Penn Team Advances Complex Aortic Care

Patients with aortic disease often find themselves facing complex surgery. At Penn Medicine, the cardiovascular and vascular surgical teams have more experience with these technically demanding procedures and the complex circulatory issues that surround them than any other center in the area. In fact, Penn is known nationally and internationally for successfully performing complex interventions on high-risk patients.

In addition to performing hundreds of procedures every year, Penn’s complex aortic program is also unique because of its integrated surgical team.

“We have a core group of cardiovascular and vascular surgeons who started the aortic program together,” said Ronald M. Fairman, MD, chief of vascular surgery and endovascular therapy. “This partnership is more clinically and academically productive, and it is a model few hospitals

or academic medical centers can replicate.”

The largest artery in the body, the aorta arises from the left ventricle of the heart. Anatomically, it goes up (ascending aorta) from the heart, bends (aortic arch), and then goes down (descending aorta) through the chest and abdomen. The descending aorta is subdivided into the thoracic aorta that descends within the chest and the abdominal aorta that descends within the belly.

Cardiovascular surgeons perform most surgery involving the thoracic aorta, while surgery involving the abdominal aorta is performed by vascular surgeons. Many complex aortic cases involve both the thoracic and abdominal aorta and the aortic surgeons at Penn work together, producing better outcomes for patients.

Conditions Requiring Surgery

The primary cause for aortic surgery is aortic aneurysm, when the artery wall weakens and expands or bulges as blood is pumped through it. An aneurysm can develop anywhere along the course of the thoracic and abdominal aorta.

Aortic dissection occurs when the inner lining of the aorta tears. At the tear site, the blood begins to flow into the wall of the aorta creating two channels, a true and false lumen. As this potentially life-threatening condition advances, the false lumen expands and may compress the true lumen of the aorta as well as important branches of the aorta. Rupture of the aorta is catastrophic. Type A dissections begin in the ascending aorta and Type B dissections in the descending aorta.

Aortic Remodeling

Traditionally, aortic surgery has focused on treating those life-threatening conditions, according to Joseph E. Bavaria, MD, vice chief of cardiovascular surgery and director of Penn’s thoracic aortic surgery program. At Penn, classic open repair of aortic dissections is now being augmented by the use of endovascular stent grafts that reinforce the weak spot in the aorta.

“We have gotten very good at fixing these life-threatening conditions,” Dr. Bavaria said. “Now we are focusing on what happens after the surgery and how we can give patients the best chance of long-term survival. We recently introduced the concept of aortic remodeling. By identifying potential dissections early and placing stents to reinforce the arterial wall, we can stop blood flow to the false channel. By removing the pressure on the wall of the artery we can stop the tear.”

Penn is a world leader in the concept of aortic remodeling and researchers recently published one of the first papers describing the use of stents as an adjunct to open repair.

Penn cardiovascular surgeons are also developing advanced methods for performing aortic arch surgery and valve-sparing aortic root procedures.

“Our methods have advanced to a point where we can repair almost any leaking (insufficient) aortic valve problem without replacing the valve,” Dr. Bavaria said.

Penn surgeons routinely perform the most complex aortic procedures including:

• Aortic root reconstruction
• Valve-sparing aortic root replacement
• Aortic valve repair
• Thoracic aortic aneurysms
• Abdominal aortic aneurysms
• Thoraco-abdominal aortic aneurysms
• Aortic dissection; Types A and B
• Mechanical and biological valve conduits
• Minimally invasive methods of aortic aneurysm repair (endovascular stent grafts)

Personalized Heart Care

The complex aortic program at Penn Medicine is currently enrolling patients genetically predisposed to developing aneurysms in a new genetic trial. By looking for genetic markers physicians hope to be able to identify those people with the highest risk for a life-threatening rupture.

“We know that 25 percent of catastrophic Type A dissections start at a size of less than five centimeters,” Dr. Bavaria said. “We need to identify those 25 percent. We may be able to recommend elective aneurysm repair based on genetic information. That’s a new concept.”

Penn is one of only five centers in the country participating in the NIH-funded GenTAC Program and is one of the top enrollers in the trial. In fact, Penn surgeons have been leaders in every endovascular therapy and aortic clinical trial in the U.S. for nearly 20 years, according to Dr. Fairman.

“We treat aortic disease as a team. Our surgeons, anesthesiologists, nurses, surgical facilities and units are focused on treating these patients, and we have incomparable experience and outcomes,” Dr. Fairman said. “By collaborating on advancing aortic therapies we can make greater strides. It’s a model of care that only exists at Penn.”

For more information about the complex aortic program at Penn, please visit PennMedicine.org/heart. Appointments can be scheduled by calling 800-789-PENN (7366).