An aneurysm surgery performed by two local doctors last October may have been a once in a lifetime opportunity.
Not only that, it's the only time this particular operation has been performed in this particular way in Billings. Not just in Billings, but in the United States.
And, as far as Dr. Joe Dillard and Dr. Barry Winton know, it's never been done anywhere around the world - at least it's never been reported.
The case started early last year with patient Paul Caruso. The 82-year-old Helena man had been diagnosed with an aberrant origin of the right subclavian artery.
Basically, Caruso had an anatomical defect of one of the main arteries stemming off the aortic arch of his heart - it was in the wrong place but was still getting the job done.
Dillard said Caruso's condition was caught on a previous MRI and otherwise may never have been noticed.
"This is extremely rare. It occurs in less than .5 percent of people," Dillard said. "In many people, it's never diagnosed because it doesn't always cause problems."
The defect itself wasn't the main problem. But, in combination with a 3-inch aneurysm - or blood-filled bulge - that was discovered within that artery, the situation could quickly become problematic.
"Paul's aneurysm was large," Dillard said. "Three inches in diameter is 10 times the normal size of a half-inch artery."
Dillard, an interventional radiologist with St. Vincent Healthcare, and Winton, a cardiovascular and thoracic surgeon with St. Vincent Healthcare, agreed there was basically three ways to treat the case: 1. Do nothing, but monitor the aneurysm; 2. Perform open surgery with a major bypass; 3. Perform a less invasive operation using a stent, or wire scaffold covered with a nylon coating.
"A conventional operation is a major operation," Winton said of the second option. "Paul would not have tolerated it very well at his age."
The problem with the third option, Dillard explained, was that the necessary stent wasn't created to go where Caruso's aneurysm was located.
"So this would be an 'off-label' use of the stent," Dillard said.
During the next five months, Winton and Dillard formulated a strategy to modify an existing stent and tunnel it through Caruso's aneurysm. The likelihood of an aneurysm rupturing is much less after a stent has been placed, Dillard said.
The two Billings physicians sent Caruso's case to several other doctors around the United States for referrals.
"We went back and forth and had a lot of discussion about how to do this," Dillard said. "We wanted to make it easy but also wanted a high likelihood of success."
In October, with Dillard, Winton and several others - including representatives from Gortex, the company that produces the stent - in the operating room, Caruso underwent a minimally invasive procedure: A two-inch incision in one armpit, and another small incision in the groin area. The stent was fed through the armpit incision and created a new channel through Caruso's aneurysm.
After months of planning, the operation took about three hours and kept Caruso in the hospital one night. He was on his way home to Helena with his son the next day.
Had Caruso undergone traditional surgery, Winton said, he would have been in the hospital for a minimum of seven to 10 days.
"And that's if he would have done really well," Winton added.
Caruso recently had a successful checkup, and the aneurysm is shrinking, as Winton and Dillard suspected it would.
Because the operation and the circumstances surrounding it are atypical, both doctors will submit the case to several medical journals.
"It couldn't have gone better," Winton said. "With some patients, it wouldn't have been possible. But because of Paul's anatomy, we were able to do it."
