Emergent Aortic Aneurysm Surgery during COVID Pandemic
CVSA’s PA Thorn steps in to assist on ‘the Mother of all Surgeries’ during the the COVID-19 Pandemic
Throughout her life, Ms. Y (masked for confidentiality) terrifyingly believed she would die young. Now, the 43-year-old is optimistic about the coming decades after receiving a lifesaving open thoracoabdominal aortic aneurysm repair during the heart of the COVID-19 Pandemic.
At the root of her fear was an extensive history of female first- and second-degree maternal relatives dying from complications related to brain and aortic aneurysms. At the age of 9, Greene’s childhood was shaped by the loss her mother, age 36, due to a ruptured aneurysm.
“The year I turned 36, I didn’t do much of anything because I was convinced I was going to die,” she said. Finally, in late-2014, Ms. Y was diagnosed with Marfan Syndrome (aka “MFS”) - a connective tissue abnormality that can have significant issues on the cardiovascular system due to the weakening of the aortic tissue leading to potential ruptures and dissections. MFS is a very serious condition that requires close monitoring of both the ascending and descending aorta for signs of weakening and aneurysm formation. Ms. Y’s nightmare caught up with her in April-2020 when she felt a “searing, burning pain” in her back near the kidneys. She was later seen at a local emergency room where the physician-in-charge immediately noticed irregular pathology on a CT scan. She was immediately airlifted to a top-tier institution in Colorado on April-22 where physicians confirmed she suffered a tear, or dissection, in the inner layer of her aorta.
Dissections put aneurysms at greater risk of rupture due to the pressure build up that puts strain on already fragile aortic tissue. “The aorta is a huge vessel with multiple layers. Blood flow is supposed to be contained within the inner layer. When it tears, you get blood flow in between the layers, and that weakens the vessel”, said CVSA PA Janelle Thorn - one of our Clinical Surgical First Assist partners with extensive experience with large open aortic surgeries.
The COVID Complexity
Due to the COVID-19 Pandemic, all surgeries had been stopped to prevent the further spread of the virus and to protect Operating Room healthcare providers who would be at increased risk due to the inherent exposure to patients during open surgery. The surgeons monitored Ms. Y in the CVICU and she was placed in a special isolation room due to her deteriorating condition.
On April 24th, the lead surgeon, Dr. T in charge of Ms. Y’s care determined that the aneurysm was dangerously close to a full rupture (with the infrarenal aortic portion reaching 7cm). Dr. T quickly mobilized her team and realized she would need her very best if she had any chance of getting Ms. Y through the long and very high-risk thoracoabdominal aortic aneurysm repair. She called CVSA and indicated she would like PA Thorn to first-assist the case. Without hesitation, PA Thorn rushed to the Operating Room to begin the PPE protocols required for any surgeries during COVID.
“Of course in the back of your mind you worry about your own safety and that of your family, but I have always believed that you do whatever it takes to save a life. I hate to sound trite, but it’s why I do what I do. If someone needs lifesaving surgery, you’ll bet I’ll be there to fight for that patient. We all deserve people fighting for us - that is what I would want for my family members.”
Not only did Ms. Y have large aneurysms in her ascending and descending aorta, she had what is considered the most extensive variant - a Type II variant which spans from the upper chest deep into the abdomen.
“It’s one of the biggest operations you can have,” PA Thorn said. “We lay the patient on their side so we can work behind the heart and abdominal organs. The incision goes from the tip of the shoulder blade, around to the front of the body and down to the hip.” Thorn added that full open repairs are increasingly rare because stents, which can often be inserted through tiny incisions, are a minimally invasive solution. But because the Health geneticists said Ms. Y’s family history and underlying connective tissue disorder indicates she may have inherited a disorder that causes weak arterial tissue, stents were not an option because the devices can tear weak tissue.
Open surgery better ensured a lasting aortic repair for Ms. Y, but risked damage to her brain, spinal cord and vital organs. The operating team preventatively monitored blood profusion and electrical activity in the brain and spinal cord, and maintained blood pressure and blood flow to all vital organs. If changes had occurred, the team would have notified Dr. T and PA Thorn, so they could change their approach. An intraoperative neuro-physicist monitored Ms. Y’s brain function. An open repair of this type of aneurysm is “the Mother of All Surgeries” said PA Thorn, who has first-assisted on no fewer than 100 of these rare and challenging cases.
“This surgery is a really big day. My job is to faciliate the case and make sure Dr. T. can maintain absolute focus on the large operative field to ensure we can minimize time both on CPB, but also on DHCA,” Thorn said. “Are you a piano player? Do you have grandchildren to pick up? No one wants to come back from surgery not being themselves.”
The surgeons sewed a graft to the small portion of healthy aorta that remained in Ms. Y’s chest above the aneurysm, reinforced the device with felt and connected each branch to vital organs to the new graft. In all, eight reconnections were made to arteries from her chest down to the iliac arteries, located in the front of Ms. Y’s hips. In patients with normal aortic tissue, groups of vessels can sometimes be attached to the graft simultaneously, but Ms. Y’s weak tissue required the surgical team to painstakingly attach the vessels one by one, Thorn said.
“She’s not the only one of our patients going back to work after this type of surgery,” Thorn said. “I think that is from our technical choices and strong collaboration between vascular, cardiac, the intensive care unit and anesthesia that have given us some really good outcomes.”
Ms. Y had a remarkably fast recovery from surgery. “It saved my life,” she said. “I feel that as long as I keep up with my after care and checkups and keep my blood pressure under control, I will be fine.”
Dr. T said of her first-assist, PA Thorn:
“She’s my most trusted asset in these complex cases - she’s an extension of me. There’s no way to explain the value of a top-tier First Assist who knows your every move and can navigate even the most treacherous anatomy and do it with the level of precision required for a great outcome.”
