Endovascular Therapy

Endovascular therapy focuses on treating vascular disease, which affects the body's circulation and is a major cause of heart disease. At Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, we specialize in minimally invasive therapy and stent graft treatment for aortic aneurysm and vascular disease. Because of our affiliation with Johns Hopkins Medicine International, we internationally recognized in the care of vascular diseases and are particularly renowned for complex aortic surgery

We specialize in the following procedures:

• Aortic stent grafts - A stent-graft is positioned across the aneurysm, with its ends seated into the normal diameter aorta above and below the aneurysm. The stent-graft is delivered via specialized catheters, which are introduced through small surgical incisions in the groin. It is threaded through the abdominal aorta using X-ray guidance.
• Carotid endarterectomy - Carotid endarterectomy is an operation during which your vascular surgeon removes the inner lining of your carotid artery if it has become thickened or damaged. This procedure eliminates a substance called plaque from your artery and can restore blood flow.
• Carotid stenting - Carotid artery stenting is a procedure in which your vascular surgeon inserts a slender, metal-mesh tube, called a stent, which expands inside your carotid artery to increase blood flow in areas blocked by plaque.
• New techniques in dialysis access - Dialysis access is an entranceway into your bloodstream that lies beneath your skin and is easy to use. The access is usually in your arm or leg and allows blood to be removed and returned quickly, efficiently, and safely during dialysis or, less commonly, for other procedures requiring frequent access to your circulation.
• Non-invasive blood vessel imaging – This involves using ultrasound, CAT scans and various other techniques for viewing blood vessels without using standard surgical techniques.
• Uterine Fibroid Embolization - Uterine fibroid embolization (UFE) is a non-surgical technique that shrinks fibroids in the uterus without removing them.

Coil for Brain Aneurysm Treatments
An aneurysm is an abnormal widening or ballooning of a portion of a blood vessel. It often resembles a sac of blood attached to one side of the vessel. These fluid-filled bulges or sacs that form on the weakened walls of arteries can lead to stroke or death when they burst. Symptoms of an aneurysm usually do not appear until complications develop. They can include: hemorrhaging, weakness, numbness or other loss of nerve function. Traditional treatment for a brain aneurysm is cranial surgery where the vessel is clipped or coil embolization where a coil is inserted through a catheter in the groin to the area where bleeding can then be controlled.

It is estimated 2 percent and 5 percent of the United States population will have cerebral aneurysms, although most go undetected. In excess of 150,000 cerebral aneurysm patients are treated annually worldwide. If you have been diagnosed with a brain aneurysm, Hospital Punta Pacifica in Panama City, Panama is the place to come.

Prior to Surgery

Any necessary precautions prior to surgery will be outlined for you in the treatment plan. If you require pre-op therapy, you will receive the proper instructions. If you are a smoker, you may be asked to stop for a time prior to your surgery. You might also be asked to refrain from using vitamin E (in large does), aspirin or anti-inflammatory medicines since they can lead to increased bleeding during surgery.

The Procedure

Coiling is performed by a neuroradiologist or endovascular surgeon. An incision is used in the groin to access the artery and to allow a catheter to be inserted and guided up to the brain. This process is guided with the use of computer-aided X-ray scanners. Once the catheter is in place, a contrast dye is added to the bloodstream in order to make the artery and the aneurysm clearly visible and to aid in obtaining good images. The characteristics of the aneurysm, including shape, size and exact location, are determined and recorded; this part of the procedure is similar to an angiogram. A microcatheter is then introduced through the larger catheter and used to place coils into the aneurysm. They are individually placed and detached from the microcatheter by a small electric current and then form a mesh similar to steel wool. Blood cells are trapped in this mesh and clot in a process called "thrombosis", which seals off the aneurysm from the artery circulation.

After your surgery

After care for this surgery depends largely on what damage is done before and during the procedure. In cases where there are hemorrhages, it is not uncommon that the patient is in the hospital for 10 days to 2 weeks with extensive rehabilitation following.

Risks

Any surgery concerning the brain is considered high risk. The risks of this procedure include:

• Weakness or paralysis of an arm or a leg
• Difficulty with speech or understanding
• Vision impairment
• Confusion, memory loss and/or seizures
• Infection
• Bleeding
• Kidney damage from X-ray dyes

Surgery always has an element of risk. We have attempted to minimize that risk by having an American-trained surgeon, a professional staff and a world-class hospital ready for your Panama brain aneurysm coil surgery. At Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, we want your visit to be a safe and rewarding procedure.

