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Heart & Vascular
A partnership between ChristianaCare cardiologists and oncologists is enhancing heart care for breast cancer patients receiving high-risk chemotherapy.
The Cardio-Oncology Program was established five years ago by physician leaders from the health system’s Women’s Cardiology Clinic and the Helen F. Graham Cancer Center & Research Institute to prevent and effectively treat cardiotoxicity in breast cancer patients on chemotherapy. The program also sees women with lymphoma and ovarian and uterine cancers who receive high-risk chemotherapy and need to be monitored for cardiotoxicity.
“Through the program, cardiologists closely monitor women before, during and after chemotherapy with drugs known to cause cardiotoxicity,” explained Audrey A. Sernyak, MD, Associate Chief of Cardiology and one of the clinic cardiologists who along with noninvasive cardiologist Robin A. Horn, MD, was instrumental in developing the partnership. “The goal is to protect patients’ heart health and optimize their cancer care in collaboration with oncologists.”
There is a growing need for ongoing patient surveillance because of the emergence of new chemotherapy drugs that can cause cardiotoxicity, and because breast cancer survivors are living longer and dealing with the lasting effects of treatment, according to Dr. Horn.
“Fortunately, there are a number of actions cardiologists can take to address the complication, including prescribing medications, recommending adjustments to care plans and suggesting lifestyle modifications,” Dr. Sernyak noted. “Sometimes, chemotherapy can even be paused to give the heart time to recover from cardiotoxicity, and then resumed so treatment can be completed.”
At ChristianaCare, the Cardio-Oncology Program is structured with patient convenience and efficiency in mind. When women receive a referral, clinic staff schedule appointments for them to have an echocardiogram and see a cardiologist within one week to avoid any delay in the start of their chemotherapy.
“The appointments happen on the same day,” Dr. Sernyak explained. “First, they have their echo and immediately afterward they meet with a doctor to review their results and discuss appropriate next steps based on the findings.”
Patients then return for follow-up testing every three months and appointments with a cardiologist every six months throughout their chemotherapy regimen and beyond to evaluate their heart function and identify and treat any cardiotoxicity that may develop, Dr. Horn added.
Program cardiologists keep referring physicians closely up to date on patients’ status through the ChristianaCare electronic medical record system and personal consultations.
“We emphasize building strong, collaborative working relationships,” Dr. Sernyak said. “The oncologists appreciate the expertise our cardiologists bring to the care team, which enables them to focus on treating breast cancer. It’s a partnership designed to deliver an exceptional patient experience and achieve the best possible medical outcomes.”
To refer a patient to the Cardio-Oncology program at ChristianaCare, please call (302) 623-1929 or fill in the form on this page.
At least 6.5 million people aged 40 years and older in the United States have peripheral artery disease (PAD). Like many chronic cardiovascular conditions, the prevalence of PAD increases with age: By age 70, more than 10% of men and nearly 10% of women will be diagnosed with the disorder. By age 80, those figures increase to more than 25% and 20%, respectively.1
PAD’s most severe manifestation is critical limb ischemia (CLI). Recent research indicates that as many as 1 in 4 people who develop CLI will have an amputation within one year of their diagnosis.2 A 2021 study found that the rate of hospital admissions for CLI increased from 0.9% to 1.4% between 2011 and 2017, while PAD admissions nearly doubled, going from 4.5% to 8.9%, over the same period.3
“With the epidemic of obesity and diabetes, PAD and CLI are increasing,” said Daniel Leung, MD, vascular interventional radiologist and fellowship program director at ChristianaCare, where about 500 endovascular revascularization procedures are performed annually. “Our PAD service at ChristianaCare is very busy, and we have a wealth of expertise in the clinical management of these patients as well as endovascular procedures to save limbs threatened by CLI, performed in our state-of-the-art angiography suites.”
Both the equipment and surgical techniques used to manage PAD and CLI are rapidly evolving. One of the most novel therapies now available at ChristianaCare is transcatheter arterialization of deep veins (TADV), which is used to treat patients with the most severe CLI who have run out of revascularization options. TADV is designed to reestablish blood flow by diverting arterial flow from the tibial artery to deep veins in the foot.
“We connect the vein to the artery and backfill the tissues of the wound to get oxygen to that area,” Dr. Leung explained. “With advances like these, as well as increased awareness among referring physicians to send their patients to specialists like our team if they have PAD, I believe we are making progress in reducing the number of amputations that are done.”
He continued: “This is a rapidly evolving field with lots of innovations and novel devices and, at ChristianaCare, our patients have access to those options, including investigational procedures in clinical trials. We are involved in the development of complex revascularization techniques, such as pedal access and pedal loop revascularization to treat the very small arteries in the foot. Even though this is not generally done that frequently, it is something we do here on a routine basis.”
ChristianaCare was also involved in the trials introducing drug-eluting balloons and drug-eluting stents, which had become common in the treatment of cardiovascular disease, to treat peripheral vascular disease.
“This is now standard of care, but our patients had access to these technologies in trials before they were commercially available,” said Dr. Leung, who also stressed the importance of podiatry and wound care in the management of these patients. “Our team of vascular interventionalists regularly visits our affiliated off-site wound care center to evaluate patients for surgery, as it is more convenient for patients to be seen there.”
The interventional vascular team works closely with ChristianaCare’s team of vascular surgeons and a multidisciplinary group of experts including infectious disease physicians, endocrinologists and nephrologists, as well as the many podiatrists who work in the area. In addition, cardiologist Vikash Rambhujun, MD, has returned to ChristianaCare after a one-year fellowship at Yale University Hospital, where he studied vascular medicine and procedural care of PAD. His work is expected to complement that of the others on the multidisciplinary team.
“We also partner with primary care physicians to raise awareness,” Dr. Leung said. “Many of the patients we see have come into the emergency department with disease that is already quite advanced. By working with primary care and family practice and encouraging them to send patients to us early on, we can improve their outcomes.”
To refer a patient with Peripheral Artery Disease to ChristianaCare, please call (302) 733-5625 or fill in the form on this page.
References
1. CDC. Peripheral arterial disease (PAD). Accessed May 13, 2024. https://www.cdc.gov/heartdisease/PAD.htm#
2. Mustapha JA, Saab FA, Ranger WR, et al. Treatment of peripheral artery disease and critical limb ischemia: an observational Michigan Medicare analysis. J Crit Limb Ischem. 2023;3(2):E56-E63.
3. Anantha-Narayanan M, Doshi RP, Patel K, et al. Contemporary trends in hospital admissions and outcomes in patients with critical limb ischemia: an analysis from the National Inpatient Sample Database. Circ Cardiovasc Qual Outcomes. 2021;14(2):e007539.
ChristianaCare offers prostate artery embolization (PAE) for men with an enlarged prostate—a minimally invasive alternative to traditional surgery.
“Benign prostatic hyperplasia [BPH] is extremely common, affecting more than 50% of men over age 50 and about 90% of men older than age 80,” explained Christopher Grilli, DO, a vascular interventional radiologist.
The condition frequently causes a narrowing of the urethra that interferes with the normal flow of urine from the bladder.
“Prostate artery embolization is an innovative solution to the problem for men who have tried lifestyle changes or medications without achieving satisfactory results, and who would prefer to avoid surgery,” Dr. Grilli noted.
