FEVAR procedure corrects dangerous weakening of main artery

Host Amber Smith: Upstate Medical University in Syracuse, New York, invites you to be The Informed Patient, with the podcast that features experts from Central New York's only academic medical center. I'm your host, Amber Smith.

A vascular surgeon who offers a unique and less invasive method of repairing abdominal aortic aneurysms has recently joined Upstate Medical University's department of surgery.

Dr. Wei Li is here to explain how this procedure works and which patients it may help the most.

Welcome to "The Informed Patient," Dr. Li.

Wei Li, MD: Thank you for that introduction, and as Amber said, my name's Wei Li, and I'm a new vascular surgeon, but also, this is my return to Syracuse. I used to be a surgical resident 18 years ago, and then I continued my training journey as well as my career, until now, I came back to Upstate and rejoined the university and the hospital.

Host Amber Smith: So, welcome back to Syracuse. Now, before we get into the details of this surgery, let's review what an abdominal aortic aneurysm is. Where is this located in the body?

Wei Li, MD: It's in the abdomen, located at the biggest artery in the body, which is called (the) aorta, and basically it's a dilatation (enlarging beyond normal size) of the aorta. The medical term's "aneurysmal change."

Basically, it's like a balloon enlargement of the blood vessel. And the bigger the balloon, the higher chance for the balloon to rupture, which represents a major risk for the patients who have those aneurysms. However, there are some other symptoms related to aneurysms, such as blood clots (that) can be dislodged from the inner surface of aneurysm (that) we call a mural thrombus and dislodges distally (to a distant body area) and occludes (blocks) patients' legs or bowels.

One of my patients in Texas, two years ago, he had an aneurysm discovered, but he had presented the ER (emergency room) with an occluded vessel in the leg. And later on we found out he had a big aneurysm in the belly.

Host Amber Smith: So, let me make sure I understand this. The aorta, the biggest artery in the body, that carries the blood, if there's a weakness, and it starts ballooning, there's risk with that, but there's also the risk that it can cause a blood clot that could travel and then cause other problems in other parts of the body.

Wei Li, MD: That's correct. Although the second scenario is much less frequent compared to the first one, but they do exist as well, so when the patient comes in with a cold limb, sometimes they do have a big, enlarged abdominal area in the body, although it's rare. But they do exist.

Host Amber Smith: So what are the symptoms? How would a person know that they have an aneurysm forming in their abdomen, and how much of an emergency is it?

Wei Li, MD: Unfortunately, most of the abdominal aneurysm patients, they did not know until the aneurysm ruptured or became symptomatic, just like the gentleman I mentioned. And at the current time, since the last 20 years, we have more awareness about the aneurysms. So we started to have surveillance with ultrasounds (tests using sound waves)..

One of the things we offer now in our practice is to use ultrasound to screen individuals who had a smoking history, who is older than 65 years old, and, also who may have family history, meaning other family members who had or have such aneurysms.

Host Amber Smith: So a person who's older, you said over 65, maybe someone whose family members have had aneurysms in the past or smoking history, those people might be at higher risk. And so you might do surveillance where you look and see sort of randomly whether they have an aneurysm, even though they don't have any symptoms.

Wei Li, MD: That's correct. Some people call it a silent killer because they present to the ER hypotensive (low blood pressure), abdominal pain, and then, on scan, ultrasound or CT (an imaging method), we found the ruptured aneurysm, and that's probably the first or the last time patient knows they have aneurysm if they, unfortunately, became a mortality.

Host Amber Smith: So, let's say you do discover an aneurysm ahead of time, before it's causing symptoms or problems. How is it traditionally dealt with? How do you treat it?

Wei Li, MD: We do not treat any until those aneurysms reach a certain size, for example, 5.5 or 6 centimeters in male patients. Traditionally, probably 20 years ago or 30 years ago, we treated those aneurysms with open surgeries, which were major surgery. To this day, we still offer those kinds of surgery, but most of the time we have the luxury to have minimally invasive modalities to treat those aneurysms through catheter wire (wire inside a small, hollow tube) and without big incisions on the belly.

Host Amber Smith: So tell me more about how this is done. If it avoids putting the patient under a major operation where they're cut wide open, you're able to do this with minimal invasiveness, right, with smaller incisions? How does that work in an aneurysm situation?

Wei Li, MD: Thanks to the new technology, we're able to go through small needle hole access from both groins and insert a device we call endovascular aortic graft, so those grafts can cover the aneurysms through the inside, so the aneurysm will not get enlarged, will not be pushed or pressed by blood pressures, and prevent rupture.

Host Amber Smith: Can you compare what the recovery is like and the success rate for an open abdominal aneurysm repair versus the more minimally invasive style of procedure?

Wei Li, MD: Oh, that's a huge difference compared to 30 years ago. So 30 years ago, we'd do open abdominal aneurysmal repair, patients, most of them, stayed in the hospital a week, and with severe disabled situations even after they were discharged. Now, most people, if we repair the aneurysm electively, most of the patients can get out of the hospital the next day.

