Archive for January, 2007

Rare heart surgery performed at The Nebraska Medical Center

A world-class procedure and a first for North America. A life threatening aneurysm is successfully repaired at The Nebraska Medical Center using a complex technique dubbed the “frozen elephant trunk.” Published medical reports indicate this is the first time this groundbreaking procedure has been completed in the United States or Canada.


Ali Khoynezhad, M.D., Ph.D. performed the rare surgery. As a cardiothoracic and endovascular surgeon at The Nebraska Medical Center and assistant professor of cardiovascular and thoracic surgery at UNMC, he’s seen a variety of life threatening conditions that require urgent action. The situation he faced on Aug. 15 was different than most.


“Our patient was critically ill. Nearly every inch of his aorta had dissected or split,” Dr. Khoynezhad said. “Without surgery, he would have almost certainly died.”


Hours earlier, Michael McAlexander was at his Omaha home putting together a book shelf. The 54-year-old had run into health trouble before. The previous year he had suffered a partial dissection of his descending aorta. Brought on by extremely high blood pressure, McAlexander was put on medication to control his hypertension and was being monitored. Aches and pains were nothing new, until the inside lining along the rest of his aorta — close to his heart — ripped apart.


“I felt massive pain like nothing I had ever felt before. I didn’t know what it was, but I figured it would go away,” he said. “Three hours later my wife took me to the emergency room at the VA hospital. Within two hours I was transferred to The Nebraska Medical Center and prepped for surgery.”


Dr. Khoynezhad went into the operating room prepared to take action. He embarked on a one-of-a-kind surgery, the “frozen elephant trunk,” knowing that it provided the best option to save his patient’s life. He first replaced the ascending aorta, the aortic arch and two branch arteries to the brain, the innominate and left carotid. Badly diseased human tissue was completely replaced with a synthetic manmade material — a Dacron® vascular graft — that from this point forward would function as the aorta.


While most of the graft was stitched into place, an end portion was left extending inside the true lumen, or pathway, of the aorta. This seemingly minor detail is actually a critical part of the procedure.


“This piece of fabric is the ‘elephant trunk.’ It guides the surgical team to the true lumen, the correct channel of the aorta where blood should be flowing,” Dr. Khoynezhad said. “Remember, the dissection had split the aorta into two. If the surgeon was to misidentify the lumen and proceed with the rest of the operation in the false lumen where the vessel wall is particularly weak, it could be catastrophic.”


With the elephant trunk as his guide, Dr. Khoynezhad next repaired the damaged portion of the descending aorta. Over a guidewire, he inserted a permanent stent graft, the GORE TAG® thoracic endoprosthesis, through the newly rebuilt ascending aorta. He directed it into place in the descending aorta lying along the spinal column in the chest. Now that the stent was confining blood flow to the newly rebuilt vessel, blood could no longer reach the aneurysm allowing the bulge to shrink over time.

Adding to the complexity of this procedure — Dr. Khoynezhad and his surgical team had to initiate hypothermic circulatory arrest, cooling the patient dramatically to reduce brain and body oxygen requirements and stop blood flow in the body completely.


This process involves a heart-lung machine and cardiopulmonary bypass to first chill the blood and later, after completing the initial portion of surgery, to restart blood flow and rewarming. Once the patient’s body temperature reaches 18 degrees Celsius (64 degrees Fahrenheit), the bypass machine is stopped and the surgeon has a short window, 30 to 45 minutes, to complete the surgery that involves the arteries supplying blood to the brain.


At the same time, with the use of retrograde cerebral perfusion, a low level of cooled, oxygenated blood continues to flow to the tissue of the brain. Without this crucial component, it is not possible to replace the aortic arch. The patient would not have adequate blood flow to the brain resulting in the possibility of severe brain injury.


“This operation required an incredible amount of teamwork and precision by a very talented surgical team,” Dr. Khoynezhad said. “Every person in the operating room was focused from start to finish. The surgeons, the nurses, the anesthesiologist, the perfusionist — we all had a critically important job to do. Nine hours later, we wrapped up knowing that we had done all we could do to give our patient a second chance.”


Less than 12 hours after surgery, Michael McAlexander was breathing on his own and without the use of a ventilator. Several days later he was discharged. Numerous check-ups and scans in the months following show his recovery is going well.


