Selected Podcast
The Emory Aortic Center
Yazan Duwayri, MD and Bradley G Leshnower, MD join the podcast in this panel discussion about the Emory Aortic Center, and how it brings together the experience, expertise and passion of Emory’s cardiac and vascular surgeons to offer the latest endovascular options.
Featuring:
Learn more about Bradley G Leshnower, MD
Bradley G Leshnower, MD | Yazan Duwayri, MD
Bradley G Leshnower, MD earned his MD from the University of Texas Southwestern Medical School and did his general surgery residency and cardiac surgery research fellowship at the University of Pennsylvania. He also completed a fellowship in aortic surgery at the Hospital of the University of Pennsylvania and a fellowship in endovascular surgery at the Arizona Heart Institute. He joined the Emory Department of Surgery faculty after completing his Emory cardiothoracic surgery residency.Learn more about Bradley G Leshnower, MD
Since joining the Department of Surgery of the Emory university School of Medicine in 2011, Yazan Duwayri, MD has been heavily involved with developing Emory's use of customized fenestrated aortic endografts for treating juxtarenal aortic aneurysms. In 2012, he and Dr. Ravi Veeraswamy successfully implanted Georgia's first FDA-approved fenestrated aortic endograft as a minimally invasive treatment for patients with complex abdominal aortic aneurysms. Dr. Duwayri has continued to perform the procedure on appropriate patients referred from Georgia and neighboring states.
Learn more about Yazan Duwayri, MD
Learn more about Yazan Duwayri, MD
Transcription:
Melanie Cole (Host): Welcome to Emory Healthcare Rounds, I'm Melanie Cole. Today's topic is the Emory Aortic Center, and my guests in this panel discussion today are Dr. Yazan Duwayri - he's the Co-Director of the Emory Aortic Center and an Associate Professor of Surgery at Emory University School of Medicine - and Dr. Bradley Leshnower. He's an Associate Professor of Surgery in the Division of Cardiothoracic Surgery at Emory University School of Medicine. Dr. Duwayri, I'm going to start with you. Tell us a little bit about the myriad of aortic diseases, conditions that you see and deal with every day.
Dr. Yazan Duwayri, MD (Guest): So the aorta can be involved with multiple kinds of pathologies. The main problem that affects the aorta is related to involvement in atherosclerotic disease, and this can result in degeneration of the aorta that can result in aneurysmal degeneration, or enlargement of the aorta that could cause it to rupture.
The other thing that atherosclerosis of the aorta can result in is aortic occlusion, and this happens at a more distal portion of the aorta usually, and below the renal arteries, that is the aorta and the abdomen.
The other pathologies or results from weakening of the wall of the aorta as a result of hypertension or genetic disorders, and that problem usually manifests itself as acute aortic dissection, which can result in multiple complications such as aortic rupture or valve perfusion affecting the blood supply to the bowels, the renal arteries, as well as the lower extremities, or even the spinal cord.
Host: Dr. Leshnower, what are some of the challenges of aortic conditions? What makes this such a unique specialty?
Dr. Bradley Leshnower, MD (Guest): There's two things that come to mind. Number one is clinical judgment. We frequently monitor patients for years with asymptomatic aneurysms closely, measuring them with high definition imaging to try and get within one to two millimeters of precise size diameters as an indication of when the aorta is growing, and that an operation which is higher risk would ultimately prevent rupture and save the patient's life.
So that's the one thing with judgment, and then the second would be the technical expertise required to perform these operations. And when I think about technical expertise, I think about both open surgical techniques as well as endovascular techniques to fix the aorta both by replacing it or fixing it from the inside. At the Emory Aortic Center, I feel we possess unique expertise in both areas.
Host: Dr. Duwayri, tell us about the Emory Aortic Center, and what's it like for patients? What can they expect when they arrive there?
Dr. Duwayri: So the Emory Aortic Center is really a collaborative effort between cardiac surgery and vascular surgery, but also involves other specialties such as cardiology, genetics, and radiology. And the idea is to provide the patients with a comprehensive aortic disease management and comprehensive experience.
So usually when a patient is referred to us, we of course obtain imaging of the aorta, as Dr. Leshnower has mentioned, and this allows us to identify the pathology and whether it warrants repair or not. So at this stage of course, there is collaboration with radiology to kind of understand the problem affecting the aorta and its extent to decide whether it warrants repair or further surveillance.
