Precision Vascular Surgery Can Repair and Restore

At 60, Eugene Lee's vigor is impressive. Here is someone whose energy puts a spring in every step he takes. And he is not someone to complain about minor aches and pains. Three years ago, when his right leg became a little painful, he didn't pay much attention until one day when it gave way completely, in mid-stride. "It just buckled under me," he said. "For about 30 minutes I felt very uncomfortable. My leg wasn't swollen, but I felt something was wrong."

He could walk, but his leg felt cold and numb. He called his doctor, who squeezed him in as the last appointment of the day. That doctor took a quick look and immediately sent Lee to the local hospital. After some tests, Lee heard a verdict that shook him. "They wanted to amputate my leg," he said.

By midnight that same day, Lee and his wife, Wendy, were at Stanford Hospital & Clinics, transferred there for the higher degree of care Lee needed. Quickly surveying Lee's circulatory system, Stanford vascular specialists could easily see the aneurysm that had created a clot in Lee's right leg. They discovered another similar aneurysm in Lee's left leg. But they also found two other serious problems: a significant blockage in Lee's carotid artery, in his neck, which put him at risk for a stroke and an aneurysm deep in his abdomen, in the aorta, the main blood vessel routing blood from the heart to the rest of the body. That aneurysm had swollen the aorta to four times its normal size and looked ready to rupture. An aneurysm in a limb threatens only the limb. This large aortic aneurysm in his abdomen threatened his life.

Multiple aneurysms are not uncommon, said Ronald L. Dalman, MD, Chief of Stanford's Division of Vascular Surgery, who accepted Lee's transfer from the community hospital. "When you have four or five problems, it's about setting priorities and figuring out the best sequence of treatment," he said. "What you need is a coherent plan."

Miles of Arteries

The network of blood vessels that delivers oxygen and nutrients, fights infection and removes waste is not, perhaps, as understood or appreciated as are other major parts of our bodies like the heart, brain and lungs. When something goes wrong with that network—when an aneurysm blows open or a stroke-triggering clot forms in the brain—then it is obvious that the circulatory system, powering around its contents 1,500 times daily, is essential to life.

Vascular medicine, from the Latin word for vessel, treats the tens of thousands of miles of arteries, veins and capillaries that convey blood to do its crucial job throughout the body. 

Major vascular diseases include atherosclerosis, the build-up of fat and cholesterol that slows and diminishes blood flow, setting the scene for heart attack, stroke and high blood pressure. Clots in the system also impede blood flow, with similarly serious health impacts. Treatment varies, from medication to surgery, but problems can occur everywhere in the vascular system. As a group, vascular diseases are the major cause of illness and death in the United States.

Aneurysms can appear at any age, but they are especially common in men beyond age 60 who have smoked cigarettes, Dalman said. The phenomenon is so closely linked to smoking that, in 2007, the U.S. Congress added an abdominal and aortic aneurysm screening benefit to Medicare. If such screening were widely conducted, Dalman believes, the mortality rate could drop by half. Aortic aneurysms are the third leading cause of sudden death in men over 65, he said.

Screening is especially important with a condition that usually does not announce itself months or weeks or even days ahead of a rupture. Once rupture occurs, its fatal effects are just minutes away.

Breakthroughs in Reliable Repair

Work to identify aneurysms at the earliest possible stage is intense. In addition to caring for patients, Dalman is the director and principal investigator of Stanford's Specialized Center of Clinically Oriented Research program in aortic disease. The program, funded by the National Institutes of Health, is identifying new medical treatment strategies for aortic aneurysms to help patients avoid the need for surgery altogether. The growing importance of non-surgical management of vascular disease, Dalman said, prompted the expansion of Stanford's Vascular Center to include a focus on stem cell-based therapies.

One of the goals of this area of research, Dalman said, will be to reduce the rate of vascular disease progression by a more thorough understanding of its origins. "We need to know just what starts the cell death that causes the destruction and remodeling of the aortic walls," he said. "We're approaching that on multiple fronts." Genetics also play a significant role, he said.

Vascular patients have benefited significantly from recent technological breakthroughs, many pioneered at Stanford, including high-speed CT and MRI angiography and 3D image reconstruction technologies used to give surgeons detailed information about what was happening in Lee's vascular system. Lee also benefited from another Stanford strength, and one of the most important vascular treatment approaches: minimally invasive, or endovascular, techniques to repair aortic aneurysms. By reducing blood loss and time in surgery, these techniques, which employ a catheter threaded into the body through a small incision, have reduced the risk of death during surgical repair by more than 50%.

Stanford surgeons also developed the first two commercial aortic endografts, metal mesh tubes to fortify damaged arteries. Stanford's vascular medicine team continues to work with the Stanford Cardiovascular Biomechanics Lab, to further advance innovation in vascular treatment tools. 

Repairing Lee's aortic aneurysm became the first priority for Dalman and his collaborative team, which included a cardiovascular anesthesiologist and nurse specialists in cardiovascular care. Before he did anything else, Dalman placed an endograft in the abdominal aorta. Then, with that aorta stabilized, he removed the clot blocking blood flow to Lee's right leg. Lee recovered quickly and returned to work. Later, in a second procedure, Dalman repaired Lee’s carotid artery and repaired the left leg aneurysm with precise revascularization procedures.

Back on a Healthy Track

Lee's first stay in the hospital lasted 10 days, a difficult time of waiting and hoping. "We prayed and prayed," said his wife. "That 10 days was very important—it saved his life and saved his leg."

As soon as he was allowed to, Lee started to work on regaining his physical strength. "I walked two miles a day," he said. "It took me two to three hours, but I did it every day and I feel much better now." Lee takes his bike out for a ride often, and returned to work with no restrictions on what he can do.

Now, it's a question of managing his arterial disease and keeping very conscious watch on his health in a way that reflects what he nearly lost. What happened to him is never very far from his mind and he is quick to voice his gratitude. "I was lucky," he said. "I was at the right hospital with the right doctor."

By Sara Wykes