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OneThousandOne represents the amount of time, verbally, that it takes to count to one second. In this one second of time, a great thing happened at The Nebraska Medical Center. In fact, several great things probably happened. A patient was cured, a researcher found the missing link, a nurse treated an injury, a doctor comforted a family or maybe a child just smiled.
MOMENTS IN MEDICINE at THE NEBRASKA MEDICAL CENTER
Spring | Summer 2008

Mended Heart

On Sept. 11, 2003, actor and comedian John Ritter was suddenly stricken with severe chest pains. The star of the sitcoms “Three’s Company” and “8 Simple Rules…” was taken to a hospital in Los Angeles where, according to his relatives, he was mistakenly treated for a heart attack. Ritter, 54, died that same day.

Rather than a heart attack, Ritter had suffered a tear in his aorta, called an aortic dissection. Aortic dissection occurs when the inner layer of the aorta’s artery wall splits open, or dissects. When the aortic wall splits, the pulses of blood get inside the artery wall and under the inner layer, causing the aorta to split further.?If not properly treated, the condition can be fatal.

The evening of Jan. 15, Mary Kraft, a cook at Grand Island Northwest High School, began experiencing extreme back pain between her shoulder blades. “It was very bad,” she recalls, “and then it got worse.”

By the middle of the night, Mary couldn’t stand the pain any longer. Her husband, Richard, rushed her to the emergency room at St. Francis Medical Center in Grand Island. Doctors there examined Mary and ordered a CT scan (computerized axial tomography).

The scan indicated she wasn’t having a heart attack, as she had suspected. There was a tear in her aorta.

After being transferred to BryanLGH Medical Center West in Lincoln for further observation, Mary was sent to The Nebraska Medical Center for treatment by the physicians of the hospital’s Vascular Center.

Her condition was stabilized and monitored while Cardiothoracic Surgeon Ali Khoynezhad, MD, and Vascular Surgeon G. Matthew Longo, MD, discussed the proper treatment.

“They decided I’d be better served by a less invasive operation that they could do,” Mary recalls.

On Jan. 23, Mary Kraft became the first person in Nebraska to undergo a procedure that utilized an endovascular stent graft, a tube composed of GORE-TEX – a synthetic material known for its use in “breathable” and waterproof fabrics– supported by a nickel-titanium alloy mesh called a stent, to repair her dissected aorta.

During the minimally-invasive procedure, Drs. Khoynezhad and Longo inserted a guide wire and a catheter through Mary’s femoral artery in her leg to reach the tear in her aorta.

Watching via X-rays that appeared as moving images on a screen, they inserted a compressed graft through a larger catheter called a sheath to reach the damaged aorta. When the sheath was withdrawn, the graft remained in place, where it expanded to serve as the new wall of the artery.  

Two days later, Mary Kraft went home.

The Vascular Center at The Nebraska Medical Center is unique in the region. Devoted to the diagnosis, treatment and management of circulatory system diseases, the center brings together experienced specialists from vascular surgery, cardiology, interventional radiology, neurosurgery and cardiothoracic surgery.

“The concept is to deliver the finest care we can for patients who have a variety of different vascular disorders, using the expertise of everyone in the medical center.”
Thomas Howard, MD

“The concept is to deliver the finest care we can for patients who have a variety of different vascular disorders using the expertise of everyone in the medical center,” says Thomas Howard, MD, vascular surgeon. “By sharing our collective experience and skills to collaborate on particular vascular problems, we’ve streamlined the treatment process for our patients.”

In addition to Drs. Howard, Khoynezhad and Longo, Vascular Center physicians include Drs. Anthony Adelson, Haysam Akkad, Jason Johanning, Sushama P. Kunnathil, Thomas Lynch, Tracy Dorheim, Edward O’Leary, Iraklis Pipinos, Dick Slater and William E. Thorell.

Rather than one physician acting as director, oversight for the center is provided by an operations committee, a privileges and quality committee, and an executive committee.

“With these committees,“ Dr. Howard says, “we make sure that at each level of physician involvement, all the players are up to speed.”

Dr. Adelson, an interventional radiologist, says the Vascular Center is a “true collaborative effort. We offer patients a comprehensive evaluation of peripheral vascular disease.”

Peripheral vascular disease (PVD) refers to diseases of blood vessels outside the heart and brain, including those that carry blood to the legs, arms, stomach or kidneys. PVD affects approximately 5 to 10 percent of adults over the age of 50 and is often under-diagnosed and under-treated.

Patients with vascular diseases often have problems in different areas of their body related to the vascular system. For example, one-third to one-half of patients with significant coronary artery disease will also have significant disease in the carotid vessels, says Dr. Khoynezhad. In patients who have suffered an aneurysm, one-half will have coronary artery disease.