ChristianaCare is the only health system in Delaware that offers the procedure. During PAE, a catheter is inserted through the patient’s wrist or groin and guided by advanced x-ray imaging to the prostate arteries. Tiny beads, or microspheres, are then injected into the vessels, which partially block blood flow and gradually shrink the prostate by 30% to 40%. PAE typically takes one to three hours.
The procedure offers men with BPH many benefits, according to Dr. Grilli.
“The preservation of sexual function is a major factor for men in choosing PAE,” Dr. Grilli said. “Many also prefer the procedure over surgery because it doesn’t involve the insertion of a scope into the urethra and is substantially more comfortable for the patient.”
ChristianaCare closely monitors the effectiveness of PAE by surveying patients before and multiple times after the procedure. The results show 95% of patients report significant improvement in their BPH symptoms.
Dr. Grilli is part of a highly skilled team of four vascular interventional radiologists at ChristianaCare who specialize in performing PAE with the latest equipment and technology. Together, they perform a high volume of the procedures, which translates to greater clinical expertise and better patient outcomes.
“As a doctor, it’s very gratifying to be able to help men regain normal urinary function and experience improved quality of life,” he said.
To refer a patient for Prostate Artery Embolization at ChristianaCare, please call (302) 733-5625 or fill in the form on this page.
Atrial fibrillation, or Afib, is a heart arrhythmia associated with an increased risk for stroke, heart failure and other cardiovascular comorbidities. It is more commonly diagnosed in men and those of advancing age; roughly three-fourths of those with the condition are 65 years or older. Up to 6.1 million people in the United States have Afib, a figure that is projected to reach nearly 12 million by 2030.1
Because of patients’ increased risk, it is imperative to mitigate any structural issues with the heart that can lead to stroke, according to Kevin Tsai, MD, a clinical cardiac electrophysiologist at ChristianaCare.
“The irregular heart rhythm in Afib can cause blood to pool in the left atrial appendage (LAA), a small pouch in the upper left chamber of the heart, which increases the risk of clot formation,” Dr. Tsai said. “If a clot dislodges and travels through the bloodstream to the brain, it can cause a stroke.”
When patients with Afib arrive at ChristianaCare, clinicians assess for symptoms and treat risk factors associated with the condition, including hypertension, heart disease, diabetes, obesity, alcohol/tobacco use and sleep apnea. Patients’ stroke risk is assessed by a score calculated using multiple risk factors, including presence of congestive heart failure, hypertension and diabetes as well as history of stroke and vascular disease, among other factors, according to Dr. Tsai.
Anticoagulants (blood thinners) are traditionally prescribed to reduce patients’ stroke risk. However, in patients unable to tolerate long-term anticoagulants, perhaps due to fall or bleeding risks, ChristianaCare offers occlusion of the LAA, which has been shown to be effective in reducing Afib-related stroke.2
In addition, treatment of Afib focuses on controlling heart rate or rhythm. The aim is generally to control heart rate without converting Afib to a normal rhythm. This treatment is commonly used for patients who tolerate Afib well without symptoms. Rhythm control aims to restore and maintain normal rhythm and is commonly used for patients who have limiting symptoms from Afib.
“Roughly 20% of patients with Afib have no symptoms and, for them, we typically employ the rate control strategy,” Dr. Tsai said. “However, the remaining 80% have symptoms that can greatly diminish quality of life, such as palpitations, shortness of breath and fatigue. Rhythm control strategy is used in these patients to reduce the overall Afib burden by modifying electrical properties of the heart with antiarrhythmic medications and/or catheter-based ablations.”
Although catheter ablation has been shown to be more effective in maintaining normal rhythm, antiarrhythmic medication is currently first-line therapy, according to Dr. Tsai. In patients with Afib that is refractory to antiarrhythmic therapy, catheter ablation can be considered. (Future guidelines may change with recent large clinical trials showing favorable results with the approach; it currently has a class Ia indication with reduction in mortality in patients with heart dysfunction and heart failure due to Afib.)
Generally, the goal of ablation is to disable the cells in the heart that are responsible for triggering and propagating Afib. Two common ablation methods are cryoablation (freezing these cells) or radiofrequency ablation (heating the cells). Both approaches are offered at ChristianaCare, and they can be performed safely and effectively as outpatient procedures.
In cryoablation, electrophysiologists use a balloon catheter to freeze the targeted heart cells, disabling their ability to transmit electrical currents. This procedure can be tricky, however, because if the seal between the balloon, which contains nitrogen refrigerants, and the cardiac tissue isn’t closed, the flow of warm blood can make the procedure less effective, according to Dr. Tsai. The freezing strategy, although mostly safe, can damage nearby structures.
In radiofrequency ablation, electrophysiologists use a catheter to deliver heat to the targeted cardiac cells, rendering them unable to transmit electrical signals. This heating strategy, in rare cases, can also cause collateral damage to nearby structures, Dr. Tsai said.
The most recent advancement in Afib is pulsed-field ablation (PFA), which was approved by the FDA in December 2023 and involves a large electrical current (1 microsecond in duration) that causes cardiac cells to undergo apoptosis. ChristianaCare is expected to begin offering PFA within the next year, and Dr. Tsai believes it will change the treatment landscape of rhythm control for Afib.
“The benefit of PFA is that different tissues in your body absorb the electrical field at different amplitudes,” Dr. Tsai explained. “You can deliver PFA and it will only affect the cardiac cells without adverse effects to nearby structures, including the esophagus, arteries/veins and the phrenic nerve.”
To refer a patient with Atrial Fibrillation to ChristianaCare, please call (302) 623-1929 or fill in the form on this page.
References
1. Colilla S, Crow A, Petkun W, et al. Estimates of current and future incidence and prevalence of atrial fibrillation in the U.S. adult population. Am J Cardiol. 2013;112(8):1142-1147.
2. Moras E, Gandhi K, Yakkali S, et al. Left atrial appendage occlusion as a strategy for reducing stroke risk in nonvalvular atrial fibrillation. Cardiol Rev. 2024 Jul 30. doi:10.1097/CRD.0000000000000757
ChristianaCare’s new multidisciplinary Center for Aortic Health brings together some of the region’s leading subspecialty experts in cardiovascular care, including vascular surgeons, cardiologists, cardiothoracic surgeons, interventional radiologists and others, to centralize the care of patients with aortic disease and improve their outcomes.
New 2024 guidelines from the European Association for Cardio-Thoracic Surgery and the U.S. Society of Thoracic Surgeons, which have reclassified the aorta as an independent organ on par with the heart, lungs and brain, recommend bundling the treatment of the aorta in a separate specialty in close coordination with other specialties.1
“Aortic pathology requires specialized management, and we provide the most optimal care for these patients when we work together seamlessly,” said one of the Center’s co-directors, vascular surgeon Kathryn E. Bowser, MD. “There are cutting-edge developments constantly going on in this field, and a center like this one is needed to give patients the best options.”
Led by Dr. Bowser, preventive cardiologist Stephen Meng, MD, and cardiothoracic surgeon J. Daniel Robb, MBBS FRCS, the Center proactively identifies patients with aortic pathology such as aortic aneurysms and aortic dissection before these conditions become emergent; provides them with the latest in medical, surgical and endovascular management; and maintains ongoing coordinated longitudinal care for months and years afterward. Other patients presenting with life-threatening acute aortic dissection receive emergency lifesaving complex surgery and are similarly followed longitudinally.