Correcting Brain Arteriovenous Malformations
Brain arteriovenous malformations are collections of non-standard blood vessels which develop in the brain. They include a blood vessel "nidus" (or nest) where the arteries connect directly to veins, instead of through the complex collection of very small vessels called capillaries. Brain arteriovenous malformations can occur in any area of the brain, and may be either small or large. If they hemorrhage, they usually do so with a limited amount of blood, unlike the hypertensive hemorrhages of other stroke patients. Loss of function varies depending on both the location of the brain arteriovenous malformations and the amount of bleeding. Many patients have very small hemorrhages, often multiple. They experience convulsions before even knowing about the presence of brain arteriovenous malformations. Some patients suffer with headaches, often unrelated to the brain arteriovenous malformations which are usually found with a CT scan or brain MRI. In only a few instances, children are born with large brain arteriovenous malformations and may experience heart failure because the malformation makes the heart work beyond its capacity.

These lesions are surrounded by a very discrete layer of abnormal, nonfunctioning brain tissue, thus allowing their removal with relative safety to the surrounding brain. This factor is of the utmost importance to the brain surgeon, who can take advantage of this natural separation between normal brain tissue and the abnormal vascular malformation.

The surgery for brain arteriovenous malformations or any other condition of the brain is serious and you will want the best of care. That is the reason you need to consider a trip to Panama City, Panama and Hospital Punta Pacifica.

The Procedure

There are three different methods of treating brain arteriovenous malformations; radiation, embolization and invasive surgery. A patient’s symptoms and the location of the brain arteriovenous malformation dictate which method is employed by the neurosurgeon.

Radiation

If there is a very small brain arteriovenous malformation that is deep within the brain, the patient is considered fortunate. It is possible to give focused beam radiation to the malformation, and avoid surgery. In cases such as these, the malformation will most likely disappear within two years.

Embolization

Larger malformations may be surgically corrected with a technique called embolization. With this procedure an angiogram becomes a therapeutic tool much like the procedure for correcting an aneurysm. An angiogram is capable of filling the malformation in order to eliminate the blood supply to the malformation. This surgery is the easiest alternative in some cases and has performed successfully.

Surgery

If treatment is deemed necessary and the other methods are not considered to be options, invasive surgery is required. Microsurgical resection, due to advances in microscopic visualization, computer assisted stereotactic guidance and electrophysiologic monitoring, has become a much safer and successful procedure. When possible to perform, surgical resection is the preferred method of treatment because it provides an immediate and permanent elimination of the risk of hemorrhage, improvement in neurologic function, and a decrease in the incidence of seizures. The disadvantage is that it requires an open operation, meaning that the skull is opened and the surgeon has a clear view of the affected region.

After your surgery

Your recovery will be directly related to the type of procedure that you have to treat you brain arteriovenous malformation. Recovery from radiation will be similar to other radiation treatments and the AVM will likely disappear in two years or less. Recovery from embolization is rapid and the results are almost immediately known. While surgery requires an open cranial procedure, microsurgical resection is greatly reducing the effects of this procedure.

Risks

Surgical risks with a brain arteriovenous malformation procedure are similar to other intracranial treatments; stroke, loss of function in other areas of the body and even death. Loss of function is dictated by the area of the brain affected by the brain arteriovenous malformation.

Surgery always has an element of risk. We have attempted to minimize that risk by having an American-trained surgeon, a professional staff and a world-class hospital ready for your Panama brain arteriovenous malformation surgery. At Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, we want your visit to be a safe and rewarding procedure.

Unilateral Carotid Stent
Unilateral carotid stenting is a surgical procedure in which your surgeon inserts metal-mesh tubing called a stent inside your carotid artery to increase blood flow in areas blocked by plaque.

Because of hardening of the arteries, plaque builds up in the walls of your arteries as you age. As plaque increases, your arteries will narrow and stiffen. Eventually, enough plaque may build up to reduce blood flow through your arteries, or cause blood clots or pieces of the plaque to break away and block the arteries in the brain beyond the plaque.

