Aneurysm Treatment

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Surgery to treat aortic aneurysms, those that occur in the body's main artery, depends on the size and location of the aneurysm and your overall health. 2020-03-06 Aneurysm Treatment
All you need to now about Aneurysm Treatment

Diseases of the arteries can lead to dilation of the vascular wall, this is called aneurysm. There are several locations where an arterial aneurysm is more common.

The following aneurysm of the artery is more common:

All aneurysms run the risk that the dilated and weakened arterial wall can no longer withstand the blood pressure at this point. The result is the painful tear (rupture) with blood leakage to the outside.

The rupture risk increases with the maximum diameter of the aneurysm. It should then be an invasive vascular treatment, when the diameter has reached a certain size. Every aneurysm can be seen individually here and no general recommendation can be made as to when an invasive therapy makes sense. In addition to the size of the aneurysm plays an essential role in the appearance of whether growth has taken place so far, and what other diseases are present in the affected patient.

In the Aortensprechstunde you will be fully informed about your aneurysm disease. Then you can ask your questions. Together with you, it will then be determined which procedure makes the most sense in your case.

Concentrated competence: More than 130 top doctors from Munich and the region explain their best therapies to common diseases or frequent complaints for potential patients. Today it's about vascular diseases. These include, for example, narrowing of the carotid artery and aortic aneurysms. There is a great danger behind this technical term. Because if these enlargements of the main aorta burst, the patient is in acute danger to life. Medical doctors speak of "silent killers" - because the patient usually has no complaints at first. It is therefore advisable to have an appropriate preventive medical check-up. If the aneurysm is discovered at an early stage, specialists can remove it using modern surgical technology. Further topics of this episode: strokes and venous diseases.

Aneurysm is a pathological, sometimes life-threatening dilation or sagging of a blood vessel.

Aneurysm I

Type or name of the therapy: Surgical therapy of the abdominal aortic aneurysm (abdominal aortic aneurysm).

These examinations are necessary: ​​Clinical examination, ultrasound (B-scan or duplex sonography), CT angiography (computed tomography with contrast medium), clarification of other organs (especially heart, lungs, kidneys) before an operation.

Two surgical procedures:

  1. Endovascular therapy with stent prostheses, which are anchored via the inguinal vessels from the inside (“endovascular”) above and below the aneurysm. This takes the pressure off the enlarged wall of the diseased main artery.
  2. Open replacement of the enlarged aorta by inserting an artificial main artery as a simple tubular prosthesis or so-called Y prosthesis. For this purpose, the abdominal aorta must be surgically exposed and temporarily clamped above and below the aneurysm (large skin incision, greater stress on the heart, lungs, kidneys).

The procedure: Both surgical procedures are performed under general anesthesia, in individual cases the endovascular therapy can also be performed under local anesthesia (groin). The endovascular therapy lasts 60 to 90 minutes, the open surgery between 90 minutes and 3 hours. Inpatient treatment averages 5 to 7 days (endovascular) and 10 to 14 days (open surgery).

Aneurysm II

Type or name of the therapy: Surgical replacement of the ascending main artery (ascending aorta), possibly up to the so-called aortic arch.

These examinations are necessary: ​​interrogation, physical examination to assess the rest of the vascular system and the heart valves, X-ray, cardiac ultrasound, CT with contrast medium, left heart catheter examination with coronary angiography (cardiac catheter).

The typical complaints: Usually no complaints at first. Only when such aorta outbreaks become very large can they lead to symptoms such as shortness of breath, difficulty swallowing or hoarseness in the chest.

Here's how it works: The enlarged section of the aorta is replaced by a so-called tubular prosthesis - this is a stent made of high-tech plastic threads. The connections between the prosthesis and the own main artery are sewn with a nylon-like thread. You need the so-called heart-lung machine to maintain the blood circulation while working on the opened aorta. The heart is shut down with a so-called cardioplegic solution for the duration of the operation.

The procedure: The operation takes place under general anesthesia using the heart-lung machine, access by longitudinal splitting of the breastbone, which is stabilized again with wires at the end of the procedure. The duration of the operation is about three to four hours. The patient is then monitored in the intensive care unit for a day or two. Most patients stay in the hospital for about two weeks and then do three-week rehab.

3D printer vessels help with aortic aneurysms

Thanks to a vascular model from the 3D printer, the vascular doctors at Leipzig University Hospital were able to help seven people and thus save their lives.

Because an individually created plastic model helps doctors to create and implant a precisely fitting prosthesis in the event of a life-threatening sacking of the aorta, the main artery. The unique procedure used was developed by a research group at the Leipzig University Hospital and has now been successfully used in practice. The project has now been awarded the local IQ Innovation Award by the city of Leipzig.

