The aorta is the most important artery in the entire body. It supplies all organs and tissues with blood and when it becomes ill it creates serious problems. This is what happened to Paolo (not his real name), a 65-year-old gentleman from the province of Avellino with many cardiovascular risk factors (hypertension, diabetes, high cholesterol, cigarette smoking), saved at the Fondazione Policlinico Gemelli Irccs in Rome thanks to a precision vascular surgery operation that used a custom-made prosthesis.
Paolo came close to breaking the aortic arch – the first section of the large vessel, located in the upper part of the chest – due to the ulceration of a large atherosclerotic plaque (penetrating aortic ulcer). Rupture of the aorta at this level results in massive chest hemorrhage that can rapidly lead to death. When such an event occurs, the cardiac surgeon usually intervenes and replaces the arch of the aorta with a vascular prosthesis, suturing it to the healthy part of the aorta. A complex operation that involves opening the chest, or sternotomy under general anesthesia; it is performed in extracorporeal circulation with the heart stopped, cooling the patient. The operating risk is very important and Paolo would not have been able to bear it, given his health conditions. For this reason, during a meeting of the Gemelli Aortic Team, a specialist multidisciplinary team made up of cardiac surgeons, vascular surgeons, cardiologists and cardioanaesthetists of the Department of Cardiovascular Sciences directed by Massimo Massetti, full professor of Cardiac Surgery at the Catholic University of the Sacred Heart, campus of Rome, it was decided to opt for a percutaneous intervention, using an endoprosthesis.
“It is a minimally invasive operation – explains Yamume Tshomba, full professor of Vascular Surgery at the Catholic University, director of the School of Specialization in Vascular Surgery and director of the Uoc of Vascular Surgery of the Gemelli – which does not require the need for surgical incisions. The vascular endoprosthesis used to repair the aorta is enclosed in an introducer with a diameter of a few millimeters, which is inserted from the vessels of the groin, puncturing the skin, and then goes up to the section of the aorta to be repaired. seat is released, to 'line' the diseased section of aorta from the inside, reinforcing its wall and thus preventing rupture”.
“When the section to be repaired is the arch of the aorta – underlines Tshomba – there is a big problem consisting of three important arterial trunks: the brachiocephalic trunk (which then divides into the right subclavian artery and the right common carotid artery), the left common artery and the left subclavian artery which cannot be covered by the endoprosthesis. To avoid obstructing these important vessels (which carry blood to the brain and upper limbs), specialized companies are used to 'customise', i.e. adapt the prosthesis based on the anatomy of the individual patient, creating fenestrations and/or ramifications to allow the perfusion of the arterial trunks that arise from the aortic arch. This is a procedure that however requires a few weeks and in Paolo's case we did not have this time available, because the rupture of the arch was imminent and would not allow us to wait. For this reason we contacted the greatest expert in the world in this field, Ludovic Canaud, professor of Thoracic and Vascular Surgery at the University Hospital of Montpellier (France ), known throughout the world for having the largest case history in this type of intervention. Canaud came specifically to Gemelli, in an emergency situation, to adapt the endoprosthesis to be applied to Mr Paolo”.
“The vascular prosthesis was extracted from its introducer – describes Giovanni Tinelli, associate professor of Vascular Surgery at the Catholic University and head of the Endovascular Therapies Unit at the Fondazione Policlinico Gemelli Irccs, who participated in the operation – and in a sterile environment we created the fenestrations with an electrocautery to allow the patency of the epiaortic trunks. In this specific case we made fenestrations on the prosthesis, the first of 32 millimeters to allow the patency of the brachio-cephalic trunk (anonymous trunk) and the left common carotid artery; the second of 8 mm to allow patency of the left subclavian artery. The endoprosthesis was then inserted again into the introducer, through which we positioned it in the portion of the aorta at risk of rupture, while maintaining the patency of the trunks supra-aortic, thanks to the fenestrations made in this tube of synthetic fabric supported by a metal structure”.
“When faced with a complex patient – comments Massetti – the sharing and discussion of the case within the Aortic Team is very important, but equally important is a collegial discussion, even international, with pioneers of certain technologies. This is the working method of a multidisciplinary team, which brings together skills and resources in order to propose and implement a 'cure' that is increasingly personalized to the patient's needs”. “Since it was an urgent and 'off label' operation – concludes Tshomba – the patient was asked to sign a specific informed consent. The alternative would probably have been to see him die within a short time”. Paolo is well today, we read in a note. He returned to his house in the province of Avellino a few days after the operation and his CT scan is perfect. These 'author's cuts' at Lucio Fontana saved his life.
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