Friday, May 15, 2009 - Noon
Matthew Eagleton, MD
Vascular Surgeon, Cleveland Clinic Department of Vascular Surgery of the Sydell and Arnold Miller Family Heart & Vascular Institute
The aorta is the largest artery and is the blood vessel that carries oxygen-rich blood away from the heart to all parts of the body. When an artery wall in the aorta weakens, the wall abnormally expands or bulges, causing an aortic aneurysm. An abdominal aortic aneurysm (AAA) is an enlargement of the lower part of the aorta that extends through the abdominal area and is a major health risk that may not have related symptoms until a life-threatening event occurs, such as aneurysm rupture. Cleveland Clinic vascular surgeon Matthew Eagleton, MD discusses this condition and how to treat it.
Cleveland_Clinic_Host: Welcome to our Online Health Chat with Dr. Matthew Eagleton. We are thrilled to have them here today for this chat. Lets begin with the questions, but first, thank you for joinging us Dr. Eagleton.
Speaker_-_Dr__Matthew_Eagleton: Thank you - I am happy to be here.
hghfrt: I am 50 years old and had a CT scan - it showed I have calcification and atherosclerosis of the aorta - what does that mean for my future risk of aneurysm - should I be followed by a doctor?
Speaker_-_Dr__Matthew_Eagleton: The presence of calcification and atherosclerosis within the aorta is not entirely abnormal for someone as young as you. It does not however place you at any significantly increased risk for developing an AAA. It does demonstrate however that you do have atherosclerotic disease of your arteries. You should be followed routinely by a primary care physician. In addition, you should practice a healthy lifestyle by not smoking, eating a low fat diet, and exercising routinely.
Smithw: My father died from an aneurysm and I wonder if it is hereditary
Speaker_-_Dr__Matthew_Eagleton: Aneurysms do run in families. We do not know however the specific genetic defect that causes them. It is recommended in your situation to get screened for the presence of an aneurysm when you approach 60 years of age.
Abdominal Aortic Aneurysm (AAA) Diagnosis
lopwise2: How is an AAA diagnosed and what are the signs that you may have one?
Speaker_-_Dr__Matthew_Eagleton: Most AAA do not cause any symptoms - occasionally however, some patients may experience minor back or abdominal pain. Rarely, small pieces of clot lining the aneurysm may break off and block off small arteries in the leg or foot. This is not common.
The time at which aneurysms cause significant symptoms is when they rupture or pop. Patients experiencing this will have severe back or abdominal pain. If you know you have an aneurysm, and you experience these symptoms - you should seek medical attention immediately.
AAA can be diagnosed with a number of procedures including ultrasound, CT scans and MRI. Most aneurysms are detected incidentally while patients are undergoing studies for other reasons. Screening is recommended using ultrasound in patients with a family history of aneurysmal disease or who are considered high risk for aneurysms due to a history of smoking and high blood pressure. Typically an ultrasound is used in these situations for the presence of an AAA
matthewt: I have an aortic aneurysm found when having a CT scan for another unrelated problem. But I have no symptoms. Does symptoms have anything to do with the severity of the problem. The doctor said I need to be followed closely but I feel fine.
Speaker_-_Dr__Matthew_Eagleton: Most aneurysms do not cause symptoms until they rupture, which is a life-threatening problem. Size of the aneurysm is the real predictor of whether the aneurysm has a high risk of rupture or not. Smaller aneurysms carry a lower risk for rupture and may often just be observed. It is important however to continue to have follow up with your doctor regarding this as aneurysms do increase in size over time. You will not experience any symptoms with this change in size. The only way for your doctor to know if your aneurysm is enlarging is to get an ultrasound or CT scan.
clemson007: What are the best tests to diagnose an abdominal aortic aneurysm?
Speaker_-_Dr__Matthew_Eagleton: The three most common tests are: Ultrasound, CT scan and MRI.
Ultrasound is usually the most frequently used screening tool to initially diagnose patients thought to be at high risk for the presence of an AAA.
CT scan and MRI are more invasive but provide a greater amount of detail regarding the aneurysm. They are typically used in planning surgical repair of an aneurysm or in cases when ultrasound does not provide enough information.
Thoracic vs. Abdominal Aortic Aneurysm (AAA)
lnt: How does a AAA differ in severity or treatment from an ascending thoracic/aortic root aneurysm? Is 4.3 to 4.7 cm large and is pregnancy safe? I am a nurse and 39 years old/
Speaker_-_Dr__Matthew_Eagleton: Both AAA and ascending aortic root aneurysm can be life-threatening problems - just in different locations in the body. Treatment however is quite different. Ascending aortic root aneurysms require surgery with replacement of the aorta through an incision in the chest
Abdominal aortic aneurysms can be repaired with conventional surgery through an incision in the abdomen or endovascular surgery through small incisions through groins.
Endovascular surgery is not currently available to treat ascending aortic aneurysms.