“The team at the Center for Aortic Health utilizes a multidisciplinary approach that emphasizes patients’ long-term heart health,” said Dr. Robb, who serves as a co-director of the Center along with Drs. Bowser and Meng. “We also pride ourselves in having expertise and experience with multiple surgical and treatment approaches so that we can truly offer patients the best options for their specific needs. We strongly believe that these various approaches are best used in a multidisciplinary team setting to provide patients with inclusive and optimal care.”
For surgical procedures, the Center offers a state-of-the-art hybrid OR, located in the Gerret and Tatiana Copeland Heart & Vascular Interventional Suites, where both open surgery and endovascular procedures can be performed in the same space, with access to advanced imaging technologies including angiography, ultrasound and CT. It’s the only OR of its kind in Delaware. Within the next year, a second hybrid OR will be constructed, increasing the Center’s capacity to manage complex cases.
Thoracic endovascular aortic repair (TEVAR) and endovascular aortic repair (EVAR) have become the first choice of treatment in many patients with thoracic and abdominal aortic aneurysms, respectively. However, many patients have anatomy that is not suitable for standard TEVAR/EVAR procedures, according to Dr. Robb. Novel endograft devices have made TEVAR/EVAR possible for more patients, and ChristianaCare is recognized by device manufacturers as a high-volume institution with the expertise needed to implant these newer models.
“For example, in 2023, we became the first center in Delaware to implant the GoreÒ TAGÒ Thoracic Branch Endoprosthesis, a novel endograft designed to repair the descending thoracic aorta in cases of aneurysm, transection or dissection,” Dr. Bowser said. “Within the next few months, we will also be offering Gore’s Thoracoabdominal Branch Endoprosthesis, another endograft option that allows us to tailor treatment to a patient’s specific anatomy. These are just two examples of the ongoing developments in the field to which patients in the Center for Aortic Health will have access.”
“Patient selection is clearly key to achieving the best possible outcomes in these procedures,” Dr. Robb added.
Another aspect of this customized care for aortic disease is seen in women.
“We are learning more about aortic pathology in women,” Dr. Bowser noted. “Most existing research had primarily been done in men, but more recent studies demonstrate that we must account for differences not only in vasculature size but other factors that may affect care decisions.”
For example, studies have shown that women have a threefold increase in the risk for aortic dissection or rupture, and acute aortic syndromes, such as aortic dissection, occur at smaller aneurysm sizes in women than men.2
“A 5-cm aneurysm in a woman is much more likely to rupture than a similarly sized aneurysm in a man,” Dr. Bowser said. “Our center incorporates all of the latest research into our decision making to create a personalized treatment plan for each patient.”
It was a very specific decision to name the program the “Center for Aortic Health,” according to Dr. Meng.
“We are not just focused on pathology and surgery,” he said. “Our program is distinguished by a patient-centered focus that aims to prevent catastrophes with education and screening. For example, we have been in discussion with the program at Nemours Children’s Health about transitioning some of their pediatric aortic patients into our care as they reach adulthood. There are familial conditions such as Marfan syndrome, Loeys-Dietz syndrome and vascular Ehlers-Danlos syndrome that can raise the risk of aortic pathology conditions. We believe it is important to have a lifelong care plan, not only for the patient but for their family members who may be affected. The Center for Aortic Health offers our community convenient access to world-class expertise right here in their local area.”
To refer a patient to the Center of Aortic Health at ChristianaCare, please call (302) 733-5700 or fill in the form on this page.
References
1. Czerny M, Grabenwöger M, Berger T, et al. EACTS/STS guidelines for diagnosing and treating acute and chronic syndromes of the aortic organ. Eur J Cardiothorac Surg. 2024;65(2):ezad426.
2. Boczar KE, Cheung K, Boodhwani M, et al. Sex differences in thoracic aortic aneurysm growth. Hypertension. 2019;73(1):190-196.
Transcatheter aortic valve replacement (TAVR) at ChristianaCare is revolutionizing the treatment of severe aortic stenosis in older adults.
“TAVR has almost completely replaced open-heart surgery for these patients over the past decade,” said interventional cardiologist and fellowship program director Erin Fender, MD. Dr. Fender is part of a multidisciplinary team that specializes in performing the minimally invasive procedure for the health system’s Structural Heart Disease Program.
The procedure is used to replace a narrowed aortic valve that is obstructing a patient’s blood flow from the heart to the body. If not treated, aortic stenosis can lead to heart failure and death. Though still relatively new, TAVR is already the most common procedure performed by members of ChristianaCare’s Structural Heart Disease Program, directed by Wasif Qureshi, MD, an interventional cardiologist in the health system.
During the procedure, an interventional cardiologist inserts a catheter in the femoral artery which is then guided into the left ventricle allowing implantation of a biological valve to replace the diseased aortic valve. Once in place, the valve immediately restores healthy blood flow. The entire process typically takes less than an hour.
TAVR offers a number of advantages over surgery, according to Dr. Fender:
“These benefits make the TAVR procedure a safe and effective option for the majority of older adults with serious cases of aortic stenosis, including patients in their 80s and 90s,” Dr. Fender noted. “Our interventional cardiologists do hundreds of procedures a year, supported by cardiac surgeons, cardiac nurses and other professionals with extensive experience in TAVR. This multidisciplinary approach and large number of cases translates to advanced expertise that ensures patients receive high quality care.”
ChristianaCare’s TAVR success rate is 99%, and many large clinical trials have repeatedly demonstrated that the long-term survival rates for TAVR equals that of surgery.
“We’re proud to be Delaware’s leader in performing the procedure,” Dr. Fender said.
At ChristianaCare, patients benefit from a timely and efficient TAVR process. When a patient is referred, a cardiac nurse immediately contacts them to arrange every aspect of their care and address any questions or concerns they may have. The nurse assists the patient in scheduling necessary testing and appointments with an interventional cardiologist and cardiac surgeon—often all on the same day to maximize convenience.
After the TAVR, patients return to ChristianaCare for postoperative checkups and then are seamlessly transitioned back to the care of their local doctor. Through the process, the TAVR team keeps the referring physician informed about their patient, the outcome of the procedure and instructions for follow-up care.
“We strive to develop collaborative relationships with doctors by providing thorough communication and being available for consults when needed,” Dr. Fender explained. “By the time the patient meets with me or one of my colleagues, we’ve already reviewed their testing results and are prepared to recommend a course of action, including scheduling their procedure, if appropriate. All of this typically happens within just a few weeks. It’s a well-coordinated pathway focused on delivering an excellent patient experience.”
To refer a patient for TAVR at ChristianaCare, please call (302) 733-1507 or fill in the form on this page.
General Surgery
Bariatric surgeons at ChristianaCare are using weight-loss procedures as a tool for patients with obesity to foster improved health metrics across a number of disease states.
Patients undergoing Roux-en-Y gastric bypass and sleeve gastrectomy have not only lost weight but have also seen positive improvements in comorbid type 2 diabetes, hypertension, and cardiovascular and kidney disease, as well as reduced levels of low-density lipoprotein (“bad cholesterol”) and hemoglobin A1c. Many of these patients have struggled maintaining a healthy weight despite other interventions such as exercise programs, dietary changes and even medications, according to Elizabeth McCarthy, MD, a minimally invasive bariatric surgeon at ChristianaCare.
“For a lot of patients, bariatric surgery is the last stop in their weight-loss journey,” Dr. McCarthy said. “They have been living with obesity for some time and are dealing with a number of health complications as a result. Some have even been told they will die unless they lose weight and have the surgery. Our goal at ChristianaCare is to guide these patients and their families through surgery, and we provide them with support before, during and after their procedures to help them get the best results.”
