How 1 cardiologist adapted an aneurysm procedure for cardiovascular surgery

Richard Smalling, MD, PhD, is one of the few cardiologists in the country using coil embolization to treat hypertrophic obstructive cardiomyopathy.

Coil embolization is traditionally used on aneurysms, but Dr. Smalling, director of cardiology at Bellaire, Texas-based UTHealth Heart & Vascular, and others have adapted the procedure to help patients who cannot undergo open heart surgery or other invasive treatments. The procedure is an alternative to alcohol septal reduction and provides more control and does not damage surrounding tissue as severely.

Using a catheter, Dr. Smalling feeds coils into position to plug the blood vessel supplying the bulge. This causes the bulge to shrink.

He performed his first procedure on a 73-year-old woman in the early 2000s. The hospital had brought in an expert from Rochester, Minn.-based Mayo Clinic to perform an alcohol septal ablation, but during the surgery, “He pulled off his gloves and said nothing can be done and walked out,” Dr. Smalling told Becker’s. “We had all this experience with coiling various things, so I thought, ‘This lady has nothing to lose.’ We dropped four coils in and all of a sudden the pressure dropped across that blockage to zero.” After three days, the patient went home with no pacemaker and no symptoms. 

Since 2007, Dr. Smalling has done the procedure on more than 50 patients.

“Our mortality rate is zero and our pacemaker rate is zero. So it appears to be quite successful and we’re in the process of writing the results,” he said. 

He shared stories of patients undergoing the procedure and returning home with no symptoms after a few days. 

“We did not copy techniques used to treat brain aneurysms,” Dr. Smalling said. “There was a lot of parallel development among vascular specialists [while coil embolisms and trans stent aneurysm coiling techniques were developed and adopted by neurosurgeons and radiologists], so I don’t think anyone can claim a ‘first in man’ status of the procedure.”

The only downside to the procedure is the time required to place the coils. He said there are only a few institutions around the country using coil embolisms.

“You have to be very patient,” Dr. Smalling said. “I think a reason structural work is still focused on alcohol is because coils slow you down too much. We’re going to try to show how much better it is if you take some time.”