Each year, more than 200,000 U.S. adults are diagnosed with an abdominal aortic aneurysm (AAA). The condition is a weakening of a major blood vessel in the abdomen that supplies blood to the kidneys and lower extremities. The blood vessel balloons out and, if left untreated, can rupture and cause hemorrhaging and death.
AAAs are the 10th leading cause of death in men age 55 and older, and 15% to 25% of patients have a parent with the same type of aneurysm.
With early detection, AAAs can be treated successfully with surgery. Skilled physicians can detect larger aneurysms by palpitation – pressing on the abdomen to feel for pulsating bulges.
That was the case for my patient, Charlie Hazzard, a 76-year-old retired executive for OxyChem who continues to teach at the UT Dallas Naveen Jindal School of Management.
In late 2019, Charlie’s primary care doctor, UT Southwestern's Steven Leach, M.D., noticed a lump in Charlie's abdomen and sent him for an ultrasound. He was diagnosed with an AAA and, sure enough, it was an AAA in a complex location – close to Charlie's renal arteries, which branch off to supply the kidneys with blood.
Though most centers recommend open surgery for complex AAAs that extend into the kidney vessel or beyond, we offer a minimally invasive procedure called fenestrated endovascular aortic repair (FEVAR). Using advanced custom stent grafts – flexible devices that support the aorta and keep blood flowing to essential organs – we can repair complex AAAs with just one small incision in the underarm and a couple of needlesticks in the groin.
UT Southwestern is one of just 10 sites in the U.S., and the only one in North Texas, with access to these advanced stent grafts through an investigational device exemption (IDE) by the U.S. Food and Drug Administration. Although the most basic advanced fenestrated stent grafts are approved for commercial use, the most sophisticated advanced ones are only available through physician-sponsored IDEs.
Here at UT Southwestern, we perform two to four FEVAR procedures a week. The risk of death during open surgery is anywhere from 5% to 20% – with FEVAR, it’s less than 1%. And, because we open neither the chest nor the abdomen, patients typically recover faster with less pain and next to no visible scarring.
A year later, Charlie says he feels like "one of the luckiest guys in the world" – first because Dr. Leach found the AAA before it was at risk for rupturing and, secondly, because he referred Charlie to the Advanced Aortic Endovascular Program at UT Southwestern, where he had access to an innovative procedure offered at few other places.
About the FEVAR procedure
We design custom stent-grafts like Charlie's by creating a blueprint of the patient's aorta from CT imaging. Then we use a 3D printer to make a 3D prototype that is used to design a graft plan, which we send to Cook Medical Inc, the device manufacturer in Australia. Designing the devices ourselves means less production time so patients may be able to get their surgeries within a month of ordering, rather than six to eight weeks.
To place the device, we make a few small needle sticks in the groin to access the femoral artery, the main blood vessel there. Then we make a one-inch incision below the armpit to access another blood vessel. Between these insertion points, we thread small tubes called catheters to the aorta.
Using a fusion of X-ray, ultrasound, and CT scan images, we move the collapsed stent-graft device and surgical tools into place through the tubes. These multiple layers of imaging give us clearer guidance with 80% less radiation than traditional imaging.
Each device is built with preloaded guidewire technology, some of which have been designed by our team at UT Southwestern, which allows us to more accurately and deftly position the device.
Once the stent graft is in position, we slowly expand it, guiding the fenestrations – the arms of the device that support the bowel, liver and renal arteries – into place to repair the aneurysm. Then, we remove the catheter and tools and close the underarm incision and groin need access site.
Advanced FEVAR procedures typically lasts four to six hours. Risks are low but can include bruising and hematoma in the groin or underarm insertion site, bleeding, or leaking around the device.
Patients typically recover in the intensive care unit for one or two days and go home within a week after the procedure.
We advise patients to avoid lifting anything heavier than 5 to 10 pounds for a month. We’ll do a CT scan at that time to see the integrity of the stent graph and the repair, or presence of leaks, component separation, or stent narrowing, after which patients should be able to resume normal activities without restrictions. Patients will need to return once a year for five years for a follow-up CT scan as required by our FDA exemption protocol and yearly thereafter for general surveillance purpose.
Charlie on his procedure, recovery:
"Leading up to surgery, I was scared," Charlie said. "I’m not a young man anymore and I didn’t know what to expect. My wife of 53 years, Carol, is a retired operating room nurse and asked all the questions.
Dr. Timaran could not have been more kind. He answered every question, walked us through the options, showed us models and diagrams, and never once appeared to be in a hurry. I can’t tell you how much that meant to us. We walked out of every meeting with him with confidence."
"Dr. Timaran's face was the first thing I saw when I woke up from surgery," Charlie said. "I remember it like it was yesterday. Dr. Timaran leaned in and said, 'You know, Charlie, you have perfect internal organs!'
“I still laugh thinking about that, and I love telling friends that story.
I couldn’t believe how good I felt afterward. I had very little pain, and I was able to go home just a few days after surgery. It took me a few weeks to get my stamina back, but less than a year later, I feel like I never had surgery.
I’m truly one of the luckiest guys in the world. I had a great doctor discover my aneurysm early, and Dr. Timaran treated me with a procedure offered at few other places. My ICU nurses were exceptional.
Thanks to all of my providers at UT Southwestern, I’m back to my normal life: reading lots of books, teaching exceptional students, and, best of all, enjoying time with my family."
Risk factors, symptoms, and the FEVAR option
Too often, abdominal aortic aneurysms are not found until they rupture. Some AAAs are found incidentally, such as when a patient has a CT scan or X-ray for an unrelated condition.
It’s important to know your family history and the risk factors, which include high blood pressure, high cholesterol, and smoking. Men are more at risk, suffering nearly 60% of deaths from aortic aneurysms in 2018, according to the Centers for Disease Control and Prevention. The U.S Preventive Services Task Force recommends that all men and women age 65 to 75 with a history of smoking – and some who have never smoked but have other risk factors – should get a one-time ultrasound screening for AAA.
AAAs generally cause no symptoms, though some patients report a pulsing sensation in the abdomen and/or throbbing, deep pain in the chest, lower back, groin, buttocks, or abdomen.
Small aneurysms may pose less threat of rupture and can be monitored over time. However, large AAAs are more concerning, and surgery is often recommended.
If your doctor recommends open surgery, ask whether FEVAR is an option for you. More than 90% of our patients with aortic aneurysms can have FEVAR, though, some with large or unusually located AAAs may require open surgery.
Our goal is to provide the most effective and least invasive treatment for patients with heart and vascular conditions. Above all, we want to help patients like Charlie safely and quickly return to their normal lives.