A 4.3 - 4.7 cm aneurysm is not considered large in either location. In either location an aneurysm of that size requires close follow up. Check with your doctor regarding pregnancy - there are many variables that affect pregnancy - you should consult a vascular or cardiac surgeon and an OB that has experience with high risk pregnancy.
Abdominal Aortic Aneurysm (AAA) – When is surgery recommended?
rose_bud502: I have an abdominal aorta aneurysm. CT SCAN shows 5.1. When is surgery recommended.
Speaker_-_Dr__Matthew_Eagleton: in general - surgery is typically recommended for aneurysms that are approximately 5.5 cm. However, each individual needs to be assessed by their surgeon and other physicians to best determine their specific risk for surgery. In some instances, surgery may be delayed until the aneurysm is larger if the patient is considered higher risk than the average population.
lewis22: What are the indications of abdominal aortic aneurysm repair?
Speaker_-_Dr__Matthew_Eagleton: In general, most surgeons recommend repair for AAA that are approximately 5.5 cm. However, each patient must be evaluated to identify his or her specific risk for aortic aneurysm surgery. In high risk patients, surgery may be delayed until the aneurysm is larger.
Abdominal Aortic Aneurysm (AAA) Surgery
jenningsm: Hello - my dad has an aneurysm after the curve that is 5 cm. He is 65 years old. When he was 55 years old he had an abdominal aorta aneurysm operated on for 9 cm. Will they wait that big for this aneurysm. Also - wonder if because it will be his second surgery if his risk will be a lot higher for complications
Speaker_-_Dr__Matthew_Eagleton: It is unlikely that they would wait until the aneurysm is 9 cm again. It is generally recommended that AAA be repaired when they reach about 5.5 cm.
Re-do surgery for recurrent aneurysm does present with higher risk than someone who has not had aneurysm surgery before. Choose a center that has experience with re-do operations.
stevie: My mother is 75 years old. She has been diagnosed with a abdominal aortic aneurysm. The aneurysm is now larger than 5mm. I would like to find out what my mother's options are
Speaker_-_Dr__Matthew_Eagleton: It is difficult to provide you with specific information regarding your mother. There are typically 3 options with regard to aneurysms. Watchful waiting or observation; repair with conventional surgery; or repair with endovascular surgery. The choice will depend on the size of the aneurysm and your mother's other medical problems. I would recommend you consult with an experienced vascular surgeon to help better define her risks.
lenoir: I live in Uruguay and I don't have any health insurance. I have an AAA and was recommended endovascular surgery. I would like to know the cost of the surgery.
Speaker_-_Dr__Matthew_Eagleton: Each patient's case is different and costs are based on appointments made. We have a special service for international patients that can help you answer your question. Please call Global Patient Services at 001 216 444 8184 or email email@example.com.
carriehn: My dad is 80 years old and has a size 6 abdominal aneurysm. He really is not that sick - but that aneurysm is very big. What can you do for an 80 year old male?
Speaker_-_Dr__Matthew_Eagleton: In general it would be recommended to repair a 6 cm AAA. Age is not typically a contraindication to surgery. Other factors such as your father's other medical problems would play a larger role in determining if he is a candidate for surgery. Both conventional and endovascular surgery can safely be performed in 80 year olds.
Abdominal Aortic Aneurysm (AAA) – Endovascular Repair
bb87: In the last year my aneurysm has grown from 4.9 cm to 5.8 cm. My doctor said I need surgery as soon as possible. Is a minimally invasive endovascular procedure an option?
Speaker_-_Dr__Matthew_Eagleton: Endovascular surgery or stent graft repair of AAA is a very durable option for patients in need of AAA surgery. Not all patients however are candidates for endovascular repair. There are some anatomic requirements that will allow this type of repair to be successful. You should consult with your vascular surgeon as to if you specifically are a candidate for this approach.
illu65: How many endovascular stents do you do at your institution? Is there ever a problem with finding the right size of stent?
Speaker_-_Dr__Matthew_Eagleton: Over the past several years we have repaired several thousand patients with either endovascular or open surgical repair. Size can be an issue with regard to endovascular repair and in some situations patients are not candidates for this procedure due to the size or shape of their aneurysm and the adjacent aorta. Your vascular surgeon should be able to tell you whether you are a candidate or not based on a CT scan.
bearhug45: I have heard that a stent graft can migrate and move. How often does that occur? What happens if that occurs?
Speaker_-_Dr__Matthew_Eagleton: Migration of stent grafts is very uncommon but it can occur. There are a number of different factors that can contribute to this complication. If the stent graft migrates this often needs to be repaired. The type of repair that is done depends on the anatomy of the aorta and the location of the migrated stent graft. In many cases, this can be repaired with the placement of an additional stent graft. In some cases however, it requires removal of the stent graft and conventional surgical repair of the aneurysm.
Cleveland_Clinic_Host: Dr. Eagleton, recently an article came out from ISCT in regards to "Minimally Invasive Repair of Ruptured Triple AAA Could Save More Lives Than Traditional Open Surgery" - can you please comment on it and provide your thoughts?
