It took a trip to a textile store… yes, a textile store. It was late 1940s, and Michael DeBakey (who would later become the most innovative and most distinguished cardiovascular surgeon in the world) was thinking how to address a major clinical need for a deadly disease – ruptured aortic aneurysm.
Albert Einstein just died of one, with echoes of his sudden death reverberating in the world and in the medical community. Einstein consulted doctors, including DeBakey, but no treatment options existed at that time.
‘What if we replace the aorta with an artificial tube to treat the aneurysm,’ thought DeBakey. ‘But what material?’ He started attending textile stores and tried several materials, but they were no good. Finally, a clerk indicated that they had just gotten some new material from the US Army. WWII had ended and there was a surplus of a parachute material called DACRON.
DeBakey bought a bunch of it, tried that on animals, and it was perfect. Within several years surgical treatment of aortic aneurysm was offered with Dacron grafts, saving millions of lives. As technology progressed, decades later aneurysm repair made its way into the endovascular therapy world.
By now we routinely offer patients endovascular treatment of aortic aneurysms. They no longer require large surgeries with clamped aortic flow, and a scar from stem to stern. We do it all through tiny holes in the femoral arteries.
As we have to achieve a perfect seal of the newly placed graft to avoid future aneurysm growth, we often have to anchor the stent-graft in the external iliac artery, occluding blood flow into internal iliac arteries, which provide flow to rather vital organs in our body. It is common that after flow cessation to internal iliac arteries, our post-aneurysm treatment patients enjoy their postoperative reduced risk of sudden death from a ruptured aneurysm, but curse their doctors daily for new onset of buttock claudication, and worse yet, a new onset of erectile dysfunction.
Recently, a delightful and full of vigor 74-year-old gentleman with interesting life stories presented with a large aneurysm. “We are doing it, this month, no later,” I exclaimed to the patient and his wife, after staring at his scary looking images of CT angiogram. I intended to do the procedure with a solid, modern device, although it would require covering patient’s external iliac arteries, but we would get a perfect seal with it.
Endovascular medicine is a team sport. We do graft procedures together with a surgeon, so I sent the patient to my partner, Dr. Will McAlexander, a highly skillful, thoughtful, and compassionate cardiovascular surgeon at Brookwood Baptist Medical Center.
“We are NOT doing it,” he stated emphatically, his voice sounding ominous over the phone, which sent chills down my spine. What did I miss? Why wouldn’t the patient be a good candidate for the procedure? He will likely die, if we don’t proceed.
“Well, we are not doing it the way you proposed,” Dr. McAlexander said. “We absolutely have to preserve his internal iliac arteries. I just met him and his wife, and we talked about things they like to do in life. You probably did not ask, but they are a really happy couple and like to take what life offers more often that you would think.”
The next week in our hybrid room at Brookwood Baptist Medical Center, we carefully placed five different pieces of a branched endograft, not only fully preserving his internal iliac arteries, but also getting a perfect seal. The patient did very well and was discharged in two days.
The case is another life lesson for an operator - listening to what patients say or do not say is at least as important as technical skills. You just have to ask.
I saw the patient in the clinic two weeks ago. He seemed really happy. His wife also looked very happy.
Jan Skowronski, MD, MBA, FSCAI practices interventional cardiology with Cardiovascular Associates.
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