August 25, 2010
The quality of American health care is advancing at an accelerated pace, and John C. Lincoln's patients are the beneficiaries.
Cardiovascular surgeon Kevin Brady, MD, left, vascular surgeon Curtis Erikson, MD, with patient LeRoy Gorniak.
What a difference a decade makes.
A dozen years ago, surgeons couldn't repair 76-year-old Ellie Thompson's lethal thoracic aortic aneurysm without major surgery that was, in itself, life-threatening.
Fast forward to April 2009: WWII draftee LeRoy Gorniak was in and out of the hospital, back to all the normal activities of daily living, his thoracic aortic aneurysm repaired without major surgery, with only a tiny scar as evidence of his doctor's work.
Gorniak was saved with a surgical procedure that was barely an idea for future medical research when Thompson needed it in 1998. The quality of American health care is advancing that quickly, and John C. Lincoln's patients are the beneficiaries.
To understand the magnitude of this medical advance, consider the similarities — and the differences — of the two cases.
Medicine in 1998 vs. 2009: A Study in Contrasts
In 1998, Ellie Thompson was having her best day of the year. Her pneumonia was finally cured, her energy was back and she was out for lunch and a movie with her "girlfriends." But in the middle of the movie, the nagging chest pain she'd earlier felt and dismissed came back with a vengeance.
More in HealthBeat
This article appears in the September-October 2010 edition of HealthBeat, John C. Lincoln's free health newsletter.
» Subscribe now
Within the hour she was in the hospital emergency room. An X-ray showed a shadow in her chest, outside her lungs, which doctors diagnosed as pleural fluid from her pneumonia which had congealed instead of being reabsorbed by her body. They decided surgical removal of the substance was the only way to fix the problem.
Although the incision was huge, the procedure was supposed to be simple. But it didn't work out that way. Instead of pleural fluid, the surgeons found blood that had leaked from an unseen and unsuspected thoracic aortic aneurysm, a ballooning weakness in the large artery that carries fresh blood out of the heart.
This was bad. Really bad.
The doctors were not prepared to do the intricate and extensive surgery required to replace the damaged portion of the aorta with an artificial graft, so they closed the incision to wait for her to heal before deciding what to do next.
It was a tough call. The major surgery required to repair the aneurysm would be extremely risky: chances of simply surviving it were slim. If she did survive, the side effects of the surgery included possible paralysis.
At the same time, if left untreated, the aneurysm could blow at any moment, resulting in sudden death.
Back then, no alternatives existed. Today, however, they do. Gorniak's experience testifies to medicine's advances.
In 2009, Gorniak was also having a great day that was interrupted by unexpected agony. While getting ready for dinner with his family, he was wracked with excruciating chest and back pain.
He got to the hospital emergency department in less than an hour, but in addition to X-rays, Gorniak had more sophisticated, revealing and noninvasive medical images called CT scans. Gorniak's CT scan clearly showed — without invasive surgery like Thompson's — that his problem also was a weak spot, an aneurysm, in the upper section of his aorta.
How the Aorta Works
A small metal mesh tube, called an endoluminal graft, allows blood to bypass the stretched-out section of the artery and flow into the healthy aorta and its branches.
To understand what this means, it's important to know that the aorta, the body's largest artery, runs from the heart to the lower abdomen and distributes blood via its many branches throughout the body. Its top section that runs through the chest is called the thoracic aorta. Its lower section is called the abdominal aorta.
An aneurysm can be caused by age, disease or injury, but regardless of cause, it carries a huge health risk. That's because when the weak spot stretches and balloons outward — as happened to Thompson — the arterial wall thins to the point that it can burst. When that happens, even today, death is virtually unavoidable.
Treatment for Abdominal Aortic Aneurysms
Although Gorniak's procedure, minimally invasive treatment of thoracic aneurysms, only recently has become generally available, vascular surgeons have been able to treat abdominal aortic aneurysms this way for almost 20 years.
To do so, they make a relatively small incision in the groin and run a catheter up the artery to the abdominal aneurysm, where they deploy a metal mesh tube, called an endoluminal graft. Blood then travels from the healthy part of the artery through the tube, bypassing the stretched out section, and flows into the remaining section of healthy aorta and its branches.
Because blood is no longer pulsing against the stretched area, the pressure on the aneurysm is eliminated. As long as blood doesn't leak around the graft into the ballooned area, the aneurysm is no longer a health threat.
Until recently, this procedure only was done in the lower part of the aorta. Not only is it a whole lot trickier to run a catheter higher and farther up the aorta toward the heart, but important branches off the thoracic aorta carry fresh blood to the brain, lungs and arms. Blocking one of those branches could be devastating.
Repairing Aneurysms with Grafts
"The aortic branches that go to the brain and other vital areas are a major challenge," said Gorniak's vascular surgeon, Curtis Erickson, MD, who frequently works with his colleague, cardiovascular surgeon Kevin Brady, MD, at both John C. Lincoln Hospitals. "If the graft blocks blood flow to vital areas you can cause serious damage, paralysis or even death."
Some of the stent graft manufacturers are now offering grafts with openings that can be matched up with the various branches of the aorta. These may hold promise in the future, Dr. Erickson said. Now, if a graft repairing an aneurysm blocks one of the arterial branches, surgeons have to install a bypass reconnecting the blocked branch with the aorta, so life-giving blood flow can resume.
Other Medical Problems Complicate Care
Another challenge inherent in aneurysm repairs, Dr. Erickson said, is that older patients who develop aneurysms usually have other medical problems.
"We have to look for other diseases or degenerative conditions that make it more difficult for patients to bounce back after surgery, even minimally invasive surgery."
That makes predicting outcomes much more difficult, he said.
"We know once the graft is successfully deployed, the patient has an excellent chance of survival, as far as the aneurysm is concerned. But all the other factors associated with these patients, regardless of cause, will affect outcomes.
"No matter which situation you're facing," Dr. Erickson explained, "the challenge of getting a good outcome is not based completely on what you're doing to treat the aneurysm, but who you're doing it to — what other problems are present."
A Bright Future
For Gorniak, however, the future is bright.
"I feel good," he said, "and I can do everything I could do before I developed the problem. I go out every morning and evening and walk with my dog, Hilary. She's a little Bichon Frise terrier mix, about five years old, and she keeps me healthy and happy."
Return to main News page.