St. Michael's Hospital

Foundation

Raising the Flag: A Groundbreaking procedure at St. Michael's is a Toronto first!

This summer John Laine should have died. He was diagnosed with a large aneurysm (dilatation) involving the thoracic and abdominal portions of his aorta. Left untreated, these aneurysms can rupture and be fatal. In John's case, the option of cutting him open from stem to stern to repair his potentially fatal aneurysm of both the chest and the abdomen was too risky to undertake. In August, St. Michael's Hospital's team of vascular surgeons, radiologists and anesthesiologists became the first in Toronto to repair an aneurysm that also affected major arteries that supply blood to the liver, spleen, pancreas intestines and kidneys. To accomplish this, a relatively new procedure known as Endovascular Aneurysm Repair (EVAR) was performed using a unique graft called a "Fenestrated Large Aneurysm Graft" (FLAG), in which small holes in the graft (fenestrations) are precisely aligned with the takeoff of the major arteries. This allows the graft to repair the aneurysm, yet not interrupt the flow through the major vessels. It was a first for the city's medical profession and it meant that John Laine's summer days weren't his last.

"This is absolutely the most patient-centered form of treatment I can imagine," says vascular surgeon Dr. Alan Lossing about the breakthrough surgical procedure. "I am pretty excited about it and I know John (Laine) knows how lucky he is."

Luck is in the Planning

But luck seems to have little to do with it. Instead, it took four months of preparation before Lossing, along with the director of medical imaging at St. Michael's Hospital Dr. Andrew Common and colleague Dr. Cherrie Abraham from Montreal, could perform this procedure that involved a large aneurysm involving the thoracic and abdominal aorta.

During the procedure, surgeons created small incisions in the skin at the groin area where a guide-wire was threaded to the aneurysm. Using X-ray images, a long plastic tube carrying an Australian-made stent graft (a fabric tube with metal attachments) custom made to fit John's artery was inserted over the guide-wire and directed to the site of the aneurysm. Here, the tube was removed, the graft opened and anchored within the aneurysm to several major arteries to redirect blood flow and alleviate pressure on the weak aortic wall.

In the past, Dr. Lossing and Dr. Common have performed many EVAR procedures involving only the abdominal aorta. EVAR has been shown to lower mortality rates, result in less pain and fewer complications than open surgical repair in patients with aneurysms. But the tricky part of this procedure was the need to combine EVAR procedure with the use of FLAG, so that blood flow would continue through the side holes to go via the major arteries to the organs. Together the surgeons and radiologists spent hours using radiographic control to precisely align the holes in the graft with the opening of the arteries. Misalignment by even a few millimeters could result in total failure. In the end, the alignment was perfect and the procedure stunningly successful.

Endovascular Aneurysm Repair (EVAR) with FLAG only way to go in this patient

"I consider myself lucky to have had the chance at a full recovery thanks to medical advancement and the skill of Dr. Lossing," Laine said. "Overall, my recovery has gone well and if others can reap the benefits of the new procedure, why not. It's less invasive, requires less recovery time and frees up valuable hospital time. It's a no-brainer."

Dr. Lossing predicts that new procedures like EVAR will become commonplace in 10-15 years and that traditional surgery will be a thing of a past. Fewer and fewer patients will need to be opened up to repair aneurysms.

"I tell my residents that they aren't in the business of surgery, they are in the business of blood flow and whatever manages the blood flow most effectively and efficiently is what it's all about," says Lossing. "Who knows, maybe one day I will have a scalpel in my office simply as a souvenir of times past."