And during the initial meeting with the patient, we provide consultation and many times it's reassurance that this just needs to be monitored and nothing to read up on immediately. And if it does warrant intervention, of course a discussion happens usually in the background between the specialties that will be involved in repair. Frequently the repair of the aorta involves the expertise of both vascular surgery and cardiac surgery, and we do conduct regular meetings to talk about challenging cases that we encounter.
And the feedback is given to the patient about the options of repair, whether they are open surgical repair, endovascular repairs, or a combination of both, and we tell patients the benefits and the risks of each repair option, and we involve the patient in the decision making of course.
Host: Expand a little bit, Dr. Duwayri, on that multi-disciplinary care you were discussing. When you're discussing cardiac and vascular surgeons working together, who else is involved at the Aortic Center? What does that multi-disciplinary care look like?
Dr. Duwayri: So sometimes the aorta becomes diseased as a result of a genetic dysfunction or a genetic disorder, and it's important to identify the familial history of aortic conditions when a patient presents to us. And if such a history is unraveled, we usually involve genetic testing, and we have an active genetics department here. And if we need to- if the patient presents at a young age, and we need to involve genetic testing of other family members at a young age, we involve cardiologists and pediatric cardiologists as well.
Host: That's so interesting, and what a great way to have that collaborative approach. Dr. Leshnower, with the expertise and passion of Emory's cardiac and vascular surgeons, tell us- when Dr. Duwayri re-mentions those meetings that you have, and those collaborations, what does that mean for the patient when you're getting together and you're discussing a case? What does that look like?
Dr. Leshnower: Well, typically we review the images together. We decide whether we want to approach the problem with an open or endovascular technique. We consider both and then once we've made our decision, we both- the cardiac and vascular surgeon go see the patient together, introduce ourselves and why the patient is seeing not one, but two surgeons with two different specialties, explain to them in detail why we feel that combining our expertise offers extreme benefit to the patient, we explain then how our approach and why we would want to repair the aorta in a certain way, and the patients are very grateful actually that they've initially come to what they thought was to see a specific surgeon, and then now are benefiting from the expertise offered from the Emory Aortic Center.
Additionally, I would add that they are all then offered the most cutting edge technology with regard to clinical trials and devices both in the open, hybrid, and endovascular arenas, as well as they are also involved in a lot of our clinical invasive science research.
Host: Dr. Leshnower, expand a little bit about the hybrid procedures and what that means for the center and for the patient.
Dr. Leshnower: So the term 'hybrid' refers to combining open surgical techniques with more contemporary evolving endovascular techniques. So for example, if we're working on an aortic arch problem, we might perform a minimally invasive sternotomy to gain access to the ascending aorta, and then use a combination of open surgical techniques combined with stent grafts to treat arch pathology in patients who might otherwise not do as well with the standard open only surgical technique. And by combining the open and endovascular expertise that we have, we can offer the patient another treatment option.
Host: Dr. Duwayri, is there a stand-out case you were involved in? Tell us something interesting about a particular case or diagnosis.
Dr. Duwayri: Well, we recently encountered a young patient who was sixteen years old at the time of presentation. He was transferred from another facility with an extremist because he had suffered an aortic rupture while playing basketball on the field. And this is of course unusual for a young patient at his age, and therefore it was felt that this patient be managed at Emory, and therefore was transferred to our institution.
This patient of course underwent emergent treatment to treat this aortic dissection that had resulted in aortic rupture, and had excellent outcome. But most importantly, afterwards we've continued to monitor the patient's aorta, and did refer him for genetic testing that fortunately came out negative. But despite that, we continue to feel that this patient is at risk if not monitored regularly, and he has done very well over the last couple of years.
Host: Dr. Leshnower, tell us about some of the promising therapies, and what current research indicates for future developments and treatments. Speak if you would about the investigation of potential new mechanism-based pharmacologic interventions or the genetic bases, as Dr. Duwayri was just discussing a little bit. Tell us what's going on in the field and what you're looking for.
