Twins Doing Well After Complicated Aortic Surgery

Marti and Mary Alice Mullins are twins from a tight-knit family in Ashland, Ohio.

In her late fifties, Marti started experiencing strange and painful symptoms. Every time she ate, she became nauseated and would sometimes vomit. She also had abdominal pain when eating.

“I kept going back to the doctors,” said Marti. “At first, they thought it was acid reflux, but it never got any better. I started having to go to the emergency room, the pain was so bad.”

Eventually, during one trip to the emergency department, a doctor ordered a CT scan. That’s when they discovered a problem with her aorta, the largest artery in the body, which carries oxygen-rich blood from the heart to all other organs.

Imaging showed Marti had Coral Reef Aorta (CRA), a rare condition characterized by the formation of large, calcified plaques in the aorta that can block blood flow. Marti’s CRA was located in the part of the aorta where blood vessels to the liver, stomach and kidneys originate. Different from other typical types of arterial plaque, CRA plaques have an irregular and bulky shape resembling a coral reef.

People suffering from CRA may experience pain with eating and digestion because blockages keep proper blood flow from getting to the stomach, kidneys and liver. Other symptoms can include high blood pressure and pain in the legs.

Because of the pain associated with the condition, Marti had trouble with basic daily tasks like doing chores and mowing the lawn. It impacted her ability to live a normal, enjoyable life.

Treatment of CRA can be complicated. Many specialists consider the condition to be inoperable, but not experienced vascular surgeons Dr. Benjamin Colvard and Dr. Jae Cho with University Hospitals Harrington Heart & Vascular Institute. In March 2022, Marti underwent surgery with both of them at UH Cleveland Medical Center.

The surgery involved a multi-branched thoracoabdominal bypass graft with limbs going to the kidneys, liver, stomach and the lower half of the body on partial cardiopulmonary bypass. This approach is seldom done because it requires a vascular surgeon not just trained in aortic surgery, but one with thoracoabdominal experience and pump privileges. There are only a small number of centers in the U.S. that can support this approach.

“To explain in layman’s terms, this repair was done by replacing her aorta,” said Dr. Colvard. “We bypassed the aortic segment with CRA, which involved the branches going to both kidneys and all abdominal organs. We replaced it with a fabric graft. Essentially, we replaced a clogged pipe, and made sure all the connections from the pipe going to all the sinks (organs) were still connected correctly.”

Marti had a prolonged recovery, but eventually recovered fully and gained a happier and more independent life.

Through it all, Marti’s identical twin sister, Mary Alice, was by her side.

“When they’re hurting, you hurt too,” said Mary Alice. “We’re very close, and I wanted to support her through everything.”

Once Marti was doing better, her care team suggested Mary Alice get tested for the same disease since they’re identical twins and have the same genetics. They discovered Mary Alice did have CRA, but wasn’t experiencing any problems at the time.

One day, unlike Marti’s case which built slowly and lingered, Mary Alice’s symptoms came on hard, heavy and suddenly. She was rushed to the hospital.

“One day she was fine and laughing, and the next day she was deathly ill,” said Marti. “We almost lost Mary Alice a few times.”

But Mary Alice’s case was even more complicated than her sister’s. Not only did she have a CRA, she had another lesion in her thoracic aorta. In March 2024, she was admitted into the medical ICU at UH Cleveland Medical Center with severe lower leg pain, acute kidney failure pulmonary edema, acute right-sided heart failure and hypertensive crisis. Deteriorating quickly, she required dialysis and was eventually intubated. Her condition in the MICU was critical and heading toward palliative care.

With her unique anatomy and critical state, Mary Alice was not an optimal candidate for the same surgery her sister had undergone. But Drs. Cho and Colvard didn’t give up. They conceived and performed an innovative technique that provided a solution for a patient with little to no chance of survival otherwise. Mary Alice received a distal thoracic aorta and paravisceral aorta transaortic endarterectomy with the Sonopet device (an ultrasonic aspirator).

“This technique had never been reported before,” said Dr. Cho, also Chief of Vascular Surgery at UH Harrington Heart & Vascular Institute. “Instead of replacing her aorta with a fabric graft like her sister, we opened up Mary Alice’s aorta, temporarily disconnecting it from blood flow. We cleaned it with a tool that resembles a dentist’s drill for addressing cavities. These aortic lesions are hard and full of calcium, much like a tooth, and this instrument, while having been used in heart surgery and face surgery, had never been used in vascular surgery to our knowledge. It essentially drills down the calcium and suctions it out.”

The origins of Mary Alice’s arteries to her organs were also cleaned with this tool. This saved time, which was incredibly important for someone as sick as Mary Alice because she may not have survived a long operation like her sister.

After the team cleaned out her aorta through the opening, they sewed it back up, but she still needed the bottom part of her aorta fixed.

After the coral reef was removed, Mary Alice also had aortobifemoral bypass with cryograft. The standard treatment is to replace the calcified aorta with a new one. Typically, a fabric graft is used for this. Because Mary Alice had signs of sepsis or infection – the origins of which were never identified – the team could not use a fabric graft, as prosthetic materials can get infected from the blood in septic patients. Graft infections cause their own problems. The team chose to use a cryograft, which is an aorta donated from a cadaver. Human tissue is more resistant to infection.

Mary Alice made a remarkable recovery. One day after surgery, she was extubated and continued doing well. Several weeks later she resumed normal activities and sent her care team a picture of herself grocery shopping.

“We know how unique our cases were, and we’re so grateful to have this expertise to help and treat us right here in Northeast Ohio,” said Marti.

The twins are retired and enjoy spending quality time with their mother, Gloria Jean, and brother Stacy, which they’re able to enjoy even more now that they’re recovered and healthy.