Aortic aneurysm: Improved outlook after surgery

Some elderly and sick patients benefit from a minimally invasive treatment of an aortic aneurysm. However, open aortic artery operations continue to be a good (and in cases the only sensible) alternative.

About 3% of adults older than 50 suffer from visceral aneurysms

Elderly and sick patients in particular, benefit from a minimally invasive treatment of pathological dilatations of the aorta - the aortic aneurysm. However, depending on age and clinical picture, open aortic artery operations continue to be a good (and in certain cases even the only sensible) alternative.

This is illustrated by the example of a female patient who is now 37 years old and who, due to a rare disease of the connective tissue, Marfan's syndrome, suffered a life-threatening tear of this vessel with further disease-related complications. After several operations, the mother of two has now recovered to such an extent that she is able to manage her everyday life again.

Aortic aneurysms can become an emergency

The fact that the patient, Carola Zschocke, is alive at all is almost a miracle. In November 2018 she was transfer by helicopter to the Dresden University Hospital (Germany) with a diagnosed tear in her aorta. At the same time, the esophagus of the then 35-year-old was affected: the aorta, which had widened by up to ten centimeters, had rubbed a hole in the organ and at the same time pressed on the heart. "Pathological dilatation of the aorta, so-called aortic aneurysms, pose a deadly threat. If they burst, it is a matter of minutes, otherwise the chances of survival are low and if the esophagus is also affected, the patient is in an even worse position," said Prof. Christian Reeps.

Five years ago, Prof. Reeps, an experienced vascular surgeon, moved to Dresden University Hospital and significantly expanded the department of vascular and endovascular surgery. Together with his team, the surgeon was able to successfully treat the young woman and has been providing her with medical support ever since. In the hospital's new surgical center - House 32 - experts can also rely on an excellent infrastructure including two hybrid operating theaters to treat patients like Carola Zschocke.

In total, about three percent of people over 50 years of age are diagnosed with abdominal aortic aneurysms, i.e. threatening a dilatation of the aorta. Five out of 100 men over the age of 65 suffer from this disease, which urgently needs to be monitored if diagnosed in time. One in a hundred patients requires immediate treatment. Active and former smokers are particularly at risk.

Hereditary cause of the aortic aneurysm

However, diseases of the aorta can also be caused by hereditary predispositions, like Carola Zschocke, who suffers from Marfan syndrome. Only one to two people in 10,000 show this genetically determined weakness of the connective tissue, which is why it classifies as one of the current rare diseases. Among other things, it often leads to dangerous dilatation of the blood vessels and the aorta is particularly affected. This explains the aneurysm suffered by Ms. Zschocke at the end of 2018. "I got sick at work, then I vomited blood," she said.

Colleagues took her to a nearby clinic. Afterwards everything happened very quickly. In a joint emergency operation, the specialists in vascular and visceral surgery at Dresden University Hospital first replaced the torn artery and at the same time removed part of the esophagus, which was also affected. This and the follow-up operation (that included a replacement of the complete abdominal aorta including all organ and pelvic arteries) in March 2019 had to be performed by the doctors in open surgery using a kind of heart-lung machine called ECMO in order to ensure the blood supply to the organ and leg arteries during the operation. ECMO stands for "extracorporeal membrane oxygenation" - a mechanical pulmonary and circulatory replacement procedure in which the patient's blood is taken, carbon dioxide is removed, it is enriched with oxygen, and returned to the body for circulation.

The Department of Vascular and Endovascular Surgery at Dresden University Hospital relies on a broad spectrum of expertise in this field. As at only a few locations, both the most complicated aortic operations can be offered here in a minimally invasive manner using catheter procedures, as well as the open maximum therapy of aortic diseases, and operations using mechanical circulation and lung support as a matter of routine. The latter, after appropriate risk assessment, can be advantageous especially for younger patients with diseases of the entire aorta and are the method of choice for patients with connective tissue diseases and infections with extensive replacement. For younger patients, the good surgical and long-term results on which the physicians rely speak in favour of open surgery of the entire aorta.

Special therapy requires deep knowledge and competence

"This 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 University Hospital Dresden: "We are proud to be able to perform these complicated interventions as a maximum care provider in the region". These include endovascular operations, which are particularly popular with older and sicker patients. Here, in one of the Surgical Center's two state-of-the-art angiography hybrid operations, stent prosthesis tubes are inserted minimally invasively via small punctures into the inguinal arteries to stabilize the aorta, secure organ arteries and stop the inflow to the aneurysm.

The physicians do not have to open the abdominal cavity in this procedure, which is why this procedure is gentler and less physically stressful and is therefore suitable for patients of advanced 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 through the close and thus uncomplicated cooperation of vascular, thoracic and abdominal surgeons in one clinic, even the most complex surgical clinical pictures, which often require a seamless cooperation of all specialists, can be successfully treated together”, he added.

Carola Zschocke is no exception. She has been operated on several times by visceral, thoracic and vascular surgeons since the rupture of the aorta in the thoracic artery and the fistula at the esophagus. Last November, the esophagus was restored by means of gastric traction. She also received an artificial, mechanical heart valve - this too was necessary due to the after-effects of Marfan's syndrome. The patient regularly comes to the University Hospital for follow-up care.

"I am doing well so far," says the now 37-year-old mother of two children. She can already move around well on her home in Schönbrunn, Germany. Now, after the worst is over, she needs to put on weight, improve cardiac performance and generally regain her strength. She is still suffering from weakness, especially after eating. The patient continues to receive close attention to her questions and medical problems at the University Hospital Dresden.