Dr. Leshnower: Well, we have a number of clinical trials that are using branch endovascular devices to treat arch pathology and abdominal aortic aneurysm pathology as well, which involves the visceral vessels. And these are not available in very many places in the country, much less in metropolitan Atlanta. So we feel that we can offer patients who might not get treated anywhere else a treatment option.
We also are studying the aortic tissue that we actually remove from patients, we've created an aortic tissue bank, and we're working with our colleagues at Georgia Tech to study tissue biomechanics to try and learn more about aneurysm and dissections, ultimately trying to figure out in a non-invasive way which patients have a higher risk of aneurysm rupture with knowledge of their tissue biomechanics, as well as features on their CT scan or MRIs.
As far as genetics, we have- we're working with our genetic colleagues, but currently that is more of a clinical-based application of their expertise to identify family members that may be at higher risk for aortic emergencies or issues throughout their life.
Host: Dr. Duwayri, tell other physicians as a bit of a summary - this is kind of the first last word to you - what you'd like them to know about the Emory Aortic Center, and when to refer.
Dr. Duwayri: I think it's important for physicians to know that the goal of the Emory Aortic Center is to provide a comprehensive management of the aorta for the patient and the best methods possible. This may or may not result in a patient undergoing an operation, but will definitely result in offering the patient the best treatment option that is available. That can include also medical therapy and surveillance.
The options that we can offer a patient in terms of repair are vast and they include minimally invasive endovascular repair that results in rapid recovery and resumption of the patient's normal activity. It is usually what makes this technology most attractive to patients and repairing physicians.
We do maintain contact with the repairing physician to maintain these physicians' involvement in their patient's care, since usually physicians like to stay involved and continue to manage their patients after they undergo surgical intervention, and we believe this is essential for the patient's best outcome.
Usually a referral can happen through the Direct Aortic Center Line, and triage of the patient can happen through a nurse practitioner- an aortic nurse practitioner who will review the patient's record and connect them with the needed physician.
Host: Thank you for that answer, Doctor, because you really answered my next question for you in what can a physician expect from your team as far as communication after referral. So you got right to that. That was a very important point to make for other physicians. Dr. Leshnower, I'd like you to wrap up please. Give us your best information, what you would like us to take away from this segment about the Emory Aortic Center.
Dr. Leshnower: I think the Emory Aortic Center serves as a referral center for families where we can treat aortic pathology - emergent and elective problems, for the entire family - and provide comprehensive care, offering the most cutting edge technologies and therapies and really providing world class comprehensive care for aortic disease.
Host: Thank you, gentlemen, for joining us today, for sharing your expertise, and for explaining the Emory Aortic Center to other physicians, and why referral is so important, and how to go about referring a patient. Thank you, again. You're listening to Emory Healthcare Rounds. For more information on the Emory Aortic Center, please visit www.EmoryHealthcare.org/aortic. That's www.EmoryHealthcare.org/aortic. This is Melanie Cole, thanks so much for tuning in.
Melanie Cole (Host): Welcome to Emory Healthcare Rounds, I'm Melanie Cole. Today's topic is the Emory Aortic Center, and my guests in this panel discussion today are Dr. Yazan Duwayri - he's the Co-Director of the Emory Aortic Center and an Associate Professor of Surgery at Emory University School of Medicine - and Dr. Bradley Leshnower. He's an Associate Professor of Surgery in the Division of Cardiothoracic Surgery at Emory University School of Medicine. Dr. Duwayri, I'm going to start with you. Tell us a little bit about the myriad of aortic diseases, conditions that you see and deal with every day.
Dr. Yazan Duwayri, MD (Guest): So the aorta can be involved with multiple kinds of pathologies. The main problem that affects the aorta is related to involvement in atherosclerotic disease, and this can result in degeneration of the aorta that can result in aneurysmal degeneration, or enlargement of the aorta that could cause it to rupture.
The other thing that atherosclerosis of the aorta can result in is aortic occlusion, and this happens at a more distal portion of the aorta usually, and below the renal arteries, that is the aorta and the abdomen.
The other pathologies or results from weakening of the wall of the aorta as a result of hypertension or genetic disorders, and that problem usually manifests itself as acute aortic dissection, which can result in multiple complications such as aortic rupture or valve perfusion affecting the blood supply to the bowels, the renal arteries, as well as the lower extremities, or even the spinal cord.
