5-0 suture doesn’t come long enough, the CV needles aren’t big enough to sew posterior wall. I now use 4-0 on SH with 48cm length suture. Ideally, we’d have a 5-0 monofilament on a 60cm suture with a SH shaped and sized needle with the narrow guage of the CV needle.

Also, because the needles are finer and I favor supersized Castro needle holders. The needle holes which represent rents in the aortic wall are far easier to deal with using a smaller needle. Right tackle.

 

 

 

Moneyballing a Type II Thoracoabdominal Aortic Aneurysm


The innovation of sabremetrics in baseball management and finance as described in Michael Lewis’ wonderful book Moneyball wasn’t just the ability to quantify skill to predict outcomes, it was the ability to assemble that skill without overpaying. For a baseball team on a budget, spending all your payroll on a superstar makes no sense when you can get equivalent quants of skill in a statistical aggregate of no-name players with proven metrics. Rather than pay for an A-Rod, you can recruit, and pay for, 5 players that in aggregate, statistically achieve what you would get with a healthy A-Rod, so the thinking goes. How does this translate into vascular surgery? Can we arbitrage complication rates?

The open repair of type II thoracoabdominal aortic aneurysms is a heroic endeavor, putatively best done by surgeons wearing cowboy boots, and classically comes with sobering complication rates that exceed 20% for death and paralysis. Is it possible to reduce this risk by subdividing this most enormous of cardiovascular operations into component parts?

The patient is a middle aged man in his 50’s who presented with a type B aortic dissection. His dissection flap spanned from his left subclavian artery to the infrarenal aorta. He was a long time smoker and had hypertension that was difficult to control, made much worse after his dissection. He had a moderate dilatation of his thoracic aorta, maximally 36mm and tapering to 35mm in visceral segment. There was a 4.9cm infrarenal AAA where the dissection terminated.

CTA at presentation

His chest pain resolved with blood pressure control and he was discharged, but in followup his thoracic aortic segment grew and his blood pressure worsened, never getting below a 150mmHg systolic despite multiple agents. CTA two months after presentation, showed growth of his TAA to 44mm from  36mm in two months  and the visceral segment showed that his dissection flap impinged on flow to the right renal artery. His AAA remained the same. He continued to have bouts of chest pain related to hypertension.

CTA at 2mo post presentation

Twenty years ago, the board answer would have been to replace the whole aorta. In young, otherwise healthy man who had been working in road construction up to the dissection, he would have been considered a candidate for a direct open repair of the type II thoracoabdominal aortic aneurysm. From the landmark paper out of Houston by Dr. Svensson in 1993, open type II TAAA repair was associated with about a 10% death rate and 30 percent paralysis rate. Waiting a few months for the aneurysms to grow further in this patient, in the 90’s this patient would probably have ended up with an open TAAA repair. Good thing we have better options.

The goals of modern therapy are to treat the urgent indication while holding off repair of less critical segments of the aorta, and to do so in a way that each operation builds on the previous one.

This patient needed a left subclavian artery debranching and then TEVAR of his dissecting thoracic aortic aneurysm, and intervention on his right renal artery. We did this in one setting performing first a left carotid subclavian artery transposition and then percutaneous TEVAR from the left common carotid artery origin to the supraceliac abdominal aorta.

TEVAR with carotid SCA transposition

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The completion aortography showed good deployment of the CTAG device from the left common carotid artery origin to the celiac axis origin. The false lumen was no longer visualized. The right renal artery which was narrowed was treated with a balloon expandable stent.

The distal thoracic aorta, the true lumen was constrained by a chronic dissection flap. It is here I gently dilate the distal thoracic stent graft with the hopes of eliminating the distal false lumen. This is different from the acute dissection where I rarely balloon.

The TEVAR was done percutaneously, minimizing the overall time in the operating room. The technical details of the transposition can be found in the excellent paper by Dr. Mark Morasch.

 

renal PTAS

When I do this procedure for acute dissection, I quote the patient a general risk of stroke, paralysis of about 2-5% and death of 1-2 percent for someone with low cardiopulmonary risk like this patient had. He recovered rapidly and went home post op day 5.

 

Followup post TEVAR

He at 6 month post TEVAR followup, CTA showed stablility in his thoracic aorta. in infrarenal AAA grew from 5.0 to 5.7cm between the 1 month CT and the 6 month CT.

6 month CTA imaging

The terminus of the stent graft excluded the false lumen in the thoracic aorta but also resulted in filling and pressurization of the false lumen beyond and can be seen as a 44mm lateral dilation of the visceral segment of the aorta which had developed in the 6 month interval since the TEVAR.
The infrarenal neck continued the dissection and had dilated to about 36mm, but was parallel for a good length above the AAA. I decided to treat the inrarenal aorta with direct transabdominal repair. This would allow me to fenestrate the aorta, and possibly prevent further growth of the viseral segment while reserving the retroperitoneum for the visceral segment repair if it came to it. The neck diameter was 36mm.

tube graftHis operation was performed via an anterior approach with the patient supine. A tube graft repair was performed expeditiously and included resecting the dissection flap up to the clamp. Care was taken to avoid injury to the renal stent. The proximal anastomosis went well – the dilated aorta yet had strong tissue strength. A felt strip was used to buttress the aortic side of the anastomosis. The estimated risk of paralysis was less than 1% and risk of death was less than 2%. The patient recovered uneventfully and went home on POD 5.

He did well in subsequent followup, having successfully quit smoking. He retired early on disability and was becoming more active, but the visceral segment dilatation was concerning. At 6 months post infrarenal AAA repair, he underwent CTA and it showed patent thoracic stent graft and infrarenal abdominal graft. The intervening visceral segment continued to enlarge and was now 46mm. The decision was to wait another interval 9 months to see if this would stabilize. The segment grew some more and was 49mm. He wanted to give it another 6 months and at that time, CTA showed further growth over 5cm, and he had developed some abdominal discomfort. He was taken to the operating room.

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A four branch repair of the visceral segment thoracoabdominal aortic aneurysm was performed. The diaphragm was taken down and the stent graft was clamped as was the infrarenal tube graft. A premade Coselli graft was used to bypass to the right renal, SMA, celiac, and left renal in those order. The patient had a CSF drain for the case which was removed on postoperative day 2. He recovered rapidly and went home on postoperative day 6. His estimated risk of paralysis was about 2-5%, mitigated by a protocol centered on CSF drainage and blood pressure control. His risk of death was 5%. Telephone followup reveals the he is pain free at a month out and functional nearly at baseline.

This illustrates the notion that three smaller operations in an aggregate over three years achieved the equivalent of the single big open type II TAAA repair.

equivalence
Illustration on left from Svensson et al.

The idea is to make each step achievable -like coming down a mountain taking three days on well marked paths rather than base jumping off the summit.

Clearly, the patient was younger and a fast healer, and credit must also be given to the anesthesia/critical care team who see high acuity cases in volume every day and not every patient can expect to have such short stays and excellent outcome, but these are far more likely if operations are planned out in such a manner.

Reference

Svensson LG, Crawford ES, Hess KR, Coselli JS, Safi HJ. Experience with 1509 patients undergoing thoracoabdominal aortic operations.  J Vasc Surg 1993;17(2):357-36.