Fred Wilder, 84, is a retired farmer who lives in Visalia. He’s the stoic type and didn’t even realize he was having trouble getting around.
“I was short of breath a lot,” said Wilder, “breathing heavy as I walked across the room. I didn’t notice it much, but my family did.”
Still, that wasn’t what sent him to the doctor. He was exploring elective surgery at his local hospital to have a benign lipoma removed from his neck, but a pre-surgical EKG was abnormal. Further exploration showed he had aortic stenosis – his valve wasn’t opening and closing properly. The malfunctioning valve was decreasing blood flow to the aorta, the major artery leaving his heart, causing Wilder’s fatigue. The specialists in Visalia referred him to Stanford Health Care.
Wilder’s wonky valve and advanced age meant he wasn’t an ideal candidate for open surgery. He would need a minimally invasive transcatheter aortic valve replacement (TAVR), a procedure performed by Stanford’s cardiovascular medicine and cardiothoracic surgery teams. These procedures insert a catheter into a blood vessel near the groin, snake it up to the heart and insert a small, collapsible heart valve. But there was an added complication.
“In being considered for a TAVR from our multidisciplinary team, we obtain CT scans for the entire aorta since you have to deliver the device up the femorals and through the abdominal and thoracic aorta to get to the heart,” said vascular surgeon Jason Lee, M.D. “It’s a typical screening process for being considered for TAVR. Surprisingly to Mr. Wilder and his doctors, we incidentally found a large, life-threatening aortic aneurysm.”
This added a major wrinkle to Wilder’s care. Typically, planned elective surgery would have to wait several months after the TAVR to allow optimal recovery. But given the size of his aortic aneurysm, at 8.3 cm, he was at significant risk of rupture and death if untreated or delayed. Another wrinkle in Wilder’s case was the aneurysm was also complicated, with involvement of the renal arteries that supply his kidneys. Given his aortic stenosis, he was not an open surgical candidate for his aneurysm repair, but instead would need a fenestrated endovascular aneurysm repair (FEVAR). Like the TAVR, FEVAR uses a catheter to reach and repair the anomaly.
“We had a complex scenario,” said Lee, who heads the FEVAR team and is among the most experienced experts in this technique. “We had two major problems for Mr. Wilder and needed to coordinate care in a multidisciplinary fashion, which is what I believe Stanford Health Care promotes and excels in.”
Lee worked closely with cardiothoracic surgeon Anson Lee, M.D., who led Wilder’s TAVR team, and cardiologist Alan Yeung, M.D., to develop a solution. They decided to first perform the urgent TAVR under local anesthesia and then let Wilder recover for a month after the valve procedure, which is the time it took to build the custom fenestrated graft to fit his aneurysm.
“The Stanford vascular surgery team has had a long interest and experience in cutting-edge minimally invasive repair and developed a lot of the original technology,” said Jason Lee, M.D. “For Mr. Wilder, the stent-graft approach to his aorta when sealed would provide long-term durability from rupture. Fenestrated grafts are even more complicated, and it means there are custom-made holes in the graft for the branch vessels for aneurysms around the renal arteries to precisely fit the patient’s anatomy.”
Both procedures offer advantages over open surgeries. Patients can be awake, there’s less infection risk and the recovery time is significantly reduced. People usually go home the next day. Wilder recovered beautifully from both procedures.
“I did not have one second of pain from either surgery,” he said. “I did all my recovery with Tylenol.”
Both Wilder and the vascular surgery team had much to celebrate after his procedure. It was the 150th FEVAR conducted at Stanford, but most importantly, the dual procedures were completely successful.
“My blood flow increased, and I started to notice feeling in my feet that I hadn’t felt in a long time,” said Wilder. “I can walk, I can breathe, I’m not huffing and puffing. I can’t speak highly enough about the doctors and staff. Just really good people.”
And now that his cardiovascular problems have been corrected, he can even get his lipoma removed.