Bart Muhs MD- EVAR technologies Today and Beyond

Dr Bart Muhs, Assistant Professor of Vascular Surgery and Co Director of Endovascular Surgery at Yale University School of Medicine, offered some exclusive insights to VascularDeviceForum.com. Dr Muhs was trained at New York University School of Medicine as a general surgeon and vascular fellow. He subsequently completed a PHD at Utrecht University. EVAR development is lead by an outstanding line up of US trained physicians(many of them surgeons I might proudly add) , including Tim Chuter MD who have broadened their exposure in EVAR space with post doc experiences in the fertile and less regulated landscape of the European medical environment. I do think that these doctors represent the new paradigm shift of physician specialization that is not limited by historic definitions of scope of practice as you may notice from Dr. Muhs academic title in the dept of radiology. Dr Muhs is one of the thought leaders for the field of EVAR assisting in creating a vision for sound research driven innovation that leads to clinically relevant aortic stent graft design.

Some of his current investigational work includes:

Abdominal aortic aneurysm – PYTHAGORAS Study. This study evaluates a new endovascular aortic stentgraft to treat abdominal aortic aneurysm in patients who would otherwise require an open surgery.

Thoracic aortic dissection – This study evaluates the use or thoracic stentgrafts to repair acute aortic dissections or tears that can occur in the descending thoracic aorta.

Abdominal aortic aneurysm – This trial uses magnetic resonance imaging to evaluate the effect of placing aortic stentgrafts for the treatment of abdominal aortic aneurysms. Information from this trial will allow for the design and development of improved stentgrafts with better patient outcomes.

Abdominal aortic aneurysm – This institutional study evaluates prognostic factors that can be used to improve patient outcomes following open and endovascular abdominal aortic aneurysm repair.

This is the first of a two part posting from this informative conversation. The prevailing theme in the conversation is that future advances in EVAR will likely be dictated by a greater appreciation for the physiologic differences that distinguish the aneurysmal disease, dissections and traumatic aortic injuries. As well as the age related physiologic differences in these respective pathologies. Aneurysm physiology and biochemistry will ultimately influence stent graft engineerying and design.

Dr Muhs is using EKG-gated phase contrast imaging of the aorta using MRI technology. Using 2mm windows, compliance is being measured in different areas of the aortic environment. Branch segments, angulated segments, posterior wall versus the anterior aneurysm wall. These parameters can be assessed in different aneuryms morphologies, age groups. The study is sponsored by the American Geriatric Society. This study hopes to provide insight into predicting aneurysm behavior based upon this PhaseContrast MRI. Currently the study has accumulated data on normal and healthy volunteers.

Next, we focused on three distinct areas of aortic pathology:

1)Trauma

2) Dissection

3) AAA

I received quite a few questions leading up to the Dr Muhs interview regarding the use of EVAR in repair of traumatic aortic tears. This group represents the potential for significantly improved outcomes with EVAR technology. Frequently, this blunt trauma pathology is associated with other injuries like pelvic injury and intra abdominal visceral injury. Significantly, increasing the trauma score. In this setting, minimally invasive prompt means to treat this aortic injury is potentially life saving, avoiding the need for open thoracic repair.

Dr Muhs work is particularly important in this context as it should reveal the clinically significant physiologic features that characterize the young person's aorta. Dr Muhs elaborated further: Anatomically, these patients have acutely angulated thoracic arches which are highly compliant. In his experience, one pearl involved in the preparation process is the aortic diameters measured by CT scanning in the hypovolemic, compliant aorta. He described an early patient or two that would undergo successful repair acutely only to have a type I leak on follow up. He recommends approximately 30% oversizing to address this concern.

Additionally, his prediction is that future research will demonstrate that many of these patients have completely healed their injury at 12 months or so. Raising the theoretical consideration that a bio absorbable device would obviate the need for a 20 or 30 year old person to have a current devicetype in place for the rest of their life. Ie a bio absorbable aortic stent graft. More to follow in the next post including our discussion about aortic dissections, the new frontier application for stent graft technology and our evolving understanding Please share your ideas about these innovative EVAR ideas

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