Published Thursday, May 11th, 2006
By John Trumbo, Herald staff writer

Ray Nierman was a little off on his golf game one day about four years ago. Pain in his chest wouldn't go away.

The 84-year-old Richland man was experiencing an aortic aneurysm, a condition that kills one in 250 people over age 50 in the United States.

It's the 17th leading cause of death.

It occurs when high blood pressure or hypertension cause the aortic artery to expand over time weakening artery walls and allowing fluid to seep out.

The leaking fluid creates a sac that can be several times larger in diameter than the original artery. Blood flow is restricted and clotting can occur.

The only fix at that time was a bypass repair, routing the blood through a tube around the affected area inside the aneurysm and restoring proper flow from the heart.

Nierman went into surgery and spent 16 days in the hospital recuperating.

Initially successful, the repair didn't last.

The leaking resumed, enough to fill the aneurysm sac with about three-quarters of a liter of fluid in two months time.

Earlier this year, Nierman's doctor knew his patient needed a better fix.

This time, Nierman would undergo a new medical procedure, becoming the first person at Kadlec Medical Center to have an expandable stent inserted into the aneurysm via a major artery leading to his heart.

The process, known as a nonsurgical endograft using a thoracic endoprothesis, is done by an interventional radiologist, who uses a catheter to guide the sheathless stent through an artery in the right groin area into position by watching real-time X-rays.

Dr. Saravanan Kasthuri was Nierman's radiologist who did the procedure April 24.

It took about an hour to put the stent in place, release the binding so it could expand, seal off the leak, then withdraw the hardware.

The patient is sedated during the operation, but is ready to go home the next day, Kathuri said.

Nierman said he walked out of the hospital the next morning, grateful for the technology that made it possible.

There are two kinds of aortic aneurysms: thoracic and abdominal, with the abdominal being six times as common.

Kadlec has been doing endografts for abdominal aortic aneurysms for about six months, but Nierman was the first thoracic patient.

"I am excited that something like this is available for patients, where you can have a life-threatening situation, have it treated and be released the next morning," Kasthuri said.

As simple as the endograft seems in theory, preparation is needed to ensure that all goes well and to have a back-up surgical team on standby if it doesn't.

Kasthuri uses the latest CAT scan technology to get 3-D views of the aneurysm and plan his approach. Precise measurements are needed to select the right size stent. Too small won't stop the leaking and too large will stress the artery.

"It has to be within 3 (millimeters) to 5 mm," he said.

"We have to have a clinical specialist there and a cardiac-thoracic surgeon ready. Everything has to be prepared, and we have to have exact deployment," Kasthuri explained.

Kasthuri had done endografts on abdominal aneurysms, but this was his first in the thoracic area.

"I was very excited it was a success. Relieved and very happy," he said.

With this success, Kasthuri said he expects Kadlec will start doing the procedure more often, possibly one thoracic and up to three abdominal each month.

According to the Society of Interventional Radiology, abdominal aortic aneurysms affect as many as 8 percent of people over 60, with men four times more likely than women to have the condition.

Smoking, hypertension, high blood pressure and hardening of the arteries all are contributing factors.

There are few symptoms, which is why abdominal aortic aneurysms are sometimes called a silent killer. Some symptoms are abdominal pain that is constant or can come and go; pain in the lower back that may radiate to buttocks and groin; and feeling a heartbeat in the abdomen.

Ultrasound is the best way to detect an abdominal aortic aneurysm.

Kasthuri said the endograft procedure not only works well, but for some patients is the only remedy available because they are not strong enough for the kind of surgery Nierman went through four years ago.