A delicate experiment with a life on the line
After checking one last time on a scan of his patient's clogged brain artery, neurosurgeon Robert Rosenwasser was ready to go.
After checking one last time on a scan of his patient's clogged brain artery, neurosurgeon Robert Rosenwasser was ready to go.
He donned his zebra-striped skirt, vest, and neck guard - 10 pounds of lead to ward off the radiation from brain X-rays taken during the procedure - and strode up to his patient.
Leonard Majeski was Rosenwasser's fifth case of the day, and after him there would be three more. Then Rosenwasser had duties as chairman of neurosurgery at Thomas Jefferson University.
The goal was to keep the 64-year-old patient from having another stroke - one that could kill him or, worse in Rosenwasser's view, incapacitate him.
It was also a chance for Rosenwasser to help prove that his approach - treating the arteries from within rather than using drugs or open-brain surgery - was best for this type of patient.
Majeski, a Chester Township resident, was a test case, one of hundreds in a nationwide clinical trial.
He was the first Jefferson patient in the study to get the experimental brain stent - a tiny mesh scaffold, common in heart care but the first of its kind for brain arteries - to prop open the blockage.
A steady bip . . . bip . . . bip from the heart monitor and the mechanical shwoosh . . . whoosh . . . shwoosh . . . whoosh of the ventilator breathing for the man filled the room.
"Is my Bob Dylan CD here?" Rosenwasser asked.
Like a guitarist testing his wah-wah pedal before launching into song, the surgeon - who played professionally in his native New Orleans in college - tapped a foot pedal to turn on the X-ray machine.
Called a fluoroscope, it hulked over Majeski and would stream scans of blood vessels in his brain to a bank of TV monitors overhead. That was how Rosenwasser would track his progress as he steered a wire through six arteries, starting in Majeski's groin and ending in his brain.
The room lights flicked off when the fluoroscope was on so the team could better see the monitors. The lights came back on when Rosenwasser pushed the foot pedal and the fluoroscope shut off.
The machine checked out.
Rosenwasser then made a small incision in Majeski's right thigh below his groin. He cut down to the femoral artery. Then he began inserting a needle-size wire that would wend its way up through six feet of vessels.
A single wrong move could puncture an artery, causing a fatal rupture.
Worst headache ever
Three weeks earlier, on July 4, the blockage, less than an inch long, had caused small interruptions in blood flow in Majeski's brain - so-called transient ischemic attacks, or TIAs.
They gave Majeski the worst headache of his life and left him temporarily unable to speak.
At first, his wife, Diane, thought he was joking when the retired equipment operator couldn't tell her the score of the Phillies game.
Then she got scared.
The couple's oldest son - Leonard Jr., a volunteer firefighter like his father - recognized the signs of a stroke.
An ambulance rushed Majeski to a hospital. After six days, he was sent home and urged to see Rosenwasser.
The TIAs had stopped, but his doctors knew he was at high risk for a more serious second attack, and that concern led to this surgery.
In the interventional neuroradiology (INR) lab, a nurse found Rosenwasser's CD, and Dylan's rasp soon joined the rhythmic sounds of the ventilator and heart monitor.
"It's gettin' dark, too dark for me to see." Shwoosh . . . whoosh . . . shwoosh . . . whoosh . . . "I feel I'm knockin' on heaven's door." Bip . . . bip . . . bip . . .
Even as he guided the wire to the blockage, Rosenwasser watched over everything in the room.
He was like an orchestra conductor at the concerts he loved but missed so often that his wife kept a list of people who could fill his seat at a moment's notice.
"What's his pressure?" Rosenwasser asked anesthesiologist Evan Weiss.
Control of Majeski's blood pressure was key.
The doctors had to maintain a delicate balance. Majeski's body had boosted the pressure to force blood through the clogged artery.
Too much pressure and a blood vessel could tear, killing him. Too little and he could suffer another stroke.
Majeski's reading was 120 over 77, indicating when the heart pumped and relaxed. Weiss called out the average.
