Heart & Vascular

Two-Stage Repair for Complex Abdominal Aortic Aneurysm

Cardiovascular Report
November 1, 2013

Ying-Wei Lum says aneurysms are being discovered more frequently because of CT imaging for other health problems.

Paul Edwards, 74, knew he had a hernia, but he put off seeking treatment for two months until one day last spring when he experienced excruciating abdominal pain. His primary care doctor sent him to the Johns Hopkins Hospital Emergency Department. There, a CT scan was performed to detect possible complications from the hernia, such as a bowel infarction. Instead, the scan revealed a silent 5.3 cm aneurysm on his right common iliac artery.

“I was surprised with the news,” says Edwards. “I didn’t know how serious it was until they explained the risk of rupture from the aneurysm.” 

Edwards was admitted and met with general surgeonMatt Weiss and vascular surgeon Ying-Wei Lum. They developed a strategy for repairing both the hernia, which was on his left side, and the aneurysm on the right.

“His case was a bit unusual,” says Lum. “While he clearly had an aneurysm on his right common iliac artery, his abdominal aorta and his left common iliac artery were also enlarged.”

Lum was concerned that if he had repaired just the aneurysm on Edwards’ right common iliac artery with a single stent graft, there could be a potential for leakage near the aortic side because it was also enlarged there.

“Given that challenge, and the presence of other abnormalities on his aorta and contralateral iliac artery, I decided to recommend a full endovascular repair of the abdominal aorta and both iliac arteries, all at the same time for the most durable repair,” says Lum.

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Lum and Weiss decided that Edwards should have his hernia repaired first. Two days after that operation, Lum began part one of a two-stage repair of Edwards’ vasculature. Through a small puncture hole in Edwards’ left groin, Lum embolized the right internal iliac artery using endovascular coils in order to prevent any backflow of the right internal iliac artery into the right common iliac artery aneurysm. Three days later, he performed an endovascular repair of Edwards’ abdominal aorta and both iliac arteries.

“I never had any discomfort from the aneurysm,” says Edwards, a former corporate communications executive who also was a reporter at The Washington Post earlier in his career. “It was the shooting pains from the hernia that made me seek treatment. I’m fortunate that the aneurysm was discovered.”

 Lum says not all patients or physicians are aware that abdominal aortic aneurysm ultrasound screening is covered by Medicare Part B for certain high-risk patients age 65 to 75. Those eligible for the one-time screening are those with a family history and men who are former smokers.

“It’s something to keep in mind,” Lum says, “because some people aren’t as fortunate as Mr. Edwards to have an aneurysm detected before it ruptures.”