You have carotid arteries located on each side of your neck and they extend from the aorta in your chest to the base of your skull. These arteries supply blood to your brain. You have one main carotid artery on each side, and each of these divides into two major branches, the external and the internal.

When plaque accumulates and reduces blood flow in your carotid arteries, you have carotid artery disease. This can create a serious issue because clots can attach to the plaque and block the blood flow to your brain. If blood flow is blocked to your brain the result is an ischemic stroke, which can cause brain damage or death. Another related problem that the plaque can cause is an arterial embolism; this is when a small piece of plaque or a blood clot breaks becomes loosened and blocks another artery downstream. If the clot blocks a tiny artery in the brain, the result can be a transient ischemic attack a mini-stroke.

When your physician wants to treat a blocked carotid artery, he or she may recommend that you have a stent inserted as an alternative to surgical removal of the plaque, known as unilateral carotid stent. During this procedure, your surgeon places a stent into your carotid artery after performing angioplasty. The stent holds the artery open by holding back the flattened plaque like scaffolding.

The Procedure

Before placing a stent, your surgeon will likely perform an angioplasty. In an angioplasty, your surgeon inserts a thin tube called a catheter with an attached balloon into a small incision over an artery in your arm or groin. Your surgeon guides the catheter to the blockage site in your carotid artery using live x-ray imaging. You will not feel the catheters as they move through your arteries because there are no nerve endings inside your arteries.

Your surgeon may insert a small balloon, basket, or filter called an embolic protection device. This device helps to prevent strokes by catching the clots or debris that may break away from the plaque during the procedure. At the blockage site, the surgeon inflates and deflates the angioplasty balloon to flatten the plaque and widen the space where the blood flows through. After the artery is open, your surgeon will remove the catheter with the balloon attached. Using a different catheter, your surgeon moves a compressed stent to the same area in your carotid artery. Once the stent has been placed, your surgeon will release it. The stent then expands to fit the artery. It is possible that your surgeon will then uses a balloon catheter to further expand the stent.

After your surgery

Immediately after the procedure, pressure is applied to the catheter insertion site in the groin or arm for 15 to 30 minutes to allow it to close and prevent bleeding. If your surgeon inserts the catheters and other instruments through your femoral artery, your physician may instruct you to stay in bed for the next several hours so that you can be monitored for any complications, such as excessive bleeding from the puncture site.

You may be instructed not to lift anything more than about 5 to 10 pounds after you return home to avoid any pressure on the incision. Your surgeon may also instruct you to only shower for a few days and to drink plenty of water to help remove the dye from your system. You will take blood thinning medications and be scheduled for periodic follow-up examinations, typically including carotid ultrasound examinations, to ensure your stent is functioning well.

Risks

Blockage by a clot or other debris in an artery in your brain, called an embolism, is a very serious complication that can occur after carotid stenting since this blockage can cause a stroke. Other risks that can cause a stroke include a blood clot forming along the stent or damage to the artery wall which is called a dissection. Re-blockage of the carotid artery, called restenosis, is also possible. The dye used in an angiogram has been known to cause damage to the kidneys, especially for those already experiencing kidney troubles. Bleeding at the incision site in the groin or arm artery, called a hematoma or a false aneurysm, can also occur, but this is unusual. Bruising and tenderness at the incision site is common and usually diminishes with time.

While there is always an element of risk, having an American-trained surgeon, a professional staff and a world-class hospital make your Panama unilateral carotid stenting at Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, a safe and rewarding procedure.

Thoracic Aortic Aneurysm Surgery
The largest artery in your body, the aorta moves blood from your heart to the other parts of your body. The thoracic aorta is the portion that runs through your chest and the abdominal aorta services your abdomen. When a weak section of your thoracic aorta expands or bulges, it is called a thoracic aortic aneurysm. Approximately 25 percent of aortic aneurysms occur in the chest, and the rest involve the abdominal aorta.

A special type of thoracic aneurysm is called an aortic dissection, and is usually associated with high blood pressure. Sometimes, blood flow forces the layers of the wall of your aorta apart, and it weakens your aorta and can cause TAA. The separation can extend from your thoracic aorta through your entire aorta and block arteries to your legs, arms, kidneys, brain, spinal cord, and other areas. Another problem associated with aortic dissection is that over time, the pressure of blood flow can cause the weakened area of your aorta to bulge like a balloon. Much like an over-inflated balloon, an aneurysm can stretch the aorta beyond its safety margin.