Because of type 2 diabetes, cardiovascular disease, kidney disease and hypertension, among other potential health problems, many patients undergoing bariatric procedures—most of which involve sleeve gastrectomy at ChristianaCare—are on multiple medications before surgery. However, after surgery, most patients can expect to take medications at lower doses or come off them altogether, according to Dr. McCarthy.
However, management of these patients doesn’t stop immediately after surgery. In fact, patients are monitored postoperatively for an indefinite period to ensure they are maintaining a healthy weight and still doing well with any comorbid conditions, she said.
“If they are struggling with weight, even postoperatively, we provide them with the education and resources they need to get back on track,” she added.
This education is actually a continuation of the patient instruction that begins preoperatively. Before surgery, patients typically meet with a nutritionist to review their diet and a psychiatrist to assess for underlying disordered eating or mental health conditions that may contribute to weight gain or hinder weight loss.
In addition, ChristianaCare has developed an online seminar that patients are encouraged to view before their initial surgical consultation. It reviews what to expect in the lead-up to surgery, during the procedure and after it. Primary care physicians and practitioners should encourage patients who are interested to sign up and learn more about bariatric surgery, Dr. McCarthy said.
On top of that, bariatric surgery patients at ChristianaCare are required to take several virtual classes, via Microsoft Teams, delivered by the Weight Management team. These classes advise patients on diet and exercise and, in general, “how to stay committed and engaged in their health journey” after surgery, Dr. McCarthy explained. “There’s a lot of work that’s involved getting to surgery, and it can take up to a year.”
That said, the goal is not to make the process more difficult; rather, it’s designed to ensure success. Currently, bariatric surgery is recommended for adults with a body mass index more than 35 kg/m2 and a medical comorbidity such as type 2 diabetes, hypertension and sleep apnea, as well for those with a BMI greater than 40 kg/m2, as they are at increased risk for these and other comorbidities, including infertility and polycystic ovary syndrome. However, less than 1% of patients who meet the criteria for surgery nationally ultimately are referred for these procedures.
“A lot of that is due to the stigma surrounding obesity,” Dr. McCarthy explained. “That’s why it’s so important for us to create an environment where patients feel supported.”
Some of that support is provided by the patients themselves. The bariatric surgery team at ChristianaCare oversees a monthly online support group led by patients who have had the procedure within the system and includes topics from the team’s dietitians, surgeons and other providers directly involved in the bariatric patient’s care.
“Patients share their experiences and encourage each other to maintain a healthy lifestyle and get the most from their surgery,” Dr. McCarthy said. “Surgery is a great tool to get you where you want to go, but it’s just that: a tool. Patients will need to keep working to be successful, and being successful requires support. That’s why we strive to have an excellent supportive practice with a multidisciplinary team that works with all of our patients preoperatively and postoperatively. That separates ChristianaCare from a lot of surgical practices.”
When a patient presents with complicated diverticulitis—with perforation, abscess, obstruction and/or fistula—to ChristianaCare, admission to the hospital is usually required.
Indeed, if the patient has peritonitis, surgical removal of a portion of the colon is required. Traditionally, this would entail removal of the sigmoid colon and creation of a colostomy. More recently, however, research has shown that it is safe and effective to remove the sigmoid colon and divert stool via an ileostomy, according to David C. Palange, DO, a colon and rectal surgeon at ChristianaCare’s Helen F. Graham Cancer Center and Research Institute. At ChristianaCare, this procedure is performed using state-of-the-art tools and approaches.
“If you become my patient, particularly for elective procedures, you’re getting a robotic or laparoscopic surgery with all incisions the size of my thumbnail,” Dr. Palange said. “Through minimally invasive techniques for robotic-assisted or laparoscopic surgery, you definitely decrease the chances of wound infection and pain.”
In fact, with the use of the robot, “the surgeon can suture and staple and perform other tasks” more quickly and accurately, reducing the risk for postoperative infection, time under anesthesia and other potential complications, he added.
A colostomy reversal remains a challenging procedure due to residual scar tissue. In contrast, ileostomy reversal is relatively easy for the surgeon to perform. As a result, with ileostomy a patient can anticipate a fuller recovery, restoring normal bowel movements, according to Dr. Palange.
Patients undergoing colostomy have about a 50% chance for reversal, but the percentage with ileostomy is much higher, he said.
Recovery times from surgery for complicated diverticulitis vary, Dr. Palange added. If a minimally invasive surgery is performed using enhanced recovery after surgery protocols, a patient typically stays in the hospital two to five days, with recovery expected to take two weeks and complete healing taking place within six weeks. With open procedures, hospital stays and recovery and healing times are much longer, Dr. Palange said.
Generally, about one in four patients with diverticulitis develop complicated disease. For the far more common uncomplicated, non-severe form of the condition, which involves localized inflammation of the diverticulum, a more conservative treatment approach is used.
Traditionally, uncomplicated diverticulitis has been managed with antibiotics and a liquid diet, and most patients recover at home without hospitalization. However, at ChristianaCare, Dr. Palange and his colleagues adhere to updated guidelines from the American Gastroenterological Association, which recommend “selective, rather than routine, antibiotic use in immunocompetent patients with mild disease.”
While antibiotics have long been the first-line therapy for acute uncomplicated diverticulitis, recent evidence suggests there is no benefit from their use in immunocompetent patients with mild acute uncomplicated diverticulitis, according to Dr. Palange.
“Historically, the use of antibiotics for acute cases has been in response to what was believed to be an immediate infection, but it is now understood that it’s the inflammation and not the infection that causes the symptoms,” he said. “This newer approach of selective use of antibiotics has not yet been widely adopted, but we’re using it here to prevent overuse of antibiotics, which can later lead to resistance and unnecessary side effects.”
Dr. Palange added: “Colonic diverticulitis remains a painful, unpredictable gastrointestinal disease that can lead to serious complications, chronic symptoms and poor quality of life. At ChristianaCare, we strive to use the latest, evidence-based approaches to give our diverticulitis patients the best possible outcomes.”
Evolving screening techniques, coupled with minimallyinvasive surgical solutions, are allowing physicians at ChristianaCare to look beyond gallstones in caring for patients with abdominal pain.
“We used to always think there was only one issue with the gallbladder—gallstones,” said Michael B. Goldberg MD, a minimally invasive surgeon practicing at ChristianaCare. “Now we know that it’s not actually only gallstones that give people gallbladder symptoms and upper right quadrant pain. There is much more to it.”
Patients experiencing this type of pain, which is often quite debilitating, may have biliary dyskinesia, a condition in which the gallbladder is not squeezing as hard or as fast as it should. Biliary dyskinesia can result in insufficient amounts of bile being ejected from the gallbladder into the small intestine.
Conversely, some patients may also have biliary hyperkinesia, when the gallbladder squeezes too fast and too hard, causing recurring biliary colic.
Both conditions can cause significant pain and discomfort. However, when testing indicates no presence of gallstones, patients’ pain would often go untreated.
“People who were suffering from right upper-quadrant abdominal pain and the inability to tolerate meals would get an ultrasound and it would look normal—with no gallstones—and we thought that was the end of the story,” Dr. Goldberg said.
Now, hepatobiliary iminodiacetic acid (HIDA) scans allow for far more detailed review of gallbladder function, enabling specialists to more properly identify the cause of their patients’ symptoms.
