Surgical Innovations

Aortic Aneurysm Surgery Preserves Patients' Valves

Allan Stewart, MD, Director, Aortic Surgery Program

Until recently, procedures to repair aneurysms located at the root of the aorta have typically required that surgeons replace both the aortic valve and the diseased section of the blood vessel. Afterwards, patients who received a mechanical aortic valve would have to take coumadin (a blood thinner) for the rest of their lives, and those who received a tissue valve faced the likelihood of repeat surgery to replace the deteriorating valve within the next ten years. But today, surgeons are finding creative ways to preserve and rebuild the patient's own aortic valve instead, avoiding both of these significant disadvantages.

"The traditional operation involves removal of both the valve and the ascending aorta, and replacement with either a mechanical or commercially available tissue valve," says Allan S. Stewart, MD, Director of the Aortic Surgery Program at NewYork-Presbyterian Hospital/Columbia University Medical Center. "But a significant number of patients have a normal aortic valve – only their surrounding tissue is abnormal. In these cases, we can remove the entire defective aorta, replace it with a Dacron graft, and rebuild the aortic valve."

CREDIT: Nancy Heim

Specializing in high-risk cases, Dr. Stewart thrives on being creative in the operating room. "It takes longer to do this operation than to replace the valve, and it's somewhat of an art form," he says. "But this procedure (called the 'David procedure' after the Canadian physician who developed it) frees patients from surgery for at least ten years, and it spares them from having to take coumadin. "He notes that the David procedure is particularly appropriate for young patients, for patients with Marfan's syndrome and other connective tissue disorders, and patients with aortic insufficiency, especially those with bicuspid aortic valves.

Since its inception in 1996, 93% of patients who underwent the David procedure remain free from symptoms. At NewYork-Presbyterian Hospital/Columbia, results have been "excellent" among the 50-plus cases performed since 2005, with 100% short-term success.

None of Dr. Stewart's patients has suffered a stroke after undergoing the David procedure. "Usually about 5-10% of patients undergoing this surgery have neurologic problems, so this is a significant step forward." Columbia is one of only a few centers in the nation with extensive experience using this technique.

Dr. Stewart has also devised novel strategies to improve the treatment of aneurysms located higher in the aortic arch. In most cases, operations to repair such aneurysms have required that patients have two major open surgeries to accomplish repairs in separate stages. To make treatment less traumatic and less invasive, Dr. Stewart is increasingly employing an alternative that limits treatment to one procedure rather than the two operations that are standard elsewhere. To do this, he replaces the aortic arch during an open procedure, then completes the repair with a stent graft, placed under direct vision. This hybrid operation allows for a complete repair in one sitting so that patients do not have to undergo a second major open-chest procedure later.

In some cases, he and collaborating physician William A. Gray, MD, Director of Endovascular Services, Center for Interventional Vascular Therapy, can even access aortic dissections through catheters placed in small incisions in the groin instead of having to perform open-chest surgery. "More and more, we are able to repair aneurysms with stents that are inserted through catheters instead of through surgical incisions. More options are available with physicians working together, "Dr. Stewart explains.

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