Dr. David Chew could have chosen any surgical specialty he wanted. He also could have chosen to work at any major hospital in the country.

Fortunately for Central Iowans who have been diagnosed with life-threatening aneurysms, Chew decided to become a vascular surgeon and brought his expertise to West Des Moines-based Iowa Heart Center.

“I enjoy challenges and I enjoy variety,” said Chew, who trained in surgery at Columbia University and completed his vascular training at Harvard Medical School. He was a member of the vascular surgery department at the prestigious medical school for seven years before being recruited to Iowa in December 2005.

Chew and his partners, Dr. Laurie Kuestner and Dr. Michael Park, perform what is arguably some of the most challenging surgery possible – repairing the major blood vessels that lead from the heart. When the walls of the aorta, the main artery carrying blood from the heart, become weakened, it can balloon out at the weak spot similar to a bald tire before a blowout, and that is what is known as an aneurysm.

About 20,000 Americans are diagnosed each year with aortic aneurysms, with the majority of them being in the abdominal part of the aorta and about 25 percent in the thoracic, or chest, area. The condition, which is about the tenth most common cause of death in the United States, often goes undiagnosed because it rarely has any noticeable symptoms. When one bursts, it’s usually fatal.

“Thoracic aneurysms, when we see them, tend to be in older patients who have more associated medical illnesses,” Chew said. “They usually have chronic obstructive lung disease, because they’re usually smokers, as well as heart disease and kidney disease.”

A new less-invasive surgical technique, in which a plastic graft is routed through the aorta from an incision in the groin or belly and then expanded to attach to the inside walls, is giving older patients who have thoracic aneurysms an alternative to open surgery to repair them. The procedure is known as endovascular stent-graft repair of aneurysms.

“Although open surgery has been successful, it really comes at a price because the recovery period is prolonged, and patients spend a long time recovering from the incision in the chest that sometimes extends down to the abdomen as well,” Chew said.

“This technology being available allows a minimally invasive way of treating these aneurysms,” he added. “The recovery period is shortened from three or four weeks to one day in the hospital and then they’re back on their feet. In order for this type of operation to succeed, there are very strict criteria that have to be met. In other words, the anatomy of the aneurysm has to be favorable for the graft to have an anchor site.”

This type of endovascular repair, in which a graft is carried to the repair site through the aorta, has been used more for abdominal aneurysms. It wasn’t until last year that the U.S. Food and Drug Administration approved a graft for use on thoracic aneurysms.

The graft, which can cost $11,000 just for one piece, is made of a specialized plastic and comes in a variety of sizes. It’s reinforced with a delicate metal skeleton that expands with the body’s temperature. It’s crimped onto the end of the catheter that the surgeon snakes up through the aorta, and then is released to its full length by the surgeon once it’s in the proper position.

“Though the length of stay is shorter, the cost of the graft makes up for the reduction in hospital costs,” Chew said. “And then if you factor in the cost of follow-up visits, plus the 10 to 15 percent chance that you have to go back in to fix a leak, then the procedure is definitely more expensive than open surgery.

“It’s all about patient selection. In a young and fit patient, open surgery gives durable results. If I was 50 years old and had an abdominal aneurysm, I would probably have an expert surgeon fix it with open surgery, because I don’t want to come back every six months to see if there is a leak. If I’m old and frail, I’ll have the endovascular repair done.”

Iowa Heart Center recommends that men who are older than 65, particularly if they have been a smoker, should have an ultrasound of their abdominal aorta to make sure they don’t have an aneurysm. “Particularly if there’s a family history, especially if the family member that had it is a woman, because it’s rare for women to have aneurysms, but when they do, family members tend to be more at risk,” Chew said.

Though Medicare does not currently pay for the screening, Iowa Heart Center has a screening program that provides a subsidized rate for patients, he said.

“We really like to catch these patients early enough such that we have favorable anatomy to do these types of repair.”