Putting It All Together
The MUSC Health Aortic Center offers cutting-edge therapies and comprehensive care for complex aortic disease
by Lindy Keane Carter
As the body’s main artery, the aorta is under a lot of pressure. Ideally, its walls will remain elastic enough to withstand millions of heart beats, but aging or disease can degrade the aorta to the point of bulging or tearing. For decades, MUSC Health surgeons have repaired aortic aneurysms, dissections, damage from trauma, and abnormalities, as well as improved aortic health in general. With the arrival of new therapies and expertise for treating particularly complex aortic pathology, MUSC Health has formalized these services into a new program called the MUSC Health Aortic Center. The Center offers the full spectrum of aortic care, from medical management of disease to cutting-edge procedures to research and clinical trials that advance breakthrough therapies. Specialists in Vascular Surgery, Cardiothoracic Surgery, Cardiology, Interventional Radiology, and Genetics work together to create integrated treatment plans, perform procedures, and track outcomes.
“The MUSC Health Aortic Center is unique in using a multi-specialty collaborative approach to provide the highest level of patient-centered care by combining innovative techniques with cutting-edge technologies,” says Joshua D. Adams, M.D., Head of Endovascular Surgery and Surgical Director of the Aortic Center.
The foundation of the Aortic Center team was laid when Renan Uflacker, M.D., then-Director of the Division of Vascular and Interventional Radiology, and Jay Robison, M.D., Chief of the Division of Vascular Surgery, performed the first endovascular aortic repair (EVAR) in South Carolina in 1996, only six years after the procedure was first described. They collaborated on several clinical trials using this new technology that is now widely accepted. John S. Ikonomidis, M.D., Ph.D. arrived in 2000 and began developing an open thoracic aortic program. As the technology progressed, Ikonomidis incorporated the minimally invasive technique of thoracic endovascular aortic repair (TEVAR) into the program. He and Uflacker performed the first TEVAR procedure in South Carolina in 2000. In 2006, Robison, Uflacker, and Claudio Schonholz, M.D., Professor of Radiology and Surgery and Assistant Director of Radiology for the Aortic Center (and one of the pioneers in endovascular aneurysm repair), reported South Carolina’s first physician-modified abdominal aortic graft to include a visceral artery, further advancing successful complex aortic endovascular procedures.
Interventional radiology (IR) continued to play an increasingly important role, as the IR team’s advanced imaging modalities, such as three-dimensional computed tomography (CT), ultrasound, magnetic resonance imaging (MRI), and intraoperative fluoroscopic imaging, provided clear images to guide the microscopic instruments. With the arrival in 2004 of Schonholz and Marcelo Guimaraes, M.D., Associate Professor of Radiology, a cohesive interdisciplinary team was formed.
“We have a combination of things that makes this place unique,” says Schonholz. “First, MUSC has been a pioneer for these types of procedures. Second, we have senior people with a lot of experience as well as the young, newly trained surgeons such as Dr. Adams,” he says. Additionally, he points out that MUSC Health can offer new devices and therapies that are not widely available, as industry invites the Aortic Center to help validate those therapies.
Thomas M. Todoran, M.D., Assistant Professor of Medicine, Director of Vascular Medicine, and Medical Director of the Aortic Center, joined the team in 2010. Fellowship-trained in cardiovascular disease, interventional cardiology, and vascular and endovascular medicine, Todoran brings a unique understanding of endovascular therapies as well as preoperative cardiovascular assessment and cardiovascular risk reduction.
“Aortic pathology is often one facet of a larger illness. Optimal care requires a global perspective of the patient’s overall condition,” he says. “Treatment of such complex patients ideally involves a comprehensive, multidisciplinary approach with all specialties working together to achieve the best outcomes. This is not a common practice at many institutions, but MUSC Health has made it a priority.”