“The HIDA scan can show us exactly how the gallbladder is functioning, and allows for more investigation in order to help our patients who are experiencing gallbladder symptoms without gallstones,” Dr. Goldberg said.
If the gallbladder is determined to be functioning incorrectly and needs to be surgically removed, current techniques allow for far easier procedures with greatly reduced recovery times.
“We use the latest minimally invasive techniques including laparoscopic and robotic surgery with smaller incisions,” Dr. Goldberg said. “It used to be that people needed to stay in the hospital when they had gallbladder surgery. Now it is done on an outpatient basis.”
Most people are able to manage the discomfort of gastroesophageal reflux disease (GERD) with lifestyle changes and medications. However, patients who have failed medical management or who don’t want to be on proton pump inhibitors, due to potential side effects, are candidates for surgery, according to Anthony R. Tascone, MD, a bariatric and foregut surgeon at ChristianaCare.
Other patients should be considered candidates for a surgical intervention are those who have Barrett’s esophagus, esophagitis or stricture from changes in their esophagus from reflux, he said. For all surgery patients, Dr. Tascone and his colleagues are using state-of-the-art procedures to achieve optimal outcomes in GERD.
For decades, fundoplication has been the gold standard for GERD surgery. During the procedure, the surgeon takes the top part of the stomach and wraps it around the bottom of the esophagus, with the goal, essentially, of bolstering the lower esophageal sphincter (LES). The procedure can entail a partial or total (Nissen) wrap, depending on the severity of esophageal motility.
Today, these procedures are minimally invasive and many surgeons at ChristianaCare are performing GERD surgeries robotically. Following surgery, most patients see improvement in their symptoms and can either be taken off medications completely or continue them at lower doses. More than four in five patients undergoing these procedures will see complete resolution of symptoms, with no need for medication.
“There are pluses and minuses to each of these approaches while the surgical outcomes for both are excellent,” Dr. Tascone said. “An important benefit of fundoplication is that the patient’s native tissue is used.”
Another GERD procedure performed at ChristianaCare involves implantation of the LINX reflux management system (J&J Med Tech), a novel device composed of a ring of magnets designed to strengthen the LES. Following surgical insertion, the LINX device is in the “closed position most of the time” to keep acid in the stomach, according to Dr. Tascone.
“The LINX has the ability to open and close so that food and drink can pass through it and patients can burp or vomit, as needed, when air forms in the stomach,” he said. “That is harder to do following fundoplication.”
In general, outcomes following LINX implantation are similar to those for fundoplication, which research leads to improved symptom control and quality of life in 90% of patients.1 Still, a downside of LINX is that up to 40% of patients develop dysphasia during the few months following the procedure.2
Another recent addition to the surgical armamentarium for GERD at ChristianaCare is gastric bypass, particularly for patients with elevated body mass index. In addition to treating GERD, gastric bypass helps treat common comorbidities, including hypertension, type 2 diabetes, obstructive sleep apnea, and hyperlipidemia, by fostering weight loss.
“So, patients will get more bang for their buck when undergoing gastric bypass surgery,” Dr. Tascone said. “The outcomes for all of these procedures are very similar, though recovery is slightly different for each option. Laparoscopic surgery has a quicker recovery time and less pain than open surgery. The primary care doctor and the surgeon can work together to help decide which is best for the patient.”
References
- John M, Irvine T, Thompson SK, et al. Antireflux surgery in patients with gastroesophageal reflux but a negative 24-hour pH study—late outcomes. J Gastrointest Surg. 2024:S1091-255X(24)00449-9.
- Fadel MG, Tarazi M, Dave M, et al. Magnetic sphincter augmentation in the management of gastro-esophageal reflux disease: a systematic review and meta-analysis. Int J Surg. 2024 May 9.
At The Hernia Center at ChristianaCare, surgeons are using innovative technological approaches, paired with highly customized individual care plans, to provide cutting-edge treatment. The approach allows for low-risk procedures with faster recovery times, for patients with either minor or major surgical needs.
“Historically, patients have been a bit wary of hernia surgery for lots of different reasons,” said Peter M. Santoro, MD, the director of robotic surgery and medical director of The Hernia Center at ChristianaCare. “They may have heard from a friend or family member how painful it was, or how hard it was to recover from the procedure. Maybe they know people who had issues with mesh or other complications from their surgery.”
Much of this, according to Dr. Santoro, was due to the fact that hernia repair has often required open surgery necessitating large incisions. Too frequently, this meant that patients were faced with complicated procedures, long hospital stays and often painful, time-consuming recoveries.
However, over the past two decades, minimally invasive techniques have revolutionized many surgical specialties, hernia care included. As technology has rapidly advanced, developments in robotic surgery have allowed for previously unthinkable improvements in both surgical accuracy and patient recovery.
“From the smallest hernias to the most complex cases that require abdominal wall reconstruction, we’ve been able to move from big-incision operations to minimally invasive surgery,” Dr. Santoro said. "A huge part of that has been the advancement of robotic surgery, which has taken hernia treatment to a level that has never previously been seen, from a technical standpoint, as well as through patient satisfaction and recovery. It’s changed the way we take care of patients with hernias.”
The most recent advancement has been in the management of complex ventral hernias, which require abdominal wall reconstruction via transversus abdominis release (TAR) procedures.
“These TAR procedures traditionally could only be conducted as an open operation, and were reserved for the most complex ventral abdominal wall hernias,” Dr. Santoro said. “The postoperative course was typically very rocky, with significant complications on a fairly routine basis.”
Now, robotic abdominal wall reconstruction via the robotic TAR procedure has enabled surgeons to adopt novel techniques in order to vastly minimize the risks associated with these procedures.
“Robotic TAR has completely revolutionized the way we deal with complex abdominal wall hernias and abdominal wall reconstruction,” Dr. Santoro said. “It’s taken an operation that was associated with about a week-long hospital stay, with a high risk of perioperative complications, and reduced it to an overnight stay with very rare incidence of complications and a much easier recovery course for the patient.”
Currently, most patients undergoing hernia repair surgery—particularly when robotic techniques are used—can expect a same-day discharge from the hospital and a speedy return to normal activities.
“A minor subset of patients may require a one-night stay in the hospital, but the vast majority will be able to go home the same day,” Dr. Santoro said.
In addition, unlike with open procedures, postoperative pain following minimally invasive surgery can frequently be managed without the use of opioids or other narcotic medications. While heavy lifting and strenuous physical activity is typically limited for a four-week period, patients can expect to be up and about within hours of their procedure, a fact that strongly benefits the recovery process.
“I expect patients to be walking around, going up and down stairs, getting in and out of the car even the same day as the operation, and certainly by the next day,” Dr. Santoro said. “We don’t want patients to be sedentary after surgery.”
As the exact needs of patients depend upon multiple factors, Dr. Santoro and his colleagues put great effort into developing and communicating plans that are unique to each person.
“With hernia surgery, the surgical process is very patient-specific,” Dr. Santoro said. “It’s a highly tailored approach even compared with other types of medicine. Every patient that has a hernia is different, and we take a very individual approach for every patient. We provide comprehensive hernia care for the state of Delaware and the surrounding areas, and medical personnel should feel very confident that their patients will be well taken care of.”
For patients with uveitis, a rare inflammatory eye disease that can lead to blindness, advances in diagnosis and treatment are allowing for lessened therapeutic burden, with fewer side effects.