"Ninety-nine," he said.
Like Majeski, one in three Americans has hypertension. That's a beating pressure of 140 or more or a resting pressure of 90 or higher, which Majeski would top if he hadn't been getting drugs through an IV.
Stroke, heart disease, and kidney failure are among the problems that can result. Majeski had open-heart surgery in 2005 to bypass clogged cardiac arteries.
"He's got bad vessels everywhere," Rosenwasser said.
The surgeon had been up this arterial path many times over nearly two decades, performing procedures both through arteries and through openings drilled in the skull.
When he set out to add the newer arterial approach to his arsenal, the wise men of neurosurgery scoffed.
They pointedly read newspapers through his presentations. No one could be expert at both, they told him. He would have to choose one.
Rosenwasser refused. Eighteen years ago, he became one of the first neurosurgeons to do both.
Now most aspiring young neurosurgeons learn his way, although such dual training is not yet part of the residency requirements, as Rosenwasser would like.
The frenetic neurosurgeon had risen at his customary 4:30 a.m. to work out and had arrived at the hospital by 6 a.m. Preparing before the operation, he was a blur of intensity.
But now he proceeded slowly. He pushed the hollow wire bit by bit through Majeski's blood vessels while tracking his progress on two monitors.
The wire was exquisitely thin; it would take three or more to equal a strand of angel hair pasta. Still, one slip could cause a stroke by dislodging plaque that had accumulated over decades of hoagies, cheesesteaks, and pizzas.
From Majeski's right thigh, the surgeon sent the wire up to the iliac artery to go through the pelvis.
From there, he merged into the aorta in the abdomen. Then like a driver taking I-95, he bypassed the heart via the ascending aorta to reach the left carotid artery in the neck.
From there, it was a straight shot to the left internal carotid and the blockage.
As the first strains of Dylan's "Tangled Up in Blue" played, Rosenwasser finally got the guide wire where he wanted it - about 2 centimeters below the blockage.
"Lord knows, I've paid some dues gettin' through," Dylan sang.
Two more monitors blinked to life, giving complete views inside Majeski's brain.
Rosenwasser injected dye.
The vessels in the brain lit up like the surgeon's beloved French Quarter except for the spot where the blood couldn't flow freely.
"Wow, look how small that artery is," he said. "We actually may need to put in a couple of stents."
Majeski's heart kept its steady bip . . . bip pace along with the shwoosh . . . whoosh of the ventilator.
Decades ago, research found that surgery wasn't best for such patients. A 1985 study comparing brain surgery with medications showed that drugs were more effective and safer.
But medications weren't ideal, either, for the 50,000 Americans who get a stroke from clogged arteries every year. With drugs alone, a quarter of them suffer a second attack within two years.
Now, Rosenwasser hoped, the trial would show that stents plus medication lowered that risk.
"All right, 20 miles of bad road," he said as he prepared to traverse that arterial highway a few more times - first with a balloon and then a stent.
"What's his pressure doing now?" Rosenwasser asked.
Majeski's average blood pressure had risen to 109 - 130 over 88.
"All right, keep his pressure up," Rosenwasser said.
Then he ordered the balloon - 3.5 millimeters in diameter and 20 millimeters long - which he would use to push the blockage against the artery wall.
At a sterile side table, the surgeon told the young neurosurgeon he was training that it was critical to get all the air out of the balloon. Even a small bubble could block the tiny arteries in the brain and cause a stroke, he said.
They worked together quickly, without rushing.
"It looks like all the air is out," Rosenwasser said.
As he turned back to the patient, he caught a rush of movement in the adjacent control room.
"What's going on in there?"
Silence. Then a nurse stepped into the lab and explained that there had been a foul-up: They weren't using a balloon designated for the research study.
Using the wrong balloon would have been a setback. It would mean extra paperwork and explanations to the scientists leading the stent trial.
But with the patient on the table and his team waiting, this wasn't the time or place to get angry.