Adams arrived in 2013. Fellowship-trained in vascular interventional radiology and vascular surgery, he is uniquely skilled to provide a customized plan based on the patient’s anatomy, aortic pathology, and associated clinical conditions. The plan may include either endovascular therapy alone or, in some cases, a hybrid approach that allows him to optimally address the most complex conditions, such as extension of an aneurysm into an internal iliac artery or complex aneurysmal involvement of the juxtarenal, perivisceral, thoracoadbominal, and thoracic aorta, including aortic dissections. These procedures include deployment of branched and fenestrated
“When a patient’s aneurysm involves a portion of the aorta that includes the origins of important arteries such as the celiac, superior mesenteric, and the renal arteries, branched and fenestrated endovascular aortic repair provides a way to stabilize that area,” says Adams. These fenestrations (or openings) in the endograft are aligned with the target arteries under X-ray guidance, allowing the endograft to obtain proximal seal in a segment of the aorta that is often healthier. Wires and catheters are then used to navigate through the fenestration and into the artery. A covered stent is used to seal the connection between the fenestration and the artery. This maintains patency of the target arteries at the same time that flow is excluded from the aneurysm. Since there are no large incisions and no cross-clamping of the aorta, this endovascular approach to these complex cases can help avoid many of the problems sometimes encountered with open surgery.
Adams and the team of specialists at the MUSC Health Aortic Center have the most experience with managing such complex aortic problems in South Carolina. The number of fenestrated or branched EVARs they performed from July 2014 to June 2015 has ranked MUSC Health twelfth in the nation for number of those procedures, according to the University Healthsystem Consortium.
One such case involved an 81-year-old man who developed a juxtarenal aortic aneurysm years after surgery to repair an abdominal aortic aneurysm. He had been told by numerous surgeons that nothing could be done since he was not healthy enough to undergo an open aortic aneurysm repair. The patient underwent a successful fenestrated EVAR and went home the next day.
In collaboration with Ikonomidis and other members of the aortic team, Adams is also performing more advanced TEVAR. He cites the case of a 44-year-old patient who was transferred to the MUSC Health Aortic Center with an acute thoracic aortic dissection. It started at the left subclavian artery and went through the descending thoracic aorta into the visceral aorta, which caused significant narrowing of the true lumen and compromised flow to the visceral arteries and the legs. The Aortic Center’s specialists deployed a covered stent graft in the proximal descending thoracic aorta over the area where blood was going out of the true lumen and into the false lumen, blocking this blood flow and restoring flow distally.
Next on the horizon, Adams says, will be using even more advanced branched and fenestrated endograft technology in the ascending aorta and aortic arch. Open surgery has been the traditional approach to repairing disease in these segments of the thoracic aorta, a challenging part of the anatomy because of the curvature and blood flow dynamics. With the arrival of newer, more conformable devices and a more precise delivery system, the endovascular approach will be possible, which will be especially beneficial for patients at high risk for surgery.
In addition, Ikonomidis and the Aortic Center team have developed treatment algorithms for the triage and management of urgent cases, and they are putting together plans for an acute aortic emergency hot line to connect South Carolina ER physicians and cardiologists with the appropriate specialist at MUSC Health.
The Aortic Center physicians are supported by a team of other skilled professionals, including experts from Cardiovascular Anesthesia services, Genetics, Rheumatology, and Infectious Disease and a nurse practitioner, Karen D. Doll, MSN, ANP-BC, CVNP-BC dedicated to coordinating care for each patient.
Ongoing clinical trials at the Aortic Center offer innovative, investigational devices and medications that are not yet available as standard of care. Adams is the principal investigator for two trials that are establishing safety in branched iliac devices and for another trial evaluating cost savings and safety of performing EVAR percutaneously in the IR suite instead of an operating room. A fourth trial is expected to begin in the near future that will evaluate a conformable abdominal aortic aneurysm stent graft to be used in patients with angulated proximal necks. Ikonomidis is the principal investigator for a trial that is evaluating novel factors for hemostasis.
At the same time, the Cardiothoracic Surgery Research Laboratory, led by Ikonomidis, is pursuing basic science research in aortic aneurysm development. Jean Marie Ruddy, M.D., who won several research awards while a resident in the Ikonomidis lab, has recently joined the faculty, and is investigating biomarkers and treatment strategies that could be used to screen patients, predict the presence of disease, follow the progression of disease without CT or MRI scans, and track therapy outcomes.
The MUSC Health Aortic Center combines all of these distinctions into a comprehensive program that offers the full spectrum of aortic care to patients from all over the Southeast. For more information, go to MUSChealth.org/heart/services/aorta/.
The Aortic Center Team