Speaker_-_Dr__Matthew_Eagleton: AAA rupture is a devastating problem with over half the patients dying despite modern medical therapy. With the development of endovascular therapy we hope that this less invasive method of AAA repair may be able to improve our outcomes in treating ruptured aneurysms.
To date studies evaluating the use of endovascular surgery to treat ruptured AAAs contain a small number of patients which makes evaluating their outcomes more difficult. However, there is some evidence to suggest that patients who can get the ruptured aneurysm treated with a stent graft may do better - not all patients however will be able to get this therapy due to the makeup of their aneurysm. In these situations we will need to continue to rely on conventional surgery.
Abdominal Aortic Aneurysm (AAA) Surgery Recovery
AbirH: My husband who is 42 years old was diagnosed with abdominal aortic aneurysm. His doctor ordered surgery. Can you tell me what the recovery is like after surgery?
Speaker_-_Dr__Matthew_Eagleton: There are two types of surgery for AAA - conventional surgery which involves an incision in the abdomen and replacement of the aorta - and endovascular surgery - which requires 2 smaller incisions in the groin and repair of the aneurysm from inside the aorta.
The recovery from conventional surgery is a bit longer due to the larger incision and hospital stays tend to be about 1 week and patients are back to normal activities in about 3 months.
For endovascular surgery - hospital stays are approx. 2 days and patients are back to normal activities in about 2 to 4 weeks. Patients undergoing endovascular treatment however may require more frequent follow up visits to monitor the status of the repair.
runner65: I wonder if I have an abdominal aneurysm that is 5.6 cm and I decide to come to Cleveland for surgery - can I fly there? How long do I have to wait to fly home if ok.
Speaker_-_Dr__Matthew_Eagleton: Yes you can fly here - having an aneurysm is not a contraindication to fly. Many patients are able to fly home a few days after being discharged from the hospital.
smallworld1: My mom had aorta surgery about a year ago and still has pain around the incision on the back. Is that normal? Is there anything that could help her? Is it related to the aorta or the incision?
Speaker_-_Dr__Matthew_Eagleton: Some people can develop a chronic incisional pain. It is unlikely that the pain is due to the aorta or aneurysm repair itself. If routine pain control measures are not successful at alleviating her discomfort, she may need to seek input from a specialist in pain management.
jjames: I had an abdominal aortic aneurysm repair last summer. I wonder if I can get back to an active lifestyle this coming summer - I road a bike long distances - I admit I did some weight lifting which I guess is not allowed anymore - but are there also restrictions on high intensity exercise?
Speaker_-_Dr__Matthew_Eagleton: Following aneurysm repair provided there were no significant complications and you do not have any other aneurysms - you should have no restrictions on your activities.
kathleen3: If my husband has aorta aneurysm surgery - I wonder what the recovery is like. Can he be left alone while I go back to work? Will he be able to get up and walk around? He really had no symptoms that we knew of before surgery except he was tired a lot. Do you think he will feel better since he had the surgery?
Speaker_-_Dr__Matthew_Eagleton: Most aneurysms do not cause any symptoms. AAA surgery is rarely done to make patients feel better but is performed to prevent the aneurysms from popping. It is unlikely the aneurysm was contributing to your husband's fatigue - therefore it is unlikely that surgery to treat the aneurysm will correct this. Your husband's recovery after surgery will vary some depending on whether his aneurysm was repaired with conventional surgery or with endovascular surgery.
In either case, it is unlikely your husband will be discharged to home from the hospital if he is unable to get up and walk around by himself and perform some of the activities of daily living independently.
Abdominal Aortic Aneurysm with other arteries involved
hteller: HI - I have a descending and abdominal aortic aneurysm. I have involvement in the renal arteries and superior mesenteric artery. I wonder what surgery would involve at the Cleveland Clinic with this extent of surgery
Speaker_-_Dr__Matthew_Eagleton: The extent of your aneurysm makes repair higher risk. Surgery may or may not be recommended depending on the size of the aneurysm and your other medical problems. Traditionally, aneurysms of this extent require conventional open surgery. At the Cleveland Clinic, we do have a clinical trial evaluating the use of special stent grafts to repair these aneurysms with endovascular surgery, for a select group of patients that meet enrollment criteria. We would be happy to evaluate you at any time.
karen_s: My daughter has an aortic aneurysm that involves the renal arteries - what is your experience with this kind of condition? What are her options?
Speaker_-_Dr__Matthew_Eagleton: At the Cleveland Clinic we have a great deal of experience caring for patients with aneurysms of this type. Treatment options will vary depending on the size of her aneurysm and her other medical problems. Options include observation if the aneurysm is small or her risks are high; conventional surgery to repair the aneurysm; and in some situations endovascular surgery as part of a clinical research trial.
Cleveland_Clinic_Host: Those were all the questions we had for today, thank you for joining us and thank you Dr. Eagleton for taking the time out to answer our questions.
Speaker_-_Dr__Matthew_Eagleton: Thank you for having me today.
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