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First Time in the World: Unique Two-Stage Hybrid Surgery performed at MIOT Hospitals for Aneurysm of the Ascending Arch and Descending Thoracic Aorta in a patient with previous Kidney Transplant – Press Meet on 25 March 2009.

Mrs. Meena Tomar – Patient, Mrs. Mallika Mohandas – Chairman MIOT Hospitals, Dr. V.V. Bashi – Chairman, Centre for Thoracic & Vascular Cardio Care and Senior Cardiac Surgeon, and Dr. Murali – Interventional Radiologist)

A team of doctors headed by Dr. V. V. Bashi did a corrective surgery on Mrs. Meena Tomar, 43-year-old lady from New Delhi. This patient came to MIOT Hospitals Chennai on 05 Feb 2009 with history of back pain from September 2008. She has high blood pressure since 1994 and developed kidney failure in 2004 for which she underwent kidney transplantation. After this she was doing well till September 2008. From January 2009 doctors noticed that her kidney function was deteriorating because of the dissecting aneurysm causing diminished flow to the kidney. She needed an immediate operation to prevent failure of the transplanted kidney and to save her life from the risk of aneurysm rupture. She was investigated in New Delhi with all the tests and many hospitals told that surgery cannot be done because it is very risky. The 64-slice CT angiogram showed the following abnormalities:

Correction of this major aneurysm in a single stage is possible only by doing a major operation with the use of Heart-Lung machine, cooling the blood to 15°C and stopping the circulation for about an hour. This carried a higher risk in this patient because of kidney transplantation. Patients with kidney transplantation are on steroids and immuno-suppressant medicines and they are very susceptible to infection when we do major operation in them. So a less aggressive approach in treating this problem was formulated, which is the latest development in aneurysm surgery. This is called as the Hybrid Surgery with Arch Debranching followed by a keyhole surgery to do endovascular stenting of the aneurysm.

Stage I (18/02/2009): In the first operation the chest was opened in the midline and connected a graft from the ascending aorta to the innominate artery and left common carotid artery and ligated these arteries. This was done without the use of Heart-Lung machine and without stopping the heart, which is relatively a less invasive procedure.

Stage II (02/03/2009): In the second stage keyhole operation in groin was performed to introduce the endovascular stent graft to cover the aneurysm of the ascending arch and descending aorta. This was done under local anesthesia with the patient watching the TV screen. The patient’s recovery was very well and was discharged in 2 days.

Hybrid operation for aortic arch aneurysm is a recent development and only few cases are reported in the literature so far. MIOT has experience in this surgery in about 6 patients with success. Patients with renal transplant are considered high-risk patients for any further major surgical procedures. This case is presented to show that even such complicated problem can be treated successfully in this group of patients. The minimally invasive keyhole operation in this case has made this patient’s recovery very smooth. This patient is first in the world with renal transplant to undergo a complex operation in the thoracic aorta through a minimally invasive approach. If the procedure was not done her kidney would have failed and moreover the aneurysm would have ruptured resulting in a fatal complication. This operation has to be done in a very sterile environment, with advanced technology and with highly skilled personnel.

The surgical team was headed by Dr. V. V. Bashi and assisted by Dr. Kannan R. Nair and Dr. V. Harilal. The interventional team included Dr. Murali, Interventional Radiologist and Dr. Sivakumar, Interventional Cardiologist. The anesthesia team was headed by Dr. Aju Jacob. Besides, a team of dedicated nurses and technicians assisted the operation.

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