Minneapolis surgeon's unusual aortic procedure is saving lives

A Minneapolis vascular surgeon is one of the few doctors across the country to treat aortic aneurysms in the area between the navel and kidneys without surgery, providing a less invasive way to fix what can often be a silent killer.

"What this has done is open the door to people who were denied surgery in the past, so they can have much better results," said Dr. Jesse Manunga of Abbott Northwestern Hospital. "The idea was: 'What if we can take a graft and make it fit the patient?' "

An aortic aneurysm is a potentially deadly blood-filled bulge in the aorta, the main artery that carries blood from the heart to the rest of the body. If it bursts, it can kill a patient within seconds. Most patients don't know they have one until it is too late, although an ultrasound can spot it.

Repairing an aortic aneurysm used to mean risky surgery until about 20 years ago, when doctors began using stent grafts — tiny mesh tubes that are inserted with a catheter and allow blood to flow past the aneurysm. However, stent grafts have not been used on aneurysms in the area of the aorta near the kidneys, bowel, spleen or liver because the stent could block blood flow to those organs. For the 20 to 40 percent of patients with an aneurysm there, surgery was the only option.

And, for patients considered too ill for surgery, Manunga said, there was really no option at all. Doctors simply won't do the surgery and patients sometimes died.

But using a fenestrated stent graft that he designs, Manunga is helping patients who previously couldn't have stents or surgery. Armed with an array of detailed scans and meticulous measurements taken from each patient, Manunga and an Australian medical device company — Cook Medical — tailor stent grafts for each patient's unique anatomy. The company cuts precise holes in the stent to match Manunga's measurements.

It usually takes four to six weeks for Manunga to get the tailored stent graft back from Cook, but in more urgent cases, Manunga can make the alterations himself. Manunga, who learned his craft at the Mayo Clinic in Rochester, is the only one who does the procedure in the Twin Cities.

Over time, as the bulge grows, it can become weak and rupture. This can lead to severe pain, massive internal bleeding or even sudden death. Most patients with a ruptured aneurysm do not survive emergency treatment, making abdominal aortic aneurysm the third-leading cause of sudden death in men over 60. About one in every 250 people over age 50 will die of a ruptured abdominal aortic aneurysm, according to the Society of Interventional Radiology.

Aneurysms often grow slowly and go unnoticed. Some never reach the point of bursting. An estimated 1 million people are living with an undiagnosed aortic aneurysm; about 200,000 people are diagnosed with it each year in the United States. Most of those cases occur below the kidneys and do not need the specially designed stent.

Last October, Peter Eichten had no idea what was happening inside his abdomen. After 30 years working in business administration, the adjunct professor at Metro State University was having an annual physical. Since he had just turned 65 and was switching to Medicare, his doctor suggested the former smoker have an ultrasound.

The news came the next day: Eichten had an aortic aneurysm and it was big enough to need fixing.

"My doctor said, 'Well, there's this new technique. We just hired this guy,' " Eichten said. The guy was Manunga.

A CT scan a couple weeks ago showed the aneurysm was completely gone. Eichten set off for New Zealand last week with his wife, Jane.

"I thank my doctor every day for saying: 'Get this test,' " he said. And he's thankful there is another option now besides surgery. Eichten is the first patient in the Twin Cities to have this procedure. Manunga, who was recruited to Minneapolis from the Mayo Clinic last summer, participated in about 20 procedures there.

According to Dr. Gustavo Oderich, the Mayo's director of endovascular therapy, doctors there have treated more than 240 patients with fenestrated stent grafts and have been key participants in clinical trials. Only a handful of doctors nationwide have special authorization to work on patients who need grafts that accommodate multiple openings, he said.

Besides Mayo, Oderich said other sites doing the procedure include the Cleveland Clinic, the University of South Florida, Cornell University of New York and the University of San Francisco. Data show that the procedure has a 97 percent success rate and a mortality rate of 1.4 percent, less than half the 3.6 percent mortality rate for aortic aneurysm surgery.

"Ten years from now, this will be the standard of care," Manunga said.