Host Amber Smith: This is Upstate's "The Informed Patient" podcast. I'm your host, Amber Smith.

I'm talking with Dr. Wei Li. He's a surgeon at Upstate, and he offers a minimally invasive aneurysm repair that's an alternative to open surgery.

So, let's talk about which patients this procedure is best for.

Can anyone with an abdominal aortic aneurysm seek this less invasive option?

Wei Li, MD: Almost anyone, given the advancement of technology, because compared to 10, 20 years ago, now we have more graft availabilities and more types of maneuvers and devices available.

I would say probably more than 90% of patients who have the abdominal aortic aneurysm can benefit from such minimally basic technologies.

Host Amber Smith: Is there anything that would disqualify a person? Does the patient's size matter, or does the size of the aneurysm matter?

Wei Li, MD: In rare occasions, for example, patients have the very rare anatomies we call "short neck," or for example, they have no neck, we call "aneurysm neck." In that kind of situations, we may have to perform the traditionally open surgeries, but those situations are very rare.

Host Amber Smith: Now, the, short name for this is FEVAR, but that stands for something: F-E-V-A-R. What does that stand for?

Wei Li, MD: Fenestrated endovascular abdominal aortic repair is a little dense technology compared to regular EVAR (endovascular aneurysm repair), meaning we can treat the aneurysm with branch (a variation of the) technology, meaning if the neck is shorter than average, we can treat those with more advanced graft options. This technology is new, but it's not very new. I started to do this technology about 2013. The technology became available, approved by the FDA (Food and Drug Administration) in the United States in 2012.

Host Amber Smith: So I'm curious about how you instruct patients who are going to have this procedure.

How do you tell them to prepare for it? Are there tests or measurements that have to be done ahead of time?

Wei Li, MD: I think most of the test/preparation part is on the physician side, and for the patients, it's nothing specific. I think most of the time patients just show up at the hospital (on the) day of the surgery after some some blood work.

Host Amber Smith: How long does the procedure usually take?

Wei Li, MD: Normally a couple hours. And if we do fenestrated EVAR (FEVAR), it could be three, four hours. But if it's a regular EVAR, normally a couple hours.

Host Amber Smith: Is the patient awake during the procedure?

Wei Li, MD: Most of the patients are not awake. We do this under general anesthesia. Patients don't even know they've had the surgery, through the entire process.

Host Amber Smith: How long is the hospital stay afterward?

Wei Li, MD: Most of the time it's an overnight stay, and patients go home the next day.

Host Amber Smith: What are the types of complications that you're on the lookout for?

Wei Li, MD: Most common one we call "access related" because those abdominal aneurysm patients, most of them are smokers, so their blood vessels tend to be harder and with plaques, and sometimes the access could be very challenging.

And the more challenging the access, the higher chance of complications such as hematoma, meaning bleeding, or, sometimes, it can cause a second trip to the OR (operating room). The other thing is some chance of infection, but compared to open surgical repair, it's much less.

Host Amber Smith: How long is the graft meant to last?

Wei Li, MD: That was a good question 30 years ago. We started to do this kind of procedure since the 1990s. Those grafts last very, very long. The newer grafts are better, and the older genres of grafts tend to have some graft-related complications. They slide down, over time, but the newer ones tend to last much longer. And, given the patient population age of 60s-70s, probably, we expect the graft lasts for the rest of their life.

Host Amber Smith: I'm curious about what follow-up care is like. Does a patient who has undergone this procedure keep checking in with you, or do they go back to their primary care doctor?

Do they have to be followed closely?

Wei Li, MD: Since we have been doing this for 20-plus years, we have a set of protocols in terms how to follow up these patients. And most patients can be followed either by ultrasound or CAT scan, depending on the situation. They do need to return to the hospital, normally one week after surgery, to check their wounds, and in one month to check the graft, with either CAT scan or ultrasounds. Also with CAT scan with contrast (a special dye). And then depending on the situation, people come back in three- or six-month intervals or then yearly, every year.

Host Amber Smith: I'm guessing that you advise your patients to stop smoking if they are still smoking.

Does that make a difference in their recovery?

Wei Li, MD: It does. And the smoking is a big factor for any growth even, so for people who have a small aneurysm, the size is not indicated for repair if the patient stops smoking, their study suggested that smoking can accelerate the growth of aneurysms. And then for the patients stop smoking or smoking cessation is suggested for any individuals, with any vascular pathology.

Host Amber Smith: Well, Dr. Li, I appreciate you making time to tell us about this option. Thank you.

Wei Li, MD: Thank you.

Host Amber Smith: My guest has been Dr. Wei Li, a surgeon at Upstate specializing in vascular and endovascular surgery.

"The Informed Patient" is a podcast covering health, science and medicine, brought to you by Upstate Medical University in Syracuse, New York, and produced by Jim Howe. Find our archive of previous episodes at forthoodvaloan.com/informed.

This is your host, Amber Smith, thanking you for listening.