Vessel-lengthening technique offers game change for a rare vascular condition

TESLA concept for midaortic syndrome

Tissue expanders — small balloons that can be filled with saline solution or other fluids to grow skin — have long been used in plastic surgery, most commonly breast reconstruction. They’re based on the simple idea that the surrounding skin will stretch as the device expands over time. That extra skin can then help repair injuries or congenital anomalies or accommodate implants.

Now, a novel approach extends tissue expansion to blood vessels. It is transforming the way that surgeons treat a rare but serious condition called midaortic syndrome, report Heung Bae Kim, MD, Khashayar Vakili, MD and their colleagues at Boston Children’s Hospital.

Midaortic syndrome occurs when the middle section of the aorta is narrowed and typically affects children and young adults. It can cause severe hypertension and can be life-threatening if left untreated. The surgical approach to this condition would be to replace the damaged portion of the aorta with nearby healthy blood vessels. However, this usually isn’t possible because these vessels tend to be too short to adequately fill in.

To address this challenge, Kim, Vakili and their team in the Midaortic Syndrome and Renovascular Hypertension Center have pioneered a method called Tissue Expander Stimulated Lengthening of Arteries, or TESLA. It lengthens a healthy section of the adjacent normal aorta, making it long enough to replace the narrowed part.

A narrowed aorta before and after placement of the tissue expander.
A narrowed aorta before and after placement of the tissue expander.

Avoiding prosthetic grafts

The three-stage process begins with the placement of a tissue expander between the patient’s aorta and spine. Weekly injections of fluid into the expander then slowly lengthen the aorta. Once the aorta appears long enough, the expander is removed and the newly lengthened section replaces the narrowed portion of the aorta.

In a retrospective review in the June 2018 Journal of Vascular Surgery, the research group reports on five patients who underwent TESLA at Boston Children’s between 2010 and 2014. Although one child did not complete the process due to technical problems during the final operation, the other four patients successfully completed all three stages of TESLA. Follow-up for up to six years has shown no significant disease in the lengthened segment of aorta. All patients have achieved excellent blood pressure control and some are completely off medications.

“TESLA may avoid the need for prosthetic bypass grafts in some children with midaortic syndrome,” says Kim. “Although we do not yet have long-term outcomes following TESLA, our early data suggests that this approach should be considered as an alternative to prosthetic grafts in eligible patients.”

For situations where the aorta can’t be used because of too much narrowing along its length, Kim and colleagues also developed MAGIC. This technique borrows a large blood vessel in the intestines.