“Typically, we think of uveitis as having either infectious or noninfectious causes,” explained Benjamin C. Chaon, MD, medical director of the Wilmington Eye Clinic at ChristianaCare and an ophthalmologist who specializes in treating patients with ocular inflammatory and retinal diseases. “Uveitis can be associated with infections, such as syphilis, toxoplasmosis, or Lyme disease, or it can be noninfectious and associated with an underlying systemic autoimmune disease like sarcoidosis, rheumatoid arthritis, or inflammatory bowel disease. Or, it may not be associated with any underlying systemic disease and just impact the eye, such as Birdshot Chorioretinopathy.”
While the various types of uveitis share the basic feature of inflammation occurring in the vascular structures of the eye, the wide variety of causes can complicate diagnosis.
“The most important distinction we make in the initial diagnosis of uveitis is whether it’s infectious or noninfectious,” Dr. Chaon said. “Sometimes this can be difficult to determine, particularly if a patient develops uveitis following cataract surgery or another type of ocular surgery.”
In recent years, advancements in metagenomic deep-sequencing technology have helped to ease the diagnostic process. This technique allows ophthalmologists to take a small sample of fluid from the front part of the eye during a patient’s clinic visit and conduct testing to determine whether there is the presence of bacteria or fungus.
“This was not always possible in the past, as we often needed larger sample volumes to culture,” Dr. Chaon said. “This was difficult to do from the eye, as it is such a small space. This new technology allows us to more readily make the diagnosis of an infectious uveitic condition. That has been an exciting development in the field of uveitis in the last few years.”
Treatment, too, has advanced, moving beyond the use of corticosteroids. The advent of biologic therapies for the management of uveitis has allowed specialists to significantly decrease their reliance on steroids.
“It used to be that corticosteroids were the mainstay of uveitis treatment, but steroids have a lot of systemic side effects,” Dr. Chaon said. “Biologics are medications we use for patients with other rheumatologic conditions, such as adalimumab or infliximab, which target specific inflammatory molecules. Often these medications are helpful with getting control of the uveitis and allowing us to get patients off of—or to a lower dose of—steroids.”
Advances in regional steroid therapy have also allowed for more targeted treatment options with potentially fewer systemic side effects. For patients with vision-threatening complications of uveitis like macular edema, ophthalmologists historically relied on periocular steroid injections into the sub-Tenon’s space around the eye, with patients often requiring treatment every three to four months.
Recent data from the PeriOcular versus INTravitreal Corticosteroids for uveitic macular edema or “POINT” trial1 has demonstrated that intravitreal delivery of steroid medication directly into the vitreous cavity is superior to periocular steroid injections in the improvement and/or resolution of macular edema.1 Still, patients being treated with an intravitreal steroid medication, like the dexamethasone intravitreal implant (Ozurdex, Allergan), may need injections every few months, which can be quite burdensome, particularly for working-age individuals that uveitis disproportionately effects.
“That’s a lot of injections for patients, and every injection in the eye carries with it a small risk of infection,” Dr. Chaon said.
In contrast, the intravitreal steroid injection Yutiq (fluocinolone, Alimera Sciences) can provide up to 36 months of inflammation control in one dose. Another new medication called Xipere (triamcinolone, Bausch & Lomb) uses a novel drug delivery mechanism to allow the steroid to be injected into the suprachoroidal space—the area between the choroid and the sclera. Research has shown that this approach may result in more effective control of inflammation and a lower risk of increased intraocular pressure.
Although those with uveitis may require regular clinical visits to monitor their disease, reducing the frequency of injections can result in greatly increased patient satisfaction.
“In a lot of cases, uveitis tends to be a chronic disease, and patients do tend to need chronic treatment,” Dr. Chaon said. “So, treatment options that may lessen their treatment burden can be a big relief.”
Reference
- Thorne JE, Sugar EA, Holbrook JT, et al; Multicenter Uveitis Steroid Treatment Trial Research Group. Ophthalmology. 2019;126(2):283-295.
Neurosciences
To address this issue in New Castle County, home to 60% of Delaware’s population, ChristianaCare has partnered with the county’s emergency medical services (EMS) to become an early adopter of Twiage, a novel prehospital communication and intrahospital care coordination technology. The system is designed to facilitate communication between hospital personnel and EMS to accelerate lifesaving emergency care by reducing dependence on radio communication.
Twiage is available to EMS personnel for free, and the HIPAA-compliant app can send notifications with patient vital signs, symptoms (including EKG results) and interventions to the hospital in seconds, along with photos, additional details in text chats and digital voice memos. That information is readily available to health-system vascular neurologists on their cellphones, according to Kim Gannon, M.D., Ph.D., the medical director of ChristianaCare’s Comprehensive Stroke Program and physician executive of the Neurosciences Service Line.
“When neurologists can have that information available, prior to the patient’s arrival at the hospital, it can make all the difference in the world because seconds truly matter in stroke care,” said Dr. Gannon. ChristianaCare’s stroke program is one of the largest nationally and one of only 300 comprehensive centers across the country. “With this system, paramedics can communicate with our stroke teams while they’re on their way to the hospital, which gives our staff time to access and review the patient’s chart. This is particularly important if the patient is unable to speak for themselves or doesn’t have a family member present.”
Research suggests that stroke patients lose approximately 1.9 million brain cells per minute during care delays, making rapid initiation of antithrombotic therapy crucial, added Doug Huisenga, the senior program manager for ChristianaCare’s systemwide stroke program. However, although these drugs are widely used and effective, there are contraindications in many patients, including a history of cerebral hemorrhage and/or ischemic stroke (within the past three months).
“That’s why having access to a patient’s personal health information is so important,” he said.
Efficient stroke care represents a particularly acute need in Delaware, which is actually located in the northernmost reaches of the so-called “stroke belt,” the region comprising most of the Southeastern United States that has the highest incidence of stroke mortality in the country. The state actually has the second-highest incidence of stroke mortality (56.8/100,000 people in the general population) in the country, behind Mississippi.
Of note, hypertension and hyperlipidemia as well as tobacco use are very common in Delaware. ChristianaCare is the only comprehensive stroke center on the I-95 corridor between Baltimore and Philadelphia.
The initiative with New Castle County EMS and ChristianaCare means Delaware is now one of 12 states nationally in which the Twiage system is in use. By providing patient data and GPS-tracked ETA for all incoming ambulances in real time, Twiage helps reduce hospital efficiency and enables earlier initiation of treatment, meaning lives are saved.
“ChristianaCare is already likely in the top 1% of hospitals nationally in door to needle time,” said Huisenga, referring to the initiation of antithrombotic treatment. “However, one of the ways we can make that even better is to improve prehospital communications — and that’s what we’ve done with Twiage thanks to this collaboration with New Castle County EMS.”
Cutting-edge magnetic resonance (MR)-guided focused ultrasound technology is allowing neurologists at ChristianaCare to provide outpatient procedures for patients struggling with essential tremor (ET) and Parkinson’s disease.
Developed in the early 2000s, and approved by the FDA in 2016, the technique allows for tremor control without surgical incisions, meaning that patients can recover quickly, are not at risk of destabilizing infections and are able to experience immediate reduction of their tremors. This summer, Justin Martello, M.D., the Parkinson’s and movement disorders director at ChristianaCare Neurology Specialists, will use the technology for ET and Parkinson’s patients as the first in the state of Delaware to offer this treatment.
In focused ultrasound, MRI is used to develop a detailed picture of a patient’s brain. Ultrasound wavelengths are then used to heat and kill the specific cells responsible for causing the individual’s tremors, essentially creating a lesion in the region of the brain.
