The University of Washington is participating in clinical trials of new devices that allow treatment of aneurysm disease with much smaller operations. Treatment is provided mainly at the new endovascular suite at the VA hospital , but all patients, veteran and non veteran, are eligible for care. This web page will tell you about aneurysm disease and its treatment, describe the University program, and explain how to learn more about us.

An aneurysm is a weakening of an artery that causes it to expand, like an over-inflated balloon. The danger is that it will break (rupture) causing internal bleeding. The most common location of aneurysms is the aorta, which is the main artery carrying blood from the heart to the body. Most develop in the abdomen just below the level where the aorta gives off branches to the kidneys (right below the rib cage) and just above where it divides into the two arteries (iliacs) that go to the legs and pelvis (the level of the belly button).

Aneurysms can also form in other parts of the aorta (in the chest, for example) and in other arteries, such as the iliacs. It is fortunate that these are less common since they are more difficult to fix. About 5 percent of men over the age of 65 are affected. The condition is much more common in those who have artery disease elsewhere (heart, carotids, legs) and in association with high blood pressure, a family history of aneurysms, and smoking.

The image at the top of this page is a 3-D reconstruction from the CT scan of a patient with an abdominal aortic aneurysm (image courtesy of MEDICAL MEDIA SYSTEMS, a division of Interact Medical Technologies Corp.). The arteries are in shown in red. One of the black-and-white CT images used for the reconstruction is also displayed. The aneurysm is the bulging area and is below the origin of the arteries to the kidneys. Below the aneurysm, the aorta divides into the two iliac arteries that supply the legs with blood.

Aneurysms rarely cause symptoms before they rupture. Unfortunately, rupture causes death in the majority of cases. At first the bleeding may be contained by the tissues surrounding the aorta in the back of the abdomen. The patient experiences the sudden onset of abdominal pain and faints due to low blood pressure, but may be easily revived by intravenous fluids. It may not be long, however, until the bleeding breaks into the surrounding abdominal cavity, causing rapid loss of blood from the circulation and death within minutes.

Most patients with ruptured aneurysm in the Seattle area are revived in the home by Medic One and then transported rapidly to the regional trauma center, Harborview Medical Center, which is staffed by University of Washington attending physicians and residents. Patients who arrive in the emergency room at Harborview with a measurable blood pressure have a contained rupture and a 50 percent chance of survival. In contrast, only 10 percent of those in shock (no obtainable blood pressure) survive. Speed is of the essence. Patients can be in the operating room within 10 minutes of arrival at Harborview, where a completely staffed operating room is always on standby.

Aneurysms can be felt on physical examination if the patient is not obese. The best test is an abdominal ultrasound, which is safe, harmless, non-invasive, and accurate. It uses sonar imaging of the abdomen (the same technique u sed to check the fetus in pregnancy). Because the disorder is partially inherited and is much more common in men than women, it is suggested that first-degree relatives of aneurysm patients (sons, and brothers) have an abdominal ultrasound at age 55 unless they are so thin that physical examination of the aorta is reliable.

When Einstein's aneurysm ruptured there was little that could be done except to wrap it with cellophane in the hope that the inflammation and scarring that resulted would prevent exsanguinating hemorrhage. Unfortunately, Einstein, like Lucille Ball and Conway Twitty, eventually died from bleeding of his aneurysm. (Roy Rogers survived his rupture.)

In the early 1950's Drs. Dubost, DeBakey, and Cooley developed an operation to replace the diseased segment of aorta with a tube made of Dacron. This method is extremely effective at preventing rupture. It requires a major operation, but modern surgery and anesthesia allows it to be done safely, with zero to two- percent mortality in otherwise fit patients. Most clinicians agree that aneurysms that are more than five centimeters wide should be repaired in patients who are otherwise heal thy (the normal aorta is about two centimeters, or just under an inch wide). Smaller aneurysms should be followed regularly with ultrasound to monitor widening, which tends to occur at a rate of 4 to 5 millimeters (half a centimeter) a year.

Over the past several years an exciting new approach has been developed, called endovascular therapy. Instead of opening the abdomen and sewing in a replacement part, the new graft is folded into a tube, or catheter, inserted in to a leg artery, and threaded to the diseased location under fluoroscopic guidance. Once positioned properly, the graft is released. Metal stents attached to the graft cause it to expand against the inside wall of the aorta above and below the aneurysm, effectively excluding the diseased segment from the circulation and thereby preventing its rupture.

Because this procedure does not involve opening the abdominal cavity or clamping the aorta while it is being repaired, there is considerably less patient discomfort and much more rapid recovery. Patients who are poor candidates for the standard operation due to heart or lung disease may be able to undergo this less strenuous procedure. This new method may do for aneurysm surgery what laparoscopic surgery did for gallbladder operations, greatly reducing the magnitude of the operation, the associated risk and discomfort, and the length of hospital stay.

The main disadvantage of endovascular therapy is the fact that it is new. Several centers have been using this technique for many years, but the devices and their delivery systems have undergone many changes during this time. In contrast, conventional treatment has changed little over the last forty years and works well in the majority of cases. It is not known if devices that are placed inside the artery, pushing against the inner wall will be secure over many years. It is possible that they could detach from the artery, causing a kink in the graft or a leak into the aneurysm cavity, or could erode through the vessel wall causing a leak into the surrounding tissue. For this reason patients who have this procedure must have special x-ray studies (computerized tomography, or CT scans) on a regular basis to ensure that leaks do not occur. Further treatment with additional endovascular grafts can be used to treat some of these leaks. Other complications are possible, as with any manipulation of diseased arteries, including tearing of an artery when the device is passed through the leg vessels or blockage of an artery due to damage caused by the catheter. Some patients will require conversion from the endovascular method to a standard operation if complications arise.

The University of Washington is participating in a number of trials of new endovascular devices. Patients qualify if their arteries will allow passage of the device and if there is an adequate length of relatively normal aorta below the kidney arteries to allow secure attachment to the vessel wall. To determine this, patients need to undergo a special form of CT scan that allows three-dimensional views of the arteries and exact measurements of their dimensions. Our team is happy to discuss this therapy with interested physicians and patients. We can be reached via e-mail (kohler@u.washington.edu,glickerman@seattle.va.gov) or through the following numbers:

More about the UW endovascular program: http:/weber.u.washington.edu/~kohler