04/09/2017
APOLLO CARDIAC DOCTORS PERFORMS THE FIRST HYBRID PROCEDURE FOR AORTIC ANEURYSM IN THE CITY
An eighty-year old lady was having a huge dilatation of the arch of aorta, which was leaking and could have ruptured at any instance and may have caused instantaneous death of the patient. Her detailed workup in the form of aortic angiogram and CT Aortic angiogram confirmed the diagnosis as well as the exact extent of the disease. Dr K Roshan Rao senior consultant cardiologist said that as there was involvement of the brain and upper limb arteries which limit the application of endovascular approaches, but as the patient was too fragile to withstand the extensive surgery, Endovascular treatment was the treatment of choice for her but the stent would have caused blockage of arteries supplying her brain and upper limbs.
This led him to go for a hybrid procedure- the first part was surgical and second one- interventional endovascular stenting.
WHAT IS HYBRID ENDOVASCULAR REPAIR
Dr Sarita Rao, senior consultant in cardiovascular interventions at Apollo Hospital explained that, hybrid procedures have been introduced as a less-invasive alternative to conventional open repair, avoiding the need for a thoracotomy and, in many patients, aortic cross-clamping. The first report was from UCLA in 1999, and since then ONLY 300 hybrid procedures have been reported worldwide, so it’s a rarity in itself, also the cost of the procedure is very high, the mean stay was around 21 days in most of the Meta analysis. These are the few reasons that make the efforts of Apollo docs more laudable as the patient was discharged 3 days after the procedure and approximately ½ the cost.
Since its introduction, hybrid repair has been widely adopted as an alternative to open surgery. Its current role in the treatment of patients with complex aortic aneurysms has evolved, have relegated hybrid procedures to high-risk patients who are neither candidates for total endovascular repair or open surgery.
Dr Rao stressed on the importance of Patient selection, case planning, and technical aspects of the procedure are key for successful outcomes. A minimum length of 2 cm of parallel aortic wall without excessive calcification or thrombus is required in the thoracic aorta, and longer seal zones may be needed in the aortic arch which is why modified debranching was required in our case.
In the first part a team of surgeons implanted a graft from her right artery of the brain to left common carotid artery (supplying the left side of brain) and left subclavian artery (supplying the left upper limb). This ensured that even if the mouths of these arteries are blocked by the stent, the blood supply will be maintained by the innominate (the common right sided artery of brain and limb) artery through the graft.
This was done under local anaesthesia thereby minimizing the risk of general anaesthesia.
Once the circulation to the brain and upper limb was secured, interventional cardiologists Dr.D Sarita Yadav Rao and Dr Roshan Rao along with senior cardiac anaesthetist Gupta, implanted the bulky stent graft in the dilated part of the thoracic aortic aneurysm covering left sided brain and upper limb artery which were already grafted so there was no risk of any compromise to the brain and upper limb.
Dr Sarita Rao also stressed that Team effort by the surgical and interventional team led to complete cure of the patient with minimal risk. The patient recovered well without any complications and was discharged from the hospital on the 3rd post-operative day.
Dr K also pointed out that this case ushers the new era of more and more hybrid procedures In coming time where both the cardiac surgeons and cardiologist work in tandem for better patient care and comfort, a win – win situation for both.
Indore, India Niramaya Managelete