“We can pretreat the region at low levels of heat energy without causing any damage,” Dr. Martello said. “This stuns the cells. We can then review the MRI and ask the patient how they are feeling.”
Adding to the procedure’s safety is the fact that it can be nondestructively tested and guided by immediate patient feedback, according to Dr. Martello. In ET patients, the procedure can be done on both sides of the brain — albeit in separate treatments about nine months apart — to achieve full relief from tremors affecting both sides of the body.
“If the tremor is still there or the patient has side effects, we know we are not in the right spot, but we haven’t done any permanent damage so we can move on to a different area,” Dr. Martello noted. “By doing that, we can make sure we are treating the correct area and avoiding side effects.”
Essential tremor is the most common movement disorder in the United States, affecting an estimated 6.4 million people.1 The disorder typically occurs later in life and is an inherited condition in up to 70% of patients.2
“Everyone has a tremor center of their brain,” Dr. Martello explained. “For patients with tremors it is not functioning correctly.”
Focused ultrasound has been found to be very effective for tremor. A study published in The New England Journal of Medicine in 2016 determined that patients’ mean scores for hand tremor improved by 47% at three months in the cohort receiving the treatment, compared with 0.1% in study participants who underwent a sham procedure.3 And the noninvasive nature of the technique makes it particularly appealing for older patients who may be poorly suited for an invasive approach.
“The results can be dramatic,” Dr. Martello said. “Patients who have been living with this for decades are able to come out of the procedure and drink from a glass.”
Dr. Martello and team will select a very specific area of the brain to create a small lesion to decrease or eliminate the tremor. They have to weigh treating a larger area of the brain for more tremor reduction against possible increased risk of side effects.
Recent five-year data have been promising, showing that Clinical Rating Scale for Tremor scores significantly improved by 73.3% and 73.1% from baseline at both 48 and 60 months post-treatment, respectively.4
“Back in the day, we wanted to treat the whole tremor so we did big lesions, but we saw side effects such as balance issues,” Dr. Martello said, adding that correcting this behavior has caused some surgeons to create too small of a lesion, which may allow for the tremors to return. “Trying to find a middle ground of treating enough of the involved cells, but not so much that you are getting side effects.”
References
- Crawford S, Lally C, Petrillo J, et al. How many adults in the US have essential tremor? Using data from epidemiological studies to derive age-specific estimates of prevalence. Neurology. 2020;94(15 suppl):4458.
- Lorenz D, Frederiksen H, Moises H, et al. High concordance for essential tremor in monozygotic twins of old age. Neurology. 2004;62(2):208-211.
- Elias WJ, Lipsman N, Ondo WG, et al. A randomized trial of focused ultrasound thalamotomy for essential tremor. N Engl J Med. 2016;375(8):730-739.
- Cosgrove GR, Lipsman N, Lozano AM, et al. Magnetic resonance imaging-guided focused ultrasound thalamotomy for essential tremor: 5-year follow-up results. J Neurosurg. 2022;138(4):1028-1033.
A patient diagnosed with multiple sclerosis (MS) 20 years ago would have faced significant disability, pain, and perhaps a shortened life span.
Although there’s currently no cure for the neurologic disorder, which typically occurs in young adults aged 20 to 40 years, neurologists at ChristianaCare are embracing new treatments designed to help manage the course of the disease and limit its disabling effects. Treatments include disease-modifying therapies (DMT), which can slow disease progression and relieve some symptoms.
“The best practice in managing a patient’s MS is through a multidisciplinary team approach that meets both the medical and nonmedical needs of patients, during any stage of the disease,” said Xiaoyang Li, M.D., a neuroimmunologist at ChristianaCare. “Our patients are guided through different treatment options during all stages of their lives, including instruction for patients and families about medicines and how to best manage symptoms.”
Indeed, ChristianaCare’s MS Comprehensive Center of Excellence provides the most effective advanced treatments and symptom management approaches available. Today, MS is considered a chronic disease that is manageable. If it’s diagnosed early and treatment is initiated before symptoms progress, patients can maintain function for years.
With immunotherapies such as DMTs, patients who start treatment early in the disease course can lead relatively normal lives. In MS, the immune system attacks healthy tissue and nerve cells in error, causing muscle weakness and movement problems. DMTs work by lowering the activity of the immune system, limiting its ability to attack healthy cells. In many patients, these drugs alter the course of MS, reducing their risk for disease relapse, decreasing disease activity and slowing symptom progression.
The FDA has approved more than a dozen DMTs for different types of MS, including clinically isolated syndrome, relapsing-remitting, secondary progressive and primary progressive. However, the drugs have proved most effective in treating the first three types.
Most of the DMTs recommended by neurologists within ChristianaCare’s MS Comprehensive Center of Excellence are infusion-based and can be administered in six-month dosing schedules. Because of a range of choices depending on the patient’s type of MS, treatments can be tailored for a specific patient, allowing for better disease management.
Still, although DMTs offer increased efficacy, often with fewer side effects than more traditional treatments, they do not reverse any nerve damage caused by MS that occurred prior to diagnosis.
Even with these advances, “the most important consideration in the overall management of MS is an early diagnosis and early treatment intervention with the most advanced therapies available,” Dr. Li said.
“On a daily basis, my colleagues and I treat disorders of the blood vessels in the head, neck and spine — aneurysms being one of them,” said Barbara J. Albani, M.D., the medical director for neurointerventional surgery at ChristianaCare. “Given the wide array of devices and techniques that are at our disposal we are able to tailor treatment specifically to each individual patient.”
Of these techniques, endovascular coiling is the oldest, dating back to the 1990s. The procedure involves the use of small, flexible catheters that are typically inserted via a patient’s femoral artery. Once the catheter has reached the brain, the surgeon is able to place coils in the aneurysm.
Platelets adhere to the coils and heal in a way that restricts blood from reaching the out-pouching of the aneurysm.1
“This is a very sophisticated way to treat an aneurysm without having to open up the patient’s head and displace their brain,” Dr. Albani said. “Everything is done from within the artery without causing any disruption to the brain tissue.”
Although the technique works on saccular aneurysms — those with a lollipop or mushroom-like shape — others, which are fusiform or wide-necked in shape, require alternative approaches. For these, an open celled stent can be used which has gaps that can be crossed by a wire or a microcatheter, but will hold coils into an aneurysm. The stents are placed in the parent artery near the aneurysm, and a guidewire is passed through the stent in order to place coils within the aneurysm.
“Once placed, the stents help buttress the coils in order to keep them from falling out,” she said.
For certain patients, a finer mesh stent may be used, according to Dr. Albani. These permeable, flow-diverting stents are made of a very fine-gauge mesh that looks similar to a woman’s stocking.
They act to divert blood away from the aneurysm.
“Blood can still seep in, but it is not driving into the aneurysm,” Dr. Albani said. “The analogy I use for patients is it’s kind of like a coffee filter — the water will pass through but not flow with abundance. And the more filters you put in, the less flow you get through it. Over time, the body will endothelialize; the lining of the vessels will grow over the flow-diverting stent, remodeling the blood vessel and effectively sealing it from the inside.”
More recent technologies include the Woven EndoBridge WEB Embolization System (MicroVention) and the Contour Neurovascular System (Stryker).
“The WEB system looks almost like a square ball of yarn and keeps blood from getting into the aneurysm,” Dr. Albani said.