“I’m thankful. My wife Cheryl, Dr. Khoynezhad and God have seen me through this,” McAlexander said. “It is taking a while for my strength and stamina to return. I still have aches and pains but I am feeling better.”


Variations of the frozen elephant trunk procedure for aortic dissection have been performed previously in the United States, however, instead of repairing all portions of the aorta in one session the earlier operations were split into at least two separate procedures happening days or even weeks apart.


Kim Duncan, M.D., chief of cardiothoracic surgery and professor of cardiothoracic surgery at UNMC, stresses the combined nature of the operation speaks highly of the skill and collaboration of Dr. Khoynezhad and his team in this innovative approach to patient care.


“The hybrid procedure using open surgical technique along with the intraoperative use of endovascular stenting techniques made this procedure shorter, more efficient and ultimately safer for the patient,” Dr. Duncan said. “People in this region need to know they don’t have to travel far to find the best, most advanced vascular and cardiac care. We’re providing it right here in Omaha.”


In April of 2006, Dr. Khoynezhad performed a separate groundbreaking surgery — Omaha’s first minimally invasive repair of a life threatening thoracic aortic aneurysm. This procedure also relied on an endovascular approach. The same type of thoracic aortic stent used in the frozen elephant trunk procedure was delivered through the femoral artery in the groin and expanded inside the abnormally distended aorta in the chest.


To date, the only published reports on complete frozen elephant trunk surgeries for aortic dissection come from surgeons in Germany and Japan.


Animation showing art-based snapshots of the frozen elephant trunk procedure can be viewed at http://www.nebraskamed.com/.

January 2007-Greetings and Happy New Year from the office of International Healthcare Services at The University of Nebraska Medical Center/The Nebraska Medical Center!

Newsletter Topics

  • Feature Story: Physician to Physician Collegial Consultation Services
  • 2007 Pan Pacific Lymphoma Conference-June 11-15, 2007, Maui, Hawaii
  • Bone Marrow Transplantation; A Success Story
  • Biosketch: Dr. James Armitage


Physician to Physician Collegial Consultation Services


International Healthcare Services at UNMC is very pleased to introduce its latest Collegial Consultation services.


We provide the best solution for electronic consultation, pathology review and second opinion.


In today’s world there are many times we would like to consult with another colleague or expert when treating our patients. It may be something as simple as an opinion to back up your decisions about a particular treatment, or a complex pathological diagnosis, or gene rearrangement studies, or treatment protocol recommendations.


UNMC is internationally renowned for the diagnosis, treatment and research of lymphoma, cancer care, transplantation and other serious diseases. UNMC has treated patients from all over the world. Our patients come from across the globe for initial diagnosis, second opinions, treatment, and participation in clinical research trials, bone marrow / stem cell and solid organ transplants. UNMC is among the top three transplant centers in the USA.


UNMC employs over 1,500 staff physicians/faculty/researchers in all healthcare disciplines to assist in collegial consultations.


Our service provides you with an opportunity to share opinions, discuss cases and collaborate with world-renowned physician experts at a very reasonable cost. The system employs the latest state-of-the-art, easy to use, Web-based software (provided at no cost to partner institutions) to facilitate worldwide transmission of electronic medical information, images, interactive diagnoses and “real-time” consultations in all areas of medicine. This sophisticated, yet easy-to-use, secure communication technology, enables UNMC specialists to receive patient reports for evaluation and consultation, in a matter of seconds, from any location across the globe.


Please contact us at (402) 559-3090 or email us at oihs@nebraskamed.com for more information.  You can find more information on our website under Second Opinion.


2007 Pan Pacific Lymphoma Conference – June 11-15 Maui, Hawaii

We would so enjoy seeing members of our Global Strategic Partnership Program attend the Pan Pacific Lymphoma Conference. This year it is being held June 11-15 at the Grand Wailea Hotel in Maui, Hawaii. Please review and download our brochure and contact us with any questions you may have.

