Up close and personal with aortic aneurysms

Hands-on medicine in a simulated surgical setting
November 11th, 2015

On a recent Friday morning, some 20 young scrub-clad surgeons and engineers milled about a large room in the Bioscience Park Center near the Anschutz Medical Campus. After a couple of minutes, they divided into groups and clustered around tables to listen to instructors discuss the fine points of repairing aortic aneurysms.

Attendees gather for vascular surgery conference at the Center for Surgical Innovation Nov. 6.

These were not dry medical lectures, however. At three of the tables, the instructors spoke as they thrust their hands into the open chest cavities of cadavers, exposing organs as the learners looked on intently, taking in the fine points of retroperineal, thoracoabdominal, and paravisceral aortic exposure techniques. At a second set of tables, the instruction focused on practicing putting in grafts and suturing on model torsos.

By the end of the two-hour session, the group had received a flood of information about the repair of aneurysms – ballooning that weakens the walls of the aorta, the largest blood vessel in the body. Later that afternoon, there was more hands-on training, this time on equipment that allows trainees to simulate advancing and placing endografts within the aorta using the wires, catheters, deployment devices, and X-ray imaging machines that are the tools of the craft.

The Nov. 6 event, billed as the “Mile High Aortic Tech Exchange,” took place in a 1,900-square-foot training facility that is the centerpiece of the Center for Surgical Innovation (CSI), a program developed by the University of Colorado School of Medicine. The CU Vascular Surgery and Endovascular Therapy section was co-sponsor with the CSI and CU’s Center for Collaborative Bioinnovation – a joint initiative of the Bioengineering Department and the Vascular Surgery section.

Hot ticket

Spots for the gathering filled quickly, said Sarah Massena, executive director of the CSI. That’s been the case since the center moved into the new space last February, she added. The CSI had 71 training sessions for the first quarter of fiscal year 2016 (July 1 to Sept. 30, 2015), well ahead of the total of 159 for all of fiscal year 2015, Massena said.

CU vascular surgeon Omid Jazaeri, MD (left) discusses aortic aneurysm repair with attendees.

A dozen CU surgical program faculty members participated in the vascular surgery event, which was developed and directed by Omid Jazaeri, MD, assistant professor of Vascular Surgery and Radiology. Three invited faculty – Jason Lee of Stanford; David Rigberg, from UCLA; and Murray Shames, from the University of South Florida – also participated. An educational grant from medical device manufacturer Medtronic to the CU Foundation paid for most of the expenses, Jazaeri said, but the purpose of the gathering was training and learning, not sales.

“Sometimes there are gaps in knowledge because of a lack of volume of cases and expertise, or practice patterns,” Jazaeri said. “These educational events allow physicians with expertise to come together in a focused manner to present trends and data and information about managing aortic disease. There are many different tools and devices to treat aneurysms, and our faculty are skilled in using many medical devices.”

Jazaeri noted that open and minimally invasive surgical techniques were not the sole focus of the conference. Shames, for example, addressed determining whether or not patients need aortic surgery. Jazaeri discussed radiation safety, and Beth Kujawski, manager of clinical reimbursement for the Department of Radiology at University of Colorado Hospital, provided information about coding for vascular surgical procedures involving aortic repairs.

Join the club

Standing over a cadaver, CU vascular surgeon Mark Nehler, MD (left), talks with trainees about locating a paravisceral abdominal aneurysm.

Rigberg, who is section chief of vascular surgery at Santa Monica-UCLA Hospital, said relatively small, hands-on training sessions like the one at CSI have become more common in the past several years and are especially valued in the vascular surgery community, which is relatively small.

“Every vascular trainee attends one at some point,” Rigberg said. The courses aren’t all about learning the newest techniques, either, he added. With the proliferation of endograft repair, for example, training in open procedures is more in demand, he said.

The meetings are also networking events for the highly skilled, and pathways to future positions for residents and fellows who attend, Rigberg said. “These are opportunities to meet and work with people who will be future colleagues,” he said. “They are a huge recruiting tool.”

Building name, reputation, and relationships is especially important for the vascular surgery fellowship program at CU, which is only two years old, Jazaeri said. Courses that draw clinicians and engineers from around the country “demonstrate the value of the CSI and the activities we can sponsor,” Jazaeri said.

He also sees the CSI as a way to “bridge the gap” between clinicians and engineers. The university’s Bioengineering Department, which moved into the new Bioscience 2 building across the street from the Bioscience Park Center last summer, is working with the CSI to give young bioengineers opportunities to observe simulated surgeries and gain a greater understanding of the operating-room and other clinical environments.

The collaboration is a two-way street, Jazaeri said. “I would love to have an engineer in all of my cases to identify unmet needs. As physicians we are taught to be holistic in the care of our patients, and our engineering colleagues are focused and problem solvers.”

Hand-off to hands-on

But improvements come with familiarity, and the Friday sessions pivoted on the practical. During the morning simulation, CU surgeon Mark Nehler, MD, stood over a cadaveric torso, his hands moving organs about as he spoke to the observers. Nehler demonstrated how to locate a paravisceral abdominal aortic aneurysm – a bulge in the artery where it attaches to and feeds the arteries of the liver, stomach, intestines, kidneys, and colon.

Jason Lee, MD (right), a vascular surgeon with Stanford Health Care, watches a simulation of an endograft at the CSI.

“I’m mobilizing the colon,” Nehler said, as he pushed his way deeper into the cavity with the trainees looking on. He then went on to point to the pancreas and the renal artery, keeping the kidney down while he exposed the paravisceral artery. All the while, Nehler’s listeners peered down intently as his hands worked.

In the afternoon, high-tech took over, as the trainees worked on devices that simulated the placement of endografts. The simulators allow learners to practice delivering a graft crimped to the end of a delivery device to a weakened aortic wall, using guidewires and catheters threaded through the femoral artery to the diseased area. A simulated X-ray of the structures shows the advance of the delivery device and contrast injected to show the aneurysm clearly. With a twist and push of the device’s long handle, the graft expands within the artery, reinforcing the wall.

A hole in the simulator stands in for the femoral artery, and small bearings within it mimic the friction the surgeon feels in threading the guidewires and device through the artery, Jazaeri said. The “procedure” plays out on X-ray, providing another layer of realism.

“It allows surgeons to do a case without doing a case,” Jazaeri said. “It’s a focused and direct way to practice and have discussions about comprehensive care for aortic patients.”

Next up

David Rigberg, MD, vascular surgery chief at Santa Monica-UCLA Hospital, watches as trainees practice suturing a graft to repair an aortic aneurysm.

The vascular surgery sessions were a prelude to other important upcoming conferences, Massena said. Among others, a three-day conference beginning Nov. 13 will draw neurosurgeons interested in radiofrequency and laser ablation of brain lesions. Also on tap are training sessions for spine procedures in collaboration with medical technology device manufacturer Stryker, and two events with da Vinci robotic systems, she said.

Massena and her colleagues spend dozens of hours organizing the events and juggling travel and lodging logistics for attendees. But it’s gratifying to see the CSI meet its mission, she said.

“It all comes down to patient safety,” Massena said. “We offer surgeons a chance to perfect and practice their skills before they go in the OR. The CSI is a non-stressful environment that encourages learning and asking questions to enhance safety.”

About the author

Tyler Smith has been a health care writer, with a focus on hospitals, since 1996. He served as a writer and editor for the Marketing and Communications team at University of Colorado Hospital and UCHealth from 2007 to 2017. More recently, he has reported for and contributed stories to the University of Colorado School of Medicine, the Colorado School of Public Health and the Colorado Bioscience Association.