Recent innovations in endovascular therapy offer patients a variety of methods and procedures to treat PVD. The vascular specialists at The Nebraska Medical Center are trained in the latest minimally invasive and open surgical techniques to give patients the fullest range of treatment options.

“A lot of specialists see patients for only one condition or disease,” says Dr. Adelson. “We’ll look at everything regarding the vascular system, not just what is affecting the patient at that time.

“Not only are we broad-minded, we can offer the best in treatment, as well.”

According to the American Heart Association, acute aortic dissection causes sudden chest pain often described as very severe and associated with cold sweat.?The pain may be localized to the front or back of the chest.?Typically, the pain moves as the dissection gets worse.?Other symptoms depend on the arterial branches involved and compression of nearby organs.

I knew it was a relatively new procedure, and even though I’m sure he told me, I didn’t really catch the fact that I would be the first.
Mary Kraft

Until recently, the options for treatment of thoracic (chest cavity) aortic dissection were limited.

“When you have a tear in the thoracic aorta, traditionally you do open (chest) surgery using large thoracotomy clamps, resecting the portion of aorta and using a synthetic graft as a replacement,” Dr. Khoynezhad says. “Because the blood must be clamped off during the resection, it’s a very morbid surgery. There is a 35 percent mortality rate for dissection in the last portion of thoracic aorta. In addition to the risk of death, there is a 10 percent chance of becoming a paraplegic and a 10 percent chance of suffering a stroke, or a combination of both.”

Those odds assume that the diagnosis is an aortic dissection – and not a heart attack.

“Dissection is associated with significant pain,” Dr. Khoynezhad says. “It’s very important to rule out aortic dissection promptly with a CT scan when the patient in the emergency department (ED) complains of significant chest and/or back pain.

“Therefore, it’s crucial that the patient comes to the ED promptly. If not, it may rupture before their arrival at the hospital. There is a significant number of people who suffer aortic dissection and die before they even get to the hospital.”

Aortic Dissection Procedure

A healthy heart.

An aortic dissection occurs when the inner layer of the aorta’s artery wall splits open or dissects.

During the procedure, an endovascular stent graft composed of a synthetic material called Gore-tex is inserted into the aorta where it serves as the new wall of the artery.

Once at the hospital, open surgery can be complicated.

“This is very high-priced real estate that we’re dealing with,” says Dr. Longo. “To clamp and arrest the flow of blood to the brain during the surgery makes it even more serious.”

Add to that the repair of the torn aorta.

“When an aorta tears, it is difficult to reconstruct,” Dr. Longo says. “It’s like sewing together two pieces of tissue paper.”

No matter what the extent of the tear, “you are on the clock,” he says, “because a rupture is inherently fatal.”

The American Heart Association reports that aortic dissection occurs more often in men than women.?The peak age of occurrence of proximal, or closest to the heart, dissection is between ages 50 and 55.?Distal, or farther from the heart, dissection occurs most often between ages 60 and 70.?In the majority of cases (62 percent to 78 percent), high blood pressure is the most common factor predisposing the aorta to dissection. Mary Kraft, 56, had been taking high blood pressure medication for years.

Dr. Khoynezhad says Mary was chosen to be the first for the endovascular stent grafting procedure because of the timing of her need and the anatomy her aorta offered surgeons. “She was the right patient at the right moment,” he says.

Mary recalls that as she lay in her hospital bed, she tried to absorb what Dr. Khoynezhad was telling her about the endovascular stent grafting they intended to perform.

“I knew it was a relatively new procedure, and even though I’m sure he told me, I didn’t really catch the fact that I would be the first,” she says. “I just told him, ‘You do what you have to do.’ I was in a lot of pain, and I knew my life was in their hands.”

If the traditional open surgery had been performed, Mary would likely have spent two days in the hospital’s Intensive Care Unit (ICU) with a breathing tube attached, followed by 10 to 15 days in the hospital and a recovery period of at least three months.

Instead, she was home in Grand Island less than 72 hours after the procedure.

On Feb. 7, Mary returned to The Nebraska Medical Center to undergo her first CT scan since the procedure. Afterward, Dr. Khoynezhad showed her the images from the scan, including the vivid display of the metal mesh that was now snug inside her aorta. She will undergo CT scans at three, six and 12 months, then annually.

“I feel good, really,” she says. “I get tired easily, but I’ve been very careful. I’ve kept up my daily activity, except I can’t do any heavy lifting. They say I can get back to work soon.”

Dr. Longo says Mary will have to maintain her general health and work to keep her blood pressure under control.

“While there is always the potential for something to happen,” he says, “we think she’ll do very well.”

Previous article in the Spring | Summer 2008 issue of One Thousand And One:
Drawn to Medicine