Bone Marrow Transplantation; A Success Story

Editorial in Middle East Health Magazine, Dec. 2006 by James O. Armitage, MD/University of Nebraska Medical Center, Omaha, NE, USA


It is very popular today to speak of stem cell research and the use of stem cells to treat disease.  However, many involved in the debate regarding research and clinical applications of stem cells might not appreciate that hematopoietic stem cells have been used therapeutically for half a decade.  Attempts to use hematopoietic stem cells to replace marrow aplastic anemia or to support intensive therapy of cancer began even more than 50 years ago.  However, it was not until more was understood about bone marrow functions and the nature of the hematopoietic stem cell before the procedure that we know today as hematopoietic stem cell transplantation became practical.  In the 1960’s successful allogeneic (i.e. from one individual to another) hematopoietic stem cell transplantation was reported for the treatment of leukemia and for the treatment of inherited immune defects.  Working at the University of Washington in Seattle Dr. Don Thomas (i.e. who won the Nobel Prize) and his colleagues worked out the techniques of hematopoietic stem cell transplantation to treat leukemia and aplastic anemia.  By the mid 1970s they reported 100 patients with acute leukemia treated with this approach with some patients surviving free of disease and apparently cured.


The presumed benefit of allogeneic hematopoietic stem cell transplantation was originally thought to be a consequence of the very intensive therapy administered before the infusion of hematopoietic stem cells.  It was known that unless a severely immunosuppressive treatment was applied, the patients own immune system would destroy the new hematopoietic stem cells.  Thus, high dose therapy was administered before the transplant in an attempt to allow engraftment and to eradicate the malignancy i.e. usually leukemia.  Proof that immunosuppression was also required came from attempts to do hematopoietic stem cell transplantation in aplastic anemia.  It was originally felt that simply infusing hematopoietic stem cells should cure this disease since the marrow was “empty”.  However, it became apparent that in the absence of destruction of the patient’s residual immune cells, the new hematopoietic stem cells would be destroyed.  Thus, in patients with cancer, the very intensive therapy administered before infusion of the new hematopoietic stem cells was felt to be both curative of the cancer and engraftment.


In the late 1970’s and early 1980’s, it became apparent that the new hematopoietic stem cells and the new immune system that they produced in the patient might also have an anticancer effect.  The main complication of allogeneic hematopoietic stem cell transplantation is the development of a condition known as graft versus host disease.  In this illness, the new immune system produced by the infused, allogeneic hematopoietic stem cells can recognize the patient as “foreign” and carry out an immune attack on the patient’s organs.  Injury in this condition is especially frequently seen in the skin, liver, and gastrointestinal tract, and can some times be fatal.  In the late 1970s and early 1980s remission of relapsed leukemia was noted in patients who developed severe graft versus host disease.  It was speculated that there might be a graft versus leukemia effect and that it could be therapeutically important.  Careful studies of large numbers of patients demonstrated that patients who developed graft versus host, were less likely to have recurrent leukemia.  In fact, it appeared that much of the curative effect of allogeneic hematopoietic stem cell transplantation might be from the anticancer effect of the new immune system.


This observation led to attempts at reducing the intensity of the pretransplant therapy to reduce some of the risks of the procedure.  It is possible to use predominantly drugs that impair lymphocyte function with relatively minor toxic effects in the patient and avoid very high doses of other chemotherapeutic agents or total body radiotherapy.  It became apparent that sufficient impairment of the patient’s lymphocytes could allow the new hematopoietic stem cell graft to grow and eventually destroy the residual host lymphocytes giving a complete graft.  In some cancers that seem to be particularly sensitive to immunological attack, e.g. chronic myeloid leukemia and chronic lymphoid leukemia, the graft versus leukemia effect seems to be potentially curative and the reduced intensity treatment before the transplant appears to reduce transplant related mortality.  In those patients in whom the cancer does recur, reinfusing more of the donor’s lymphocytes often will reestablish remission.  This approach is sometimes termed reduced intensity allogeneic hematopoietic stem cell transplantation, or mini transplant is now undergoing intensive study in transplant centers throughout the world.


The idea that very high doses of anticancer therapy might be curative for some patients with cancer, and that the use of reinfusion of the patients own hematopoietic stem cells could avoid the dangers of graft versus host disease, led to clinical trials in what is called autologous hematopoietic stem cell transplantation.  In this treatment, hematopoietic stem cells have to be removed from the patient and stored until after the intensive cancer therapy is administered.  Since the patient’s own hematopoietic stem cells would be used to reestablish bone marrow function after the treatment, there would be no risk of graft versus host disease.  However, early problems with this treatment approach included occasional difficulties in collecting hematopoietic stem cells that were free of contamination by cancer cells and finding a way to store the hematopoietic stem cells for extended periods of time and keep them alive.  In allogeneic transplantation, the hematopoietic stem cells are taken from one individual and reinfused quickly into another.  However, since it takes time to administer the very intensive therapy, hematopoietic stem cells in autologous transplantation have to be cryopreserved for days to weeks before they are used.  Initial attempts at autologous hematopoietic stem cell transplantation involved repetitive bone marrow aspirations from the pelvis and sternum to collect sufficient cells.  It was not unusual for 200 aspirates to be required.  However, in the mid to late 1980s it became apparent that circulating hematopoietic stem cells could be collected using the process called aphersis where the blood is taken from the body, separated by centrifugation, and the desired cells collected with the rest of the blood reinfused into the patient.


