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Less invasive treatment lowers risk for those with an abdominal aortic aneurysm

George Luzier, 92, lives in Sarasota and has owned Luzier Boats there since 1966. Luzier received a Zenith Fenestrated AAA Endovascular Graft at Tampa General Hospital on May 9. He was home two days later.
George Luzier, 92, lives in Sarasota and has owned Luzier Boats there since 1966. Luzier received a Zenith Fenestrated AAA Endovascular Graft at Tampa General Hospital on May 9. He was home two days later.
Published Jun. 8, 2017

At 92, George Luzier wasn't up for major surgery to repair a potentially life-threatening abdominal aortic aneurysm, also known as a triple-A or AAA.

The aneurysms develop silently and often grow larger over time. The larger they are, the more dangerous they can be. As with most people, Luzier's was discovered by chance a few years ago when a doctor ordered a scan of his upper body for another medical reason.

But recently he turned to a solution that is becoming more and more common.

An aneurysm looks like a big bubble bulging out from the side of a blood vessel. In the case of an AAA, it occurs on a weakened wall of the aorta, a major blood vessel that carries blood from the heart to the abdomen, pelvis and legs. If the bubble bursts, a patient can bleed to death in minutes.

According to the American Heart Association, only 20 percent of patients with a ruptured AAA survive. Patients are at highest risk for rupture when the AAA reaches a certain size, usually around 2 inches.

The Centers for Disease Control and Prevention reports that AAAs caused 9,863 deaths in 2014 and contributed to more than 17,000 deaths in 2009. About 15,000 new cases are diagnosed every year.

Men make up about two-thirds of patients in the United States. And whites are at higher risk than blacks, as are people over 65. Smoking and tobacco use increases risk by three to five times. Other risk factors include obesity, high blood pressure, high cholesterol, atherosclerosis or hardening of the arteries, some genetic conditions such as Marfan Syndrome, and family history.

Doctors had been monitoring Luzier's AAA since 2012 and earlier this year determined it was large enough to be a serious threat. They decided it required treatment.

For most patients, that means having a minimally invasive procedure to place an endovascular graft in the aorta to block off the aneurysm. The graft, made of wire mesh and fabric, looks like a tiny pair of pants and is put in place through a couple of punctures in the groin.

But a small percentage of patients, including Luzier of Sarasota, aren't candidates for the procedure because of the location of the aneurysm above the kidney arteries. There simply isn't enough aortic tissue there to create a seal for the device.

"Standard devices on the market require that the aneurysm occurs 1 to 1.5 centimeters below the (kidney) arteries," said Dr. Sean Lyden, chairman of the Department of Vascular Surgery at Cleveland Clinic. When the aneurysm is located near the kidney arteries, treatment becomes more limited.

Until recently, patients faced major abdominal surgery to have the graft placed. Access is gained through a large incision, essentially the length of the torso, followed by months of recovery. Not a good option for Luzier, who still operates a custom boat building business in Sarasota.

Fortunately, doctors gave him another option: a newer graft called Z-Fen, short for the Zenith Fenestrated AAA Endovascular Graft, developed just for patients with an aneurysm near the kidney arteries. The graft is custom-made for each patient, based on their anatomy, a process that takes about three weeks.

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Cleveland Clinic was involved in the development and clinical trials of Z-Fen, which is manufactured by Indiana-based Cook Medical. It received FDA approval five years ago.

"Z-Fen allows us to treat more patients with a minimally invasive procedure," said Lyden, noting that his department attracts patients from all across the country — including some of the most complicated, high-risk cases — because of its long track record with Z-Fen.

Luzier, however, didn't have to travel that far for treatment. His doctors at Tampa General Hospital started working with Z-Fen four years ago.

Dr. Bruce Zwiebel, director of interventional radiology at TGH, and Dr. Murray Shames, a professor of surgery and radiology at USF Health and director of the Tampa General Hospital Aortic Center of Excellence, work as a team and have put the device in more than 100 patients to date.

The procedure takes about two hours but requires special training and is complicated, using sophisticated imaging equipment. Just a few hundred physicians in the country have been trained to use Z-Fen, but their numbers are increasing, as is patient demand.

"Now that more patients are eligible for the minimally invasive procedure, our case volume has increased threefold in the last three years," said Shames. "The busier your program, the better your outcomes. We get some of Florida's most complicated cases." Most insurance plans, including Medicare, cover Z-Fen.

For patients who are candidates, it's a welcome alternative to open surgery with its higher risk for complications and infection, and its longer hospital stay and recovery.

"Patients come out of the Z-Fen procedure with a couple of stitches and Band-Aids," Zwiebel said. "They're up and walking that night and most are back to their routine in a week or less."

Luzier underwent the procedure on May 9. He went home two days later and was back to normal speed at work within two weeks.

"At first I would just hang out at the shop, didn't do anything big. Now I can do all I want," he said. "I'm tickled that it looks like it's going to work fine for me."

Contact Irene Maher at imaher@earthlink.net.

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