The Contour system, which Dr. Albani noted is shaped like an umbrella that has been inverted by the wind, can be inserted into an aneurysm and cinched down in order to serve as a wall that coils can be inserted behind. Indicated for wide-necked aneurysms, neither system uses a stent, meaning nothing needs to be placed in the parent artery, negating the need for antiplatelet medications that may not work for all patients.
“Whenever we put a stent into somebody’s artery, we have to put them on antiplatelet medications, and this usually involves keeping them on aspirin for life,” Dr. Albani said. “These devices can be a godsend for patients who can’t take aspirin, or who for other reasons we don’t want to put on blood thinners.”
Key to the ChristianaCare team’s approach is a deep understanding of, and experience with, each of the techniques, allowing them to customize each patient’s care.
“We have been early adopters of all of these things, have lots of experience using them and can tailor a patient’s treatment to what they need,” Dr. Albani said. “We have everything we need to make sure the patients are covered, and are here 24/7/365 to help with questions or concerns.”
References
- Ogilvy CS. Neurosurgical clipping versus endovascular coiling of patients with ruptured intracranial aneurysms. Stroke. 2003;34(10):2540-2542.
Patients receiving care in the Neurocritical Care Unit at ChristianaCare with concern for seizure may benefit from a new electroencephalographic (EEG) technology on-boarded by health-system neurologists.
The platform, called Ceribell® EEG (by the manufacturer of the same name), enables rapid evaluation of possible seizure activity when a standard EEG is not immediately. The technology enables ChristianaCare neurologists to quickly evaluate for seizure activity even when EEG technicians are not immediately available.
“This tool allows us to obtain a diagnosis quickly and initiate treatment as needed,” explained Huijun Wang, Ph.D., a specialist in neurology and psychology at ChristianaCare. “It doesn’t have the same sensitivity and specificity as traditional EEG, but it gives us enough information to confirm or rule out seizure in minutes, when we need it, in an emergency situation. That, combined with clinical suspicion, can be enough for us to begin treatment.”
For patients with suspected seizure, time to diagnosis is a key determinant of outcomes, similar to the door-to-needle times in the management of ischemic stroke, as indicated by research. The sooner neurologists can start antiseizure treatment in patients, the more likely they can keep the brain disorder under control.
The primary benefit of Ceribell’s Food and Drug Administration-approved EEG device is that it is completely automated and can be operated by doctors and nurses at the bedside, without a specialized EEG technician, after minimal training. The device is a reduced-montage (8-channel) circumferential EEG that produces tracings covering the frontal, temporal and occipital areas. During evaluation, electrodes are implanted in a soft, adjustable headband attached around the head and secured for electrode grip, and amplified brain signals are transmitted to a pocket-sized device that allows patient data to be entered and viewed in real time.1
Currently, the technology is being used by neurologists as well as nurses and advanced care practitioners in the neuro-ICU at ChristianaCare’s ewark facility. Pending results, it may be expanded to other facilities later this year.
In studies, Ceribell® EEG has been shown to significantly reduce time to diagnosis. A recent analysis published in the journal Epilepsia Open found that mean time to epilepsy diagnosis with the device was 23.8 minutes.2 In her experience with the technology, though, Dr. Wang said it can essentially provide diagnostic information in “real time.”
With that said, Ceribell® EEG doesn’t — and won’t — replace conventional, state-of-the-art EEG platforms, which are more accurate and provide a more complete reading of electrical activity in the brain, according to Richard K. Choi, D.O.. Many patients initially evaluated with the novel device will undergo conventional EEG later to confirm early findings, he said.
“Ceribell® EEG is really like the farmer’s dog barking in the middle of the night — it can warn us that something is or is not happening in a patient’s brain; but the farmer, or in this case the neurologist, will still need to confirm whether it’s something serious,” explained Dr. Choi, a neurologist and neurocritical care specialist at ChristianaCare. “Our use of this technology really highlights ChristianaCare’s ability to see a challenge and find an effective way to address it. It really reflects our values and behaviors, one of which is making sure we’re using all resources available to ensure the best care for our patients.”
References
- Parvizi J, Gururangan K, Razavi B, et al. Detecting silent seizures by their sound. Epilepsia. 2018;59(4):877-884.
- LaMonte MP. Ceribell EEG shortens seizure diagnosis and workforce time and is useful for COVID isolation. Epilepsia Open. 2021;6(2):331-338.
Botox (onabotulinumtoxinA, Allergan) injections have emerged as the most effective option for the treatment of chronic migraine, and specialists at ChristianaCare were early adopters of the innovative approach.
Botox is a neurotoxin that, when injected into muscle tissue, can prevent movement of the treated muscle for a limited time. Best known as a treatment for smoothing wrinkles in the skin on the face, these injections have traditionally been used to treat neuromuscular issues, including spasms and other muscle-contracting conditions.
“In addition to being the most effective treatment we have for refractory chronic migraine, Botox doesn’t have any systemic effects,” said Mitra Assidi-Khansari, M.D., a headache medicine specialist and the director of education in the Division of Neurology. “So, when we inject it into those tiny muscles on the cranial facial area, the medication basically remains in those muscles. It doesn’t float in your system, doesn’t affect the kidney or liver, and doesn’t penetrate your brain and cause cognitive side effects or changes in appetite or mood.”
Migraine headaches are extremely common, particularly in women. Up to 17% of women and 6% of men suffer from migraines.1 Chronic refractory migraine, in which patients experience frequent or long-lasting symptoms for 15 or more days per month, are somewhat less common than episodic migraine, in which patients have symptoms for less than 15 days per month.
As a result, the former “is, unfortunately, a very undertreated disorder,” noted Jessica Bradley, M.D., a headache medicine specialist ChristianaCare. “Many patients don’t seek care until the migraines have gotten bad enough that they are forced to seek treatment options.”
Botox was approved by the FDA in 2010 for use in the treatment of chronic migraine in adults with symptoms that have not responded to three other “standard treatments” (eg, calcitonin gene–related peptide antagonists and receptors). Based on the FDA guidelines, Botox can be administered every three months, for a total of four full treatments annually.
A standard protocol has been established for administering a total of 155 units of Botox. A recommended paradigm calls for injections on the frontal area, the temple, the occipital region over the cervical spinal area and on the top of the shoulders for a total of about 31 shots.
Botox exerts its effect mainly by decreasing signaling on the motor fibers and reducing muscle tension in the cranial facial areas. There are some theories indicating that it can also disrupt the signaling on the sensory fibers.
In a study involving 245 patients with migraine, 82.9% reported that Botox helped control their symptoms.2
Despite its effectiveness, patients need to set expectations on what to anticipate from Botox treatments.
“The first thing I tell patients is that the treatments often don’t work in the first session,” Dr. Bradley said. “Botox treatments often have a cumulative build up in effect, and it can take up to three rounds of treatment to reach maximum migraine control. I explain this to my patients before starting so they know what to expect and won’t feel discouraged if the first treatment does not work well. I encourage patients to try at least three rounds of Botox before determining its effectiveness.”
References
- Stewart WF, Shechter A, Rasmussen BK. Migraine prevalence. A review of population-based studies. Neurology. 1994;44(6 suppl 4):S17-S23.
- Yalinay Dikmen P, Kosak S, Ilgaz Aydinlar E, et al. A single-center retrospective study of onabotulinumtoxinA for treatment of 245 chronic migraine patients: survey results of a real-world experience. Acta Neurol Belg. 2018;118(3):475-484.