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The Future of Medicine: A Better Way to Fix Ruptured Abdominal Aortic Aneurysms
Joseph Giglia, Vascular Surgeon, UC Health University Hospital
Abdominal aortic aneurysms are a dilation of the largest blood vessel in the body. The larger the bubble or aneurysm, the greater the risk of rupture. If a rupture is not treated, that’s uniformly fatal. Most people don’t make it to the hospital—and for those that do, the standard teaching is that only 50 percent of them survive. About 15,000 people a year die in the United States from aortic aneurysms.
Aortic aneurysm surgery has been around since the mid-1950s. The results with elective repair have dramatically improved since then. But in repair of ruptures, the mortality rate has stayed at about 50 percent. The reason for that is people come in in shock, because of blood loss. Prior to the operation they need to be anesthetized. But if they’re anesthetized, they drop [blood] pressure and go further into shock, [which is] a true surgical emergency—they would be bleeding to death.
Now we have a whole protocol set up. It’s a team effort that encompasses the transport, the O.R. staff, and our [surgical] team to get people into the operating room as quickly as possible. We use local anesthesia, make a couple of incisions in the top of the leg, open the artery, put a wire up into the artery under X-ray guidance, put a balloon upstream from the tear, inflate the balloon, control the hemorrhage, stabilize the blood pressure, then proceed. You’re stabilizing the person even before anesthetizing. Once the hemorrhage is controlled, we take a step back, resuscitate the patient with blood and fluids, put in central lines, IVs, and monitoring devices, and then put the person to sleep under a controlled situation.
The ruptured aneurysm protocol goes back to at least 2005. Now, it’s been modified so everybody gets an endovascular attempt: We [try to] treat the aneurysm from the inside of the vessel using endografts, which are basically covered stents. With endovascular repair, the results are better, recovery is easier, the chances of dying are less.
Dr. George Meier [chief of vascular surgery] did the first [emergency] endovascular repair at University Hospital within our protocol in 2007, and he simplified things. It can be done in other facilities in the area, but in my opinion we’re really the only ones who can do it 24/7/365, just because of the infrastructure that we have.
To see a patient make it through, do well, and come back to the office with their family—_walking—is quite gratifying. They come in [with a rupture], they’ve been snatched away from their home by a life squad, they probably don’t know what’s happened to them, they’re lying on a gurney looking up at these lights with a stranger that they’ve never seen, in a life-threatening situation. I have a little file here—I keep these more for my mental health than anything else—of pictures of patients back in the office. In many cases they don’t remember the experience at all, which is probably a good thing.
Originally published in the January 2011 issue.