Host: Dr. Leshnower, what are some of the challenges of aortic conditions? What makes this such a unique specialty?
Dr. Bradley Leshnower, MD (Guest): There's two things that come to mind. Number one is clinical judgment. We frequently monitor patients for years with asymptomatic aneurysms closely, measuring them with high definition imaging to try and get within one to two millimeters of precise size diameters as an indication of when the aorta is growing, and that an operation which is higher risk would ultimately prevent rupture and save the patient's life.
So that's the one thing with judgment, and then the second would be the technical expertise required to perform these operations. And when I think about technical expertise, I think about both open surgical techniques as well as endovascular techniques to fix the aorta both by replacing it or fixing it from the inside. At the Emory Aortic Center, I feel we possess unique expertise in both areas.
Host: Dr. Duwayri, tell us about the Emory Aortic Center, and what's it like for patients? What can they expect when they arrive there?
Dr. Duwayri: So the Emory Aortic Center is really a collaborative effort between cardiac surgery and vascular surgery, but also involves other specialties such as cardiology, genetics, and radiology. And the idea is to provide the patients with a comprehensive aortic disease management and comprehensive experience.
So usually when a patient is referred to us, we of course obtain imaging of the aorta, as Dr. Leshnower has mentioned, and this allows us to identify the pathology and whether it warrants repair or not. So at this stage of course, there is collaboration with radiology to kind of understand the problem affecting the aorta and its extent to decide whether it warrants repair or further surveillance.
And during the initial meeting with the patient, we provide consultation and many times it's reassurance that this just needs to be monitored and nothing to read up on immediately. And if it does warrant intervention, of course a discussion happens usually in the background between the specialties that will be involved in repair. Frequently the repair of the aorta involves the expertise of both vascular surgery and cardiac surgery, and we do conduct regular meetings to talk about challenging cases that we encounter.
And the feedback is given to the patient about the options of repair, whether they are open surgical repair, endovascular repairs, or a combination of both, and we tell patients the benefits and the risks of each repair option, and we involve the patient in the decision making of course.
Host: Expand a little bit, Dr. Duwayri, on that multi-disciplinary care you were discussing. When you're discussing cardiac and vascular surgeons working together, who else is involved at the Aortic Center? What does that multi-disciplinary care look like?
Dr. Duwayri: So sometimes the aorta becomes diseased as a result of a genetic dysfunction or a genetic disorder, and it's important to identify the familial history of aortic conditions when a patient presents to us. And if such a history is unraveled, we usually involve genetic testing, and we have an active genetics department here. And if we need to- if the patient presents at a young age, and we need to involve genetic testing of other family members at a young age, we involve cardiologists and pediatric cardiologists as well.
Host: That's so interesting, and what a great way to have that collaborative approach. Dr. Leshnower, with the expertise and passion of Emory's cardiac and vascular surgeons, tell us- when Dr. Duwayri re-mentions those meetings that you have, and those collaborations, what does that mean for the patient when you're getting together and you're discussing a case? What does that look like?
Dr. Leshnower: Well, typically we review the images together. We decide whether we want to approach the problem with an open or endovascular technique. We consider both and then once we've made our decision, we both- the cardiac and vascular surgeon go see the patient together, introduce ourselves and why the patient is seeing not one, but two surgeons with two different specialties, explain to them in detail why we feel that combining our expertise offers extreme benefit to the patient, we explain then how our approach and why we would want to repair the aorta in a certain way, and the patients are very grateful actually that they've initially come to what they thought was to see a specific surgeon, and then now are benefiting from the expertise offered from the Emory Aortic Center.
Additionally, I would add that they are all then offered the most cutting edge technology with regard to clinical trials and devices both in the open, hybrid, and endovascular arenas, as well as they are also involved in a lot of our clinical invasive science research.
Host: Dr. Leshnower, expand a little bit about the hybrid procedures and what that means for the center and for the patient.
Dr. Leshnower: So the term 'hybrid' refers to combining open surgical techniques with more contemporary evolving endovascular techniques. So for example, if we're working on an aortic arch problem, we might perform a minimally invasive sternotomy to gain access to the ascending aorta, and then use a combination of open surgical techniques combined with stent grafts to treat arch pathology in patients who might otherwise not do as well with the standard open only surgical technique. And by combining the open and endovascular expertise that we have, we can offer the patient another treatment option.
