Vascular surgeons from ‘Heart and Brain’ saved a patient by performing Bulgaria’s first emergency implantation of a fenestrated endograft

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A 74-year-old patient from Gabrovo with severe abdominal pain and general impairment was admitted to the Vascular Surgery Department of ‘Heart and Brain’ on an emergency basis. After a contrast scan, a rupture (tear) of an abdominal aortic aneurysm was found. This is a life-threatening condition in which a large amount of blood pours into the abdominal cavity and the only treatment is surgical intervention.

The risk of a fatal outcome in classic open surgery for ruptured aneurysm is over 90%. Endovascular aortic aneurysm repair (EVAR) is routinely performed at Heart and Brain Hospital in Pleven, both in elective and emergency patients. The challenge in this case is that the aneurysm involves both renal arteries and the main artery feeding the bowel, and therefore standard endovascular surgery cannot be applied. The only option is to insert a fenestrated endograft, which is not available in the country and whose cost exceeds BGN 70 000.

After a lengthy analysis and a consilium between doctors from different fields, the specialists decided to apply a new approach for our country – a personalized and physiologically modeled prosthesis. This technique has been applied only once in Bulgaria, but not in emergency conditions.

With a series of measurements and precise calculations, vascular surgeons modify the implant for the specific needs of the patient through 3D imaging, followed by the fabrication of the fenestrations (holes) of the endoprostheses in a sterile environment, through which blood supply to the vital organs is ensured. This is followed by the extremely delicate process of inserting stents into the renal arteries and the mesenteric artery (the artery that supplies blood to the intestines). The operation is minimally invasive, lasting 10 hours. Through a small incision in the femoral arteries, under X-ray control in a hybrid operating room, the vascular surgery team was able to save the patient’s life. This highly complex, complex and multi-step procedure requires careful advance preparation, a lot of knowledge and additional skills of the doctors.

“We can count on the fingers of our hands the hospital centres around the world that have successfully implemented this type of surgery. The fabrication of a finished custom prosthesis would take a lot of time and money. Thanks to the teams of ‘Heart and Brain’ and my colleagues from the capital – Dr. Nikola Kolev and Dr. Dimitar Nikolov, we successfully modified an existing graft, which is covered by the NHIF. The patient was in good general condition, up on his feet the very next day,” said vascular surgeon Dr. Todor Samardzhiev, who supervised the surgery.

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