If a patient develops an aortic aneurysm, i.e. a sagging of the main artery, only timely surgery helps. Because there is a risk of tearing due to the widening of the vessel walls - a situation that is extremely life threatening. The larger the aneurysm, the faster surgery is required. "We then insert a prosthesis in the expanded area that stabilizes the vessel," explains Dr. Daniela Branzan, vascular surgeon at Leipzig University Hospital. "In order for this prosthesis to fit as well as possible, we have to adapt it individually in advance in the case of complicated cases," continues Branzan. So far, this adjustment has either been laborious and with limited accuracy by hand using the 2D images, or in the longer term and more precisely by an external company that manufactured individual prostheses. For the patients, this meant uncertainty or a waiting period of two to three months. "But we don't have this time in emergencies," said Branzan. That is why the vascular doctor was thrilled when she came across a project in-house: a research group was working on applications of 3D print models in neurosurgery.

The basis for this was the "next3D" technology platform developed by UKL doctors and scientists together with the Fraunhofer IWU. This platform contains a software-supported process chain that evaluates medical images and transfers them to three-dimensional print templates. The first product developed here at the UKL was a customized system for neurosurgical interventions, a so-called stero-taxi frame. With the help of this device, electrodes are placed in the brain with high precision. For the researchers, the other possible uses of the method were obvious: "We were certain that our method would also enable us to quickly and precisely produce aortic vascular models based on computed tomography data," says Dr. Ronny Grunert, head of the research group. The result proves him right: with the new procedure, the Leipzig vascular physicians can now produce an individual plastic vascular model with the 3D printer within 24 hours. The prosthesis can be fitted onto this model like a template and precisely adapted to the branches of the vessels. This increases the chances of a successful operation of the life-threatening aneurysm, because the treatment time is significantly reduced. The prostheses immediately fit perfectly and stabilize the endangered area without hindering other vessels. The new method has been used seven times in the last ten months for high-risk patients for whom there was no other treatment option. All patients are fine today. "It is very likely that these patients owe their lives to the new procedure," says Dr. Branzan.

The research group has already reported on these pleasing results from the use of 3D printing in vascular medicine in the renowned journal "JACC" and at several congresses. "We therefore know that there is currently only one other team in Seattle besides us that uses a partially similar procedure," says vascular surgeon Branzan. The Leipzig method is unique, a patent has already been registered. In June the project was also awarded the Leipzig City Prize at the 15th IQ Central Germany Innovation Award.

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Aortic aneurysm: improved chances after surgery


Elderly and sicker patients in particular benefit from minimally invasive treatment of pathological enlargements of the main artery - the aortic aneurysm. Depending on the age and clinical picture, however, open main artery operations continue to be a good and in certain cases even the only sensible alternative.

This is shown by the example of a 37-year-old patient who suffered a life-threatening rupture of this vessel with further disease-related complications due to a rare disease of the connective tissue, the Marfan syndrome. After several operations, the mother of two has recovered to such an extent that she can cope with her everyday life again thanks to the help of her husband.

That Carola Zschocke is still alive borders on a miracle. In November 2018 she was admitted to the Dresden University Hospital by helicopter with a diagnosed tear in the main artery (aorta). At the same time, the esophagus of the then 35-year-old was affected - the aorta, which was enlarged by up to ten centimeters, had rubbed a hole in the organ and pressed it onto the heart at the same time. "Pathological enlargements of the main artery, so-called aortic aneurysms, pose a deadly threat. If they burst, it is a matter of minutes, otherwise the chances of survival are slim and if the esophagus is also affected, the patient is even worse," said Prof Christian Reeps. Five years ago, the experienced vascular surgeon moved to the Dresden University Hospital and significantly expanded the area of ​​vascular and endovascular surgery. Together with his team, the surgeon was able to treat the young woman successfully and has been accompanying her medically ever since. In the new, operative center of the clinic - House 32 - experts can also rely on an excellent infrastructure including two hybrid operating theaters to treat patients like Carola Zschocke.

Overall, around three percent of people over the age of 50 are diagnosed with abdominal aortic aneurysms, i.e. threatening enlargements of the aorta. Five in 100 men over the age of 65 have this condition, which needs urgent monitoring if diagnosed in a timely manner. Immediate treatment is required in 1 in 100 patients. Active and previous smokers are particularly at risk.

Hereditary predispositions can also be the reason for diseases of the main artery. As with Carola Zschocke, who suffers from Marfan Syndrome. Only one to two people in 10,000 show this genetic weakness of the connective tissue, which is why it is one of the rare diseases. Among other things, dangerous dilatation of the blood vessels often occurs. The main artery is particularly affected. This explains the aneurysm in the patient from Schönbrunn at the end of 2018. "I felt sick at work and then vomited blood," she said.