Thoracic aortic aneurysms are a serious health risk because they can burst or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or death.

Thoracic aneurysms affect approximately 15,000 people in the United States each year. Some patients may have more than one TAA or may also have an aneurysm in the abdominal aorta. Only about 20 to 30 percent of patients who get to the hospital with a ruptured TAA survive. For this reason, it is crucial to treat large aneurysms early in order to prevent their rupture.

The Procedure

There are two treatment plans for a thoracic aortic aneurysm. The first is the traditional open surgical repair and the second is the endovascular stent graft repair. The procedures for these are:

Open Surgical Repair

In an open surgical repair, your surgeon makes an incision in your chest and replaces the damaged portion of the aorta with a fabric mesh tube, called a graft. The graft strengthens the weakened aorta and transports blood without causing a bulge. Many patients who have a thoracic aortic aneurysm also have heart disease or involvement of the aorta adjacent to the heart. When a complex thoracic aneurysm surgery is required, it is possible the heart surgery will be performed at the same time as open aneurysm repair.

Endovascular Stent graft repair

Instead of open aneurysm repair, your surgeon may use a promising new procedure called an endovascular stent graft. The term endovascular means that the procedure is performed inside your body using long, thin catheters. The catheters are inserted in small incisions in your groin and are threaded through your blood vessels.

During this procedure, your surgeon will use live x-ray pictures viewed to guide the stent-graft to your aneurysm. Like the graft used in open surgery, this stent permits blood to flow through your aorta without extra pressure on the damaged wall of your aneurysm. This prevents your aneurysm from rupturing. Over time, your aneurysm will shrink.

Your aneurysm must have a suitable shape to allow the stent-graft to be used effectively. With the endovascular stent-graft repair, long-term follow-up with periodic scans of the aortic repair is important to be sure that the stent-graft is working properly.

After your surgery

Your post-surgery recovery will depend on the procedure you have. For an open surgical repair, you may stay in the hospital for 5 to 7 days after the procedure. If your thoracic aortic aneurysm surgery is extensive or complex, you may require 2 to 3 months for a complete recovery.

With an endovascular stent-graft repair, the required hospital stay and following recovery are shorter than with open aneurysm repair. Your hospital stay is reduced to 2 or 3 days and you will begin the process of recovery immediately following the procedure.

Risks

Thoracic aortic aneurysm procedures are complex but relatively safe. Possible complications from the graft include:

• Leaking of blood around the graft, known as “endoleak”
• Movement, or migration, of the graft away from its initial placement
• Stent fracturing

In addition these serious complications can occur:

• Paralysis
• Delayed rupture of the aneurysm
• Infection

Surgery always has an element of risk. We have attempted to minimize that risk by having an American-trained surgeon, a professional staff and a world-class hospital ready for your Panama thoracic surgery. At Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, we want your visit to be a safe and rewarding procedure.

Aortic Aneurysm Repair
The largest artery in your body, the aorta moves blood from your heart to the other parts of your body. The thoracic aorta is the portion that runs through your chest and the abdominal aorta services your abdomen. When a weak section of your aorta expands or bulges, it is called an aortic aneurysm. Approximately 25 percent of aortic aneurysms occur in the chest, and the rest involve the abdominal aorta.

In surgical aortic aneurysm repair, your surgeon repairs or removes an aneurysm through a small incision. An aneurysm is an enlarged and weakened portion of an artery; this is a serious health concern, because as it grows larger, it can rupture. Blood clots can also form in an aneurysm and block blood flow to parts of your body, potentially leading to a stroke.

The Procedure

There are two treatment plans for a thoracic aortic aneurysm. The first is the traditional open surgical repair and the second is the endovascular stent graft repair. The procedures for these are:

Open Surgical Repair

Your surgeon will make an opening in your skin and muscle above the artery with the aneurysm. For an abdominal aortic aneurysm, your surgeon will work through the wall of your abdomen. If your aneurysm is in your knee, your surgeon will be operating on your leg.

After your surgeon prepares the site, he or she will clamp the artery above the aneurysm to stop blood from entering that area of the aorta. Your surgeon will open the aneurysm and removes the clotted blood and plaque deposits.

