Earlier this year, Health City Cayman Islands’ Chief Cardiac Surgeon Dr. Binoy Chattuparambil performed the facility’s first hybrid procedure to repair an aortic arch aneurysm. The procedure was made possible by the tertiary care hospital’s state-of-the art Hybrid Cath Lab – the only one of its kind in the Caribbean region.
The patient was a 60-year-old Honduran man who was being treated for intermittent chest pain and hypertension with worsening symptoms. The patient’s cardiologist in Honduras did a CT scan and found that the aorta was dilated to 6.4 centimeters, putting the patient at risk for a dissection or rupture. He was referred to Health City for further treatment.
Dr. Binoy, as he is known, noted that the treatment options for an aortic aneurysm are either surgical repair/replacement or percutaneous stent placement. The difficult aspect of this particular case, he explained, was that the aortic arch – the main artery which gives off blood to the brain, was involved.
“So, that makes it much more complicated, because we cannot stop the blood supply to the brain while putting in the stent. The standard treatment is [to] replace the aortic arch and the descending thoracic aorta with an artificial tube…that is major surgery. We have to split open the breast bone and put [the patient] on a heart lung machine to stop the blood circulation to the brain for some time…because while we perform the arch reconstruction we have to stop the blood supply to the brain and keep the body cooled to 20 degrees centigrade,” Dr. Binoy said.
“It’s a very major surgery, takes 8- 10 hours and the chances of complications are high – like stroke, paraplegia, bleeding and the hospital stay,” he explained.
Dr. Binoy noted that while the standard treatment has a good success rate, it carries such significant risks that the less invasive option of stent graft is preferable.
“The recent advances in this [type of] aortic surgery is the stent. This entails gaining access through a small wire through the groin, and under the X- Ray in the Cath Lab,” he explained.
In this case, however, a hybrid procedure was required due to the involvement of the aortic arch.
Dr. Binoy explained what was done: “A very small incision [was made] in the neck, [and] we performed [the] bypass from the right side of the neck vessel that carries blood to brain to the left side and then from the left side to the blood vessel that goes to the left hand. Then, we advanced the stent through the groin with a small cut in the groin, and put in two stents. The whole procedure was over in two hours’ time and he was off of the ventilator within half an hour. The next day he was in the ward and the third day got discharged. There was no blood transfusion, not much pain and no big cut.”
A CT scan was done following the procedure and the stents were seen to be working well. The patient recently had a follow up visit with Dr. Binoy in his home country, and he has fully recovered and is living a full and active life.
Within the last six months, Dr. Binoy revealed that there have been several other similar hybrid procedures performed, and all were successful.
“All [of these] patients got out of the hospital within three to four days without any blood transfusion. All are doing very well,” he said.
Dr. Binoy gave the credit for the success rate to both the facilities available at Health City’s Hybrid Cath Lab, and to the experienced team.
He said, “So we have that facility here, we have the team and…one man cannot do this kind of procedure without a strong team who are experienced in all those aspects. So we have very competent anesthesiologists, the nurses and…we have this very high-end Hybrid Lab and without which we cannot do these kinds of procedures.”
Dr. Binoy himself has extensive experience in aortic surgeries.
He said, “Aortic surgery is very close to my heart…Back in India where I was working in a tertiary care hospital, I used to do two to three of these kind of procedures a week because it was a referral center for aortic surgery. When I see patients with this kind of problems in this part of the world, often [they] don’t have facilities in the Caribbean or in Central America, I am very happy to help them. I don’t think there are many facilities in this region where they can offer these procedures, and the next option is the USA, but it’s very expensive there.”
He noted that these conditions can be life threatening at times.
Without a procedure to correct the problem, Dr. Binoy said, “Patients will die soon. Either the aortic aneurysm will rupture or they will dissect- both are fatal. So when we get to know about these patients, when we know that we can do it at a very affordable cost with a very good outcome…I am always excited to treat these kind of patients.”
Dr. Binoy also explained the rarity of the procedure in the region, due to lack of facilities and access.
“The hybrid operation for the aortic arch is offered only in the big centers of the developed nations because it needs lots of expertise and experience. Not all hospitals will have this hybrid lab, so even though a doctor has the ability to do it, the infrastructure may not be there, or if the infrastructure is there they won’t have the team who can perform this procedure. So the hybrid procedure for aortic aneurysm, especially involving the aortic arch, is not very common at all,” he said.