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Transforming Abdominal Aortic Aneurysm Care with the Alto™ Abdominal Stent Graft System

Inova’s AAA repair program has been rated as “high performing” for the fourth consecutive year by U.S. News & World Report
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With the commercial release of the Alto™ Abdominal Stent Graft System, Inova’s vascular surgeons are helping ensure the best possible outcomes for patients with abdominal aortic aneurysms (AAA). This recently FDA-approved stent graft device has expanded the number of patients who can be offered minimally invasive endovascular repair. Until now, some patients were not able to be treated using other endovascular stent devices.

AAA is among the leading causes of death in the U.S. According to the Centers for Disease Control and Prevention, the condition is more prevalent among men and people age 65 and older, with 75 percent of patients reporting a history of smoking. Patients do not typically have symptoms, although pain in the back, side, buttocks, groin or legs is sometimes reported. Common causes of AAA are a family history and risk factors such as peripheral arterial disease, high cholesterol and high blood pressure. Some infections and injuries can also cause AAA.

Both the Society for Vascular Surgery and the U.S. Preventative Services Task Force recommend a one-time AAA screening using ultrasound imaging for men age 65 years or older, particularly those with a history of smoking or a family history of AAA. An indication for routine screening in women is not as strong but can be considered if the same risk factors are present.

Implantation of the Alto device, completed for the first time at IHVI in August 2020, was the first implant surgery performed in the Washington, DC region. Inova is one of the first centers in the U.S. to offer this procedure for AAA patients. The new device differs from traditional approaches used for endovascular repair through the use of a conformable liquid polymer, which allows for the graft design to be a durable, customizable and anatomically adaptive aortic seal.

Inova’s vascular program is a recognized leader in the treatment of aneurysms and amputation prevention. In the recently released U.S. News & World Report 2020-21 ratings, the AAA program was one of three in Virginia rated “High Performing,” and the only program rated as such in the DC metropolitan area.

“We have an outstanding faculty and a supportive team that offers open and endovascular aneurysm repair. The Alto program keeps us at the forefront of clinical care and research in the management of aneurysmal disease,” said Richard Neville, MD, Medical Director of Inova Vascular Services, Associate Director of IHVI and Chairman of the Department of Surgery.

“Inova offers the entire gamut of treatment options for AAA,” according to Dipankar Mukherjee, MD, Chief of Vascular Surgery for Inova Fairfax Hospital, who served as the lead investigator for Inova’s clinical trial on the device. “Inova’s treatment options include endovascular aortic repair (EVAR) as well as open surgical repair when that may be more appropriate. We are fortunate to have available the latest in endovascular stent graft repair technology by virtue of participating in clinical trials evaluating the next generation of ever-improving endovascular stents. As such, we are able to offer the best repair using the optimal stent based on patient’s specific aneurysm anatomy.”

Expanding Range of Treatable AAA Patients

The Alto implant uses polymer sealing technology to obtain the proximal seal to eliminate pressurization of the AAA sac. This is a unique concept as far as EVAR is concerned and may prove to be a more durable treatment for the long term. There is modest early evidence to suggest that such may be the case. This implant has the ability to treat more patients with AAA, including those with short neck of the aneurysm.

“The success rate for AAA repair is excellent,” said Dr. Mukherjee. “We are able to accomplish minimally invasive repair most often without the need for even a groin incision. Patients are usually discharged from the hospital the next day. They are closely followed in the office with ultrasound examinations of the repair, and with CT angiography if there are any concerns. The mortality and morbidity of endovascular repair is superior when compared to open repair. The quality of life following endovascular repair is also superior.”

In the ELEVATE trial, treatment success was 96.7 percent at one year. The type I endoleak rate was 1.4 percent with 100-percent freedom from type III endoleak, device migration, device fracture, stent occlusion or AAA rupture. The device-related secondary intervention rate was 2.7 percent.