Autologous hematopoietic stem cell transplantation tested the hypothesis that very intensive anticancer therapy could cure some patients when standard therapy failed.  Early studies in lymphoma showed that this can, in fact, be the case.  In patients whose recurrent or resistant lymphoma still can partially respond to standard doses or chemotherapy and achieve a minimal disease state, hematopoietic stem cell transplantation can often be curative.  As is the situation with allogeneic hematopoietic stem cell transplantation, treatment doesn’t benefit patients with all cancers, but is especially effective in patients with lymphoma, certain leukemias, multiple myeloma, and occasional other cancers.


Today both allogeneic and autologous hematopoietic stem cell transplantation are widely utilized to treat patients with cancer.  Many patients who would otherwise have died of their malignancy are now cured because of these procedures.  Allogeneic hematopoietic stem cell transplantation is also utilized for patients with aplastic anemia, inherited immune deficiency states, and certain other inherited disorders of blood production.  Both allogeneic and autologous hematopoietic stem cell transplantation are being studied in the treatment of patients with other life threatening immune diseases.  It is likely that both treatments will continue to be an important part of our therapeutic armentarium for years to come.



Biosketch: Dr. James O. Armitage


James O. Armitage, M.D.
Professor, Internal Medicine
Section of Hematology & Oncology 

Academic office:
UNMC Oncology/Hematology Section
987680 Nebraska Medical Center
Omaha, NE 681980-7680


Main practice location:
Peggy D. Cowdery Patient Care Center
Lied Transplant Center
987835 Nebraska Medical Center
Omaha, NE 68198-7835


Hospital Appointments:
The Nebraska Medical Center
University Hospital


Management and classification of lymphoma and leukemia
Bone marrow transplantation


University of Nebraska Medical Center, Omaha, NE, Intern, (1974)
University of Nebraska Medical Center, Omaha, NE, Resident, (1975)
University of Nebraska, Lincoln, NE, B.S., (1969)
University of Nebraska Medical Center, Omaha, NE, M.D., (1973)
University of Iowa Hospitals and Clinics, Iowa City, IA, Fellow, (1977)’



Academic Rank:Shapiro Professor of Medicine

Department: Internal Medicine


College: College of Medicine

Membership in Societies: ASCO; ASH, AFCR, ASCR, ASCR, ASBMT, Royal College of Physicians


Biographical Sketch:
Dr. James O. Armitage graduated from the University of Nebraska Medical Center in 1973 where he completed his internship and residency in internal medicine in 1975. In 1977 he completed a fellowship in hematology-oncology at the University of Iowa Hospitals and Clinics, Iowa City, Iowa. Dr. Armitage was in private practice from 1977-79, and in 1979 he returned to the University of Iowa as an Assistant Professor of Medicine, where he developed and was director of the Bone Marrow Transplantation Program. In 1982 he returned to Nebraska as Associate Professor of Medicine and was promoted in 1987 to Professor of Medicine. He has served as Vice Chairman of the Department of Medicine (1982-90), Chief of the Section of Oncology/Hematology (1986-89), Chairman of the Department of Internal Medicine (1990-99), Dean, College of Medicine (2000-03), and presently holds the position of the Joe Shapiro Professor of Medicine. He is a member of several professional organizations as well as serving on the editorial boards of several peer-reviewed journals. He serves on several national and international committees and served as President of ASCO (1996-97) and President of ASBMT (2000-01). He has authored or co-authored 400 articles, 86 book chapters, more than 450 abstracts, and is the editor/co-editor of 21 books. He is married to Nancy Armitage and the father of four children and grandfather of two grandchildren.