Typically your surgeon will not completely remove the affected section of your aneurysm. Instead, he or she may cut through the wall of the artery to open it, and then insert a graft the same size and shape as your artery. Your surgeon will attach one end of this graft just above where the aneurysm begins and the other end below the end of the aneurysm. Another method that is less common is to attach a fabric patch to the artery wall to reduce its size and strengthen it.

For aneurysms in the head, a neurosurgeon may use clips or small clamps. The neurosurgeon will place the clip or clamp where the aneurysm attaches to the artery. This keeps blood from inflating the aneurysm and it subsequently deflates.

If clipping the aneurysm is not possible because of its location, he or she may fill the aneurysm with tiny metal or plastic coils. Using a catheter, the surgeon locates the aneurysm in order to insert the coils. The coils fill the inside of the aneurysm and block blood from flowing into it.

After your surgery

Your hospital stay may last for about 7 to 10 days. Your surgeon outline a set of special instructions to follow the surgery such as not lifting anything more than 10 pounds until your incision heals adequately.

Periodically, depending upon its location, your physician may want an imaging study to ensure that your aneurysm is not reformed and that the method of correction functioning correctly.

Risks

Complications are possible following any major surgical procedure. Some of the lesser complications that you may experience are swelling, respiratory or urinary infections, or infections at the incision site. More serious complications that are possible include:

• Heart problems
• Breathing problems
• Kidney problems
• Colon problems

Paralysis in the lower half of the body is rare following abdominal surgery but more common following extensive thoracic aortic aneurysm operation. Surgery for an abdominal aortic aneurysm can sometimes cause scar formation that can interrupts control the flow of semen into the penis as well as causing erectile dysfunction.

Surgery always has an element of risk. We have attempted to minimize that risk by having an American-trained surgeon, a professional staff and a world-class hospital ready for your Panama thoracic surgery. At Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, we want your visit to be a safe and rewarding procedure.

Bilateral Aortofemoral Stent Surgery
The aorta is the main artery of the body, measuring about one inch in diameter and located just in front of the spine. The aorta splits into two aortofemoral arteries just above the pelvis. These two arteries travel through the pelvis, to the groin, then down into the legs. Blockages in these arteries can have serious effects since they are the main source of blood flow to lower half of the body.

A bilateral aortofemoral stenting can also be known as aortobifemoral stenting. This occurs when a graft is needed at the junction of the aorta and the femoral arteries. The new graft is formed in the shape of an upside down y and the top part attaches to the aorta and the lower parts attaching to each of the femoral arteries.

Bilateral aortofemoral stenting is a procedure in which grafts are located to avoid an area of the aorta which is narrowed, weakened or blocked. This surgery requires a skillful surgeon, the kind of surgeon you will find in Panama City, Panama at Hospital Punta Pacifica.

The Procedure

After you are well-anesthetized, a large incision will be made in you abdomen. The blood vessels that are affected lie deep within your body so many of your internal organs will be carefully moved out of the way.

Blood flow through these affected vessels will be briefly stopped with clamps on either side of the area of blockage. A graft will be sewn into place on either the iliac artery or the femoral artery, in an area clear of obstructive plaque. The other end of the graft will be attached to the aorta just above the area where the blockage begins.

The clamps that were placed on the affected blood vessels will be removed. The surgeon will observe to make certain there is sufficient blood flow through the new graft. Your internal organs will be repositioned correctly. The abdominal muscle will be stitched closed and the skin will be closed with either sutures or staples.

After your surgery

Bilateral aortofemoral stenting usually takes about 3-4 hours and afterwards you will probably spend 1-2 days in bed. You will likely remain in the hospital for 5-7 days altogether.

Risks

The following are a list of possible risks from a bilateral aortofemoral stenting:

• Infection of the incision site or the graft itself
• Obstruction of the new graft by blood clots
• Bleeding
• Complications from anesthesia
• Pneumonia
• Scarring
• Heart attack
• Stroke
• Sexual problems if nerves in the pelvic area are damaged during surgery

While there is always an element of risk, having an American-trained surgeon, a professional staff and a world-class hospital make your Panama bilateral aortofemoral stenting at Hospital Punta Pacifica, Affiliated with Johns Hopkins Medicine International, a safe and rewarding procedure.