It was OK, Rosenwasser told himself. He hadn't started to put the balloon in yet, so the patient was never in danger. The study protocol required that the balloons come from a lot with serial numbers that could be traced to the patient.
Only time was lost, the neurosurgeon thought.
Bip . . . bip . . . shwoosh . . . whoosh . . .
He turned back to the side table and began to prepare another balloon, the same size as the one they'd almost used. This one had the right serial number.
The second balloon was ready. Rosenwasser made sure the patient was, too.
"Is he making good urine?"
"Evan, we really have to watch that pressure," Rosenwasser said.
Did he need more blood thinner?
"Check that every 15 minutes, please."
"Yes, sir," the scrub nurse, John Pescatore, responded.
Rosenwasser sent the balloon up close to the blockage along the guide wire.
He needed to get the balloon through a tight stretch of artery less than 1 millimeter in diameter - smaller than the head of a pin.
If he couldn't get the balloon across the blockage, the procedure would fail. The wire would be withdrawn, and Majeski would get the standard treatment - blood thinners and aspirin.
Rosenwasser pushed the wire firmly. It didn't move. He stepped back toward the patient's feet and tried again.
The wire move forward a little. He kept pushing.
Finally he got the wire through. Then he set to work on the balloon.
After 10 minutes, Rosenwasser coaxed the balloon across the blockage.
Now he was ready to blow it up. "Here comes part one of the moment of truth."
Slowly the balloon inflated, opening the artery. Rosenwasser held the balloon open for 15 seconds.
Then he deflated it.
Rosenwasser glanced at the monitors. "It's better already," he said.
He estimated the artery had tripled to about 3 millimeters in diameter.
"See that? Lord have mercy!" he exclaimed.
They were halfway home. Rosenwasser removed the balloon, taking the reverse path down the arterial highway. He instructed his team to "keep it sterile."
If the artery collapsed, he would need to quickly reinsert the balloon and try to reopen the vessel.
"Hook up the stent."
Once it was attached, Rosenwasser pushed the stent up the long guide wire.
"Slowly. Stop. Stop. Slowly. Stop. Slowly. Stop."
The stent had to extend beyond the blockage on both sides to work properly. Once released, it would pop open on its own. There was no going back.
"All right, stent's out."
Rosenwasser ordered one more injection of dye to make sure no new blockages had developed in Majeski's brain.
"OK, it's a wrap."
Rosenwasser walked out of the INR lab and shed his lead.
After the breathing tube was removed from Majeski's throat, Rosenwasser returned to check on him.
"Move your toes," he told Majeski, who responded.
That was good. He hadn't suffered a stroke, which happens in up to 7 percent of cases.
As the staff prepared to wheel Majeski up to the neurosurgery ICU on the sixth floor, Rosenwasser went to a tiny basement office.
In rapid-fire sentences, he dictated his operative note for the hour-long procedure. It took less than two minutes.
Rosenwasser had three more patients to go, including an open surgery case. And he had administrative and teaching tasks stacking up.
A half-hour after he left the INR lab, Rosenwasser slipped his white lab coat over his surgical scrubs.
He walked into the sixth-floor conference room where Majeski's wife, Diane, and son Leonard Jr. waited.
"He's OK," Rosenwasser said.
"Oh, thank God," said Diane.
Rosenwasser showed scans of Majeski's brain from before and after the procedure.
"Everything went great," he said. "Couldn't have gone better."
Then he took them to see Majeski.
"Do you feel different?" Diane asked him.
He was OK, he mumbled.
It was time for Rosenwasser to go. His first surgery in the trial was over. His next patient was being wheeled into an operating room.
Nearly 11 months later, Majeski is doing well and sticking with his drug regimen.
Rosenwasser and his Jefferson colleagues have treated 27 more patients with the stents, three as part of the trial.
And the neurosurgeon has had a good run attending the Saturday concerts by the Philadelphia Orchestra. His wife hasn't needed to tap her list of surrogates for months.
Most recently it was Mozart's Violin Concerto No. 5 in A Major.