Select Publications:
Armitage JO, Weisenburger DD, Hutchins M, Moravec DF, Dowling M, Sorensen S, Mailliard J, Okerbloom J, Johnson PS, Howe D, Bascom GK, Casey J, Linder J, Purtilo DJ: Chemotherapy for Diffuse Large Cell Lymphomas–Rapidly Responding Patients Have More Durable Remissions.  Journal of Clinical Oncology 4:160-164, 1986.


Kessinger A, Armitage JO, Landmark JD, Weisenburger DD:  Reconstitution of Human Hematopoietic Function with Autologous Cryopreserved Circulating Stem Cells.  Experimental Hematology 14:192-196, 1986


Philip T, Armitage JO, Spitzer G, Chauvin F, Jagannath S, Cahn JY, Colombat P, Goldstone AH, Groin NC, Flesh M. Laporte JP, Maraninchi D, Pico JL, Bosly A, Anderson C, Schots R, Biron P, Cabanillas F, Dicke K:  High Dose Therapy and Autologous Bone Marrow Transplantation in 100 Adults with Intermediate or High Grade Non-Hodgkin’s Lymphoma. N Engl J Med 316:1493-1498, 1987


Kessinger A, Smith DM, Strandjord SE, Landmark JD, Dooley DC, Law P. Coccia PF, Warkentin PI, Weisenburger DD, Armitage JO:  Allogeneic Transplantation of Blood-Derived, T-cell Depleted Hematopoietic Stem Cells after Myeloablative Treatment in Patients with Acute Lymphblastic Leukemia.  Bone Marrow Transplantation 4:643-646, 1989.


Armitage JO, Weisenburger DD:  New Approach to Classifying Non-Hodgkin’s Lymphomas: Clinical Features of the Major Histological Subtypes.  Non-Hodgkin’s Lymphoma Classification Project.  J Clin Oncol.16:2780-95, 1998.


Hasenclever D, Diehl V, Armitage JO, Assouline D, Bjorkholm M, Brusamolino E, Canellos Gp, Carde P, Crowther D, Cunningham D, Eghbali H, Ferme C, Fisher RI, Glick JH, Glimelius B, Gobbi PG, holte H, Horning SJ, Lister TA, Longo DL, Mandelli F, Polliack A, Proctor SJ, Specht L, Sweetenham JW, Vaughan Hudson G for the International Prognostic Factors Project on Advanced Hodgkin’s Disease: A Prognostic score for advanced Hodgkin’s disease. NEJM 339:1506-14, 1998


Allzadeh AA, Elson MB, David RE, MaC, Lossos IS, Rosenwald A, Boldrick JC, Sabet H, Tran T, Yu X, Powel JI, Yang L, Martl GE, Moore T, Hudson J, Lu L, Lewis DB, Tibshirani R, Sherlock G, Chan WC, Greiner TC, Weisenburger DD, Armitage JO, Warnke R, Levy R, Wilson W, Grover MR, Byrd JC, Boststein D, Brown PO, Staudt LM: Distinct Types of Diffuse Large B-cell Lymphoma Identified by Gene Expression Profiling.  Nature 403:503-511, 2000.


Weisenburger DD, Anderson JR, Diebold J, Gascoyne RD, MacLennan KA, Muller-Hermelink HK, Nathwani BN, Ullrich F, Armitage JO for the Non-Hodgkin’s Lymphoma Classification Project.  Systemic Anaplastic Large Cell Lymphoma.  Results from the Non-Hodgkin’s Lymphoma Classification Project.  American J Hemat 67:172-178, 2001.


Weekes CD, Vose JM, Lynch JC, Weisenburger DD, Bierman PJ, Greiner T, Bociek G, Enke C, Bast M, Chan WC, Armitage JO for the Nebraska Lymphoma Study Group.  Hodgkin’s Disease in the Elderly:  Improved Treatment Outcome With a Doxorubicin-Containing Regimen.  J Clin Oncol 20:1087-1093, 2002.


Vose JM, Sharp G, Chan WC, Nichols C, Loh K, Inwards D, Rifkin R, Bierman PJ, Lynch JC, Weisenburger DD, Kessinger A, Armitage JO: Autologous Transplantation for Aggressive Non-Hodgkin’s Lymphoma: Results of Randomized Trial Evaluating Graft Source and Minimal Residual Disease. J Clin Oncol 20:2344-2352, 2002


Armitage JO. Staging Aggressive Non-Hodgkin’s Lymphoma: A Work in Progress.  New England J Medicine 2005.