Host: Dr. Duwayri, is there a stand-out case you were involved in? Tell us something interesting about a particular case or diagnosis.
Dr. Duwayri: Well, we recently encountered a young patient who was sixteen years old at the time of presentation. He was transferred from another facility with an extremist because he had suffered an aortic rupture while playing basketball on the field. And this is of course unusual for a young patient at his age, and therefore it was felt that this patient be managed at Emory, and therefore was transferred to our institution.
This patient of course underwent emergent treatment to treat this aortic dissection that had resulted in aortic rupture, and had excellent outcome. But most importantly, afterwards we've continued to monitor the patient's aorta, and did refer him for genetic testing that fortunately came out negative. But despite that, we continue to feel that this patient is at risk if not monitored regularly, and he has done very well over the last couple of years.
Host: Dr. Leshnower, tell us about some of the promising therapies, and what current research indicates for future developments and treatments. Speak if you would about the investigation of potential new mechanism-based pharmacologic interventions or the genetic bases, as Dr. Duwayri was just discussing a little bit. Tell us what's going on in the field and what you're looking for.
Dr. Leshnower: Well, we have a number of clinical trials that are using branch endovascular devices to treat arch pathology and abdominal aortic aneurysm pathology as well, which involves the visceral vessels. And these are not available in very many places in the country, much less in metropolitan Atlanta. So we feel that we can offer patients who might not get treated anywhere else a treatment option.
We also are studying the aortic tissue that we actually remove from patients, we've created an aortic tissue bank, and we're working with our colleagues at Georgia Tech to study tissue biomechanics to try and learn more about aneurysm and dissections, ultimately trying to figure out in a non-invasive way which patients have a higher risk of aneurysm rupture with knowledge of their tissue biomechanics, as well as features on their CT scan or MRIs.
As far as genetics, we have- we're working with our genetic colleagues, but currently that is more of a clinical-based application of their expertise to identify family members that may be at higher risk for aortic emergencies or issues throughout their life.
Host: Dr. Duwayri, tell other physicians as a bit of a summary - this is kind of the first last word to you - what you'd like them to know about the Emory Aortic Center, and when to refer.
Dr. Duwayri: I think it's important for physicians to know that the goal of the Emory Aortic Center is to provide a comprehensive management of the aorta for the patient and the best methods possible. This may or may not result in a patient undergoing an operation, but will definitely result in offering the patient the best treatment option that is available. That can include also medical therapy and surveillance.
The options that we can offer a patient in terms of repair are vast and they include minimally invasive endovascular repair that results in rapid recovery and resumption of the patient's normal activity. It is usually what makes this technology most attractive to patients and repairing physicians.
We do maintain contact with the repairing physician to maintain these physicians' involvement in their patient's care, since usually physicians like to stay involved and continue to manage their patients after they undergo surgical intervention, and we believe this is essential for the patient's best outcome.
Usually a referral can happen through the Direct Aortic Center Line, and triage of the patient can happen through a nurse practitioner- an aortic nurse practitioner who will review the patient's record and connect them with the needed physician.
Host: Thank you for that answer, Doctor, because you really answered my next question for you in what can a physician expect from your team as far as communication after referral. So you got right to that. That was a very important point to make for other physicians. Dr. Leshnower, I'd like you to wrap up please. Give us your best information, what you would like us to take away from this segment about the Emory Aortic Center.
Dr. Leshnower: I think the Emory Aortic Center serves as a referral center for families where we can treat aortic pathology - emergent and elective problems, for the entire family - and provide comprehensive care, offering the most cutting edge technologies and therapies and really providing world class comprehensive care for aortic disease.
Host: Thank you, gentlemen, for joining us today, for sharing your expertise, and for explaining the Emory Aortic Center to other physicians, and why referral is so important, and how to go about referring a patient. Thank you, again. You're listening to Emory Healthcare Rounds. For more information on the Emory Aortic Center, please visit www.EmoryHealthcare.org/aortic. That's www.EmoryHealthcare.org/aortic. This is Melanie Cole, thanks so much for tuning in.