A 75 year old diabetic patient was admitted in our hospital 2 weeks back with severe breathlessness of sudden onset and chest pain radiating to back. Patient was in severe distress. So what we thought was a massive heart attack. Immediately ECG was taken to confirm the diagnosis. But ECG was normal. Next we did a Bedside Echocardiogram which showed no evidence of heart attack, but we saw some fluid around the heart. The Chest X-ray revealed a massive fluid collection outside the left lungs which caused significant deterioration in the lung function. One more finding we noticed was that in the X-ray the major vessel coming out from the heart ie: the Aorta was dilated. With this picture we considered possibility of rupture of the blood vessel with blood collecting out side the lungs. Then we did a CT Scan of the Chest to confirm our suspicion. The CT scan showed leaking Aorta with blood collecting outside the lung space.
The major problem here was where the leak was arising from. This was very close to the major blood vessels supplying the brain. The issue was how to tackle it whether surgically or alternative routes. His kidney function was also impaired. We contacted our cardiac surgeon and few others in the city as this condition was treated previously by surgery only. The option of surgery was discussed with the relatives and the high risk was explained. The relatives were not willing to take the high surgical risk. So then the option of STENT GRAFTING to the leaking aneurysm was given.
Even though Stent grafting is emerging as treatment of choice in aneurysm and dissection of major vessels only very few cases has been done on a leaking aneurysm. This is partly due to the fact that most patients with the condition never reaches the hospital or even if they reach they die before a definitive diagnosis is made and treatment is offered. The mortality rate is around 60 % in surgical management of leaking aneurysm while in stent grafting it’s around 40%.
The relatives agreed for this less invasive approach and the minimal mortality benefit it may provide. . The procedure was done successfully without comprising the blood supply to brain. His kidney functions normalized and the patient was discharged 3 days back and he walked back home.
Abnormal dilatation of the major vessels ( Aneurysm) occurs more frequently in the elderly population. As the population ages the occurrence of aneurysm also rises. In India especially in Kerala the senile population is going up because of the excellent health care in the state. In western world stent grafting is going up exponentially. In India its less than 100 stent grafting are done for unruptured aneurysms while for leaking aneurysms it is only 3 or 4 . We have no exact data on incidence or prevalence of aneurysm. In US population around 18% of patients with coronary artery disease have aneurysms because of compulsory screening of all patients above the age of 60 years. So if we extrapolate this to Indian population we should also have the same numbers or may be more. In US nearly 5000 stent graft procedures are done per year. Our coronary artery incidence is 16 times that of US. If we use the same data in Indian population we will need around 80,000 ( 5,000 x 16 ) stent grafts per year for aneurysms ! .Because of the economic situations of most patients ,neglect of the elderly , lack of awareness of this grave situation and the lack of availability of proper treatment ,most patients succumb to the illness.
The stent grafting is usually done by a team of Interventional Cardiologist or Interventional radiologist with the help of a Cardiovascular surgeon and a Cardiac anesthesiologist. The procedure is done under general anesthesia. The surgeon makes a nick in the groin and opens the major artery in the thigh. Through this vascular access a big cannula is put into the Aorta through which the stent graft is pushed up. After assessing the exact location of the aneurysm and the origin of other vessels the stent graft is placed very carefully covering the aneurysm but not blocking the origin of blood vessels supplying the major organs like ,brain , kidney and the gastrointestinal system.
Some complications that can occur with the procedure are paralysis, bleeding and impaired kidney function.
Stent graft consists of a metallic mesh made of NITINOL covered by a DACRON POLYESTER which prevents the leaking of blood. Nitinol is a Shape Memory alloy used for self expansion and is MRI compatible.
The procedure was done in our hospital ON 17TH December 2008 by a team of interventional cardiologists lead by Dr. PRATHAP KUMAR, Dr. JEYAKUMAR and Dr ISAAC MAMMEN with the help of Cardiac Surgeon Dr. MOHAN KRISHNAN and Cardiac anesthetist Dr. ASHOK JAYARAJ. |