Colleagues took her to a nearby clinic. After that everything happened very quickly. In a joint emergency operation, the specialists in vascular and visceral surgery at the Dresden University Hospital first replaced the torn thoracic artery and at the same time removed part of the esophagus that was also affected. This and the follow-up surgery with replacement of the entire abdominal artery including all organ and pelvic arteries in March 2019 had to be carried out by the doctors on the open body using a type of heart-lung machine called ECMO in order to ensure blood flow to the organ and leg arteries during the operation can. ECMO stands for "Extracorporeal Membrane Oxygenation" - a mechanical lung and circulatory replacement procedure in which the patient's blood is taken, the carbon dioxide is extracted from outside the body and enriched with oxygen and returned to the body for blood circulation.

The area for vascular and endovascular surgery at the Dresden University Hospital relies on a broad spectrum of expertise. As in only a few locations, both the most complicated aortic operations using a minimally invasive catheter method, as well as the open maximum therapy of aortic diseases, as well as operations using mechanical circulatory and lung support can be routinely offered. After careful consideration of the risks, the latter can be particularly beneficial for younger patients with diseases of the entire main artery and are the method of choice for patients with connective tissue diseases and infections with extensive replacement. For younger people, the good surgical and long-term results that the doctors rely on speak in favor of an open operation of the entire main artery.

"This maximum therapy requires special and deep knowledge and skills and a strong interdisciplinary team, which is why it is only offered in a few centers in Germany," said Prof. Michael Albrecht, Medical Director of the Dresden University Hospital: "We are proud to be the maximum care provider in the region to be able to carry out these complicated interventions. " This also includes endovascular operations, which are particularly chosen for older and sicker patients. Here, in one of the two state-of-the-art hybrid angiography operating theaters at the Surgical Center, stent prosthesis tubes are inserted into the inguinal arteries in a minimally invasive manner through small punctures in order to stabilize the aorta, secure organ arteries and stop the flow to the aneurysm.

The doctors do not have to open the abdominal cavity, which is why this procedure is gentler and less physically stressful and is therefore suitable for patients of old age. "The surgical center of the university hospital in buildings 32 and 59 offers us all optimal conditions for the often difficult operations," said Prof. Jürgen Weitz, director of the clinic for visceral, thoracic and vascular surgery: "Especially thanks to the close and therefore uncomplicated cooperation Vascular, thoracic and abdominal surgeons in a clinic can successfully treat even the most complex surgical clinical pictures, which often require seamless cooperation between all specialists. "

This is also the case with Carola Zschocke. She has been operated on several times by visceral, thoracic and vascular surgeons since the aortic rupture in the thoracic artery and the fistula on the esophagus. Last November, her esophagus was restored using a gastric pull-up. She also received an artificial, mechanical heart valve - this was also necessary due to the sequelae of Marfan's syndrome. The patient regularly comes to the university hospital for follow-up care.

"I'm fine so far," said the now 37-year-old mother of two. She can move around well on her property in Schönbrunn. Now that the worst is over, it is important to put on weight, improve cardiac output and generally regain strength. She still suffers from a feeling of weakness, especially after eating. The patient will continue to be looked after closely at the Dresden University Hospital with her questions and medical problems.

Treat aneurysms easier with visual representation?


Aneurysms are very dangerous because they can burst. The resulting internal bleeding can have serious consequences or even be fatal, especially in sensitive areas, for example in the brain. Dr. Monique Meuschke from the Friedrich Schiller University developed a form of visual representation in her dissertation that depicts the risk of a single aneurysm. The Jena computer scientist was awarded the Reichart Prize 2020 for this visualization method.

In everyday clinical practice, aneurysms are often only discovered by chance - for example, when imaging procedures such as magnetic resonance imaging (MRI) are used for unclear symptoms. But not all aneurysms have to be treated, says Meuschke, explaining the starting point for her dissertation. "Doctors have to assess how high the risk of an aneurysm is and decide whether treatment is necessary at all. This decision should be made easier with the help of a visualization."

Together with Prof. Dr. Kai Lawonn, who holds the professorship for Visualization and Exploratory Data Analysis at the University of Jena, and his team used a three-part process to create a visualization that shows the risk of an aneurysm bursting using combined data. In a first step, a three-dimensional model of the brain and the course of the vessels is created on the basis of MRI images. Using additional data from the MRT examination, Meuschke can use mathematical models to visualize the blood flow in the vessels in lines. At the same time, it calculates which forces act on the respective vessel walls, for example due to turbulence in the blood flow within an aneurysm. The data from the 3D modeling and the blood flow are then linked and combined provide information about the likelihood of a rupture or a change in the blood vessels. "The result of the visualization enables doctors to better assess the risk of an aneurysm," says Meuschke. "In this way, the number of treatments could be limited to high-risk patients."

Meuschke's visualization has so far been a pure research prototype. Nevertheless, it is already being tested and evaluated by medical partners such as the Jena University Hospital and the Herz-Jesu-Krankenhaus Dernbach. "The work of Monique Meuschke is very important in medical visualization," says Prof. Dr. Kai Lawonn. "They also show visualization researchers from other areas how the comprehensive and creative visualization techniques can be applied to other research questions."

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