Aortic Aneurysms

Podcast Transcript

Announcer:
Welcome to Cleveland Clinic Cardiac Consult brought to you by the Sydell and Arnold Miller Family, Heart Vascular and Thoracic Institute at Cleveland Clinic.
Dr. Scott Cameron:
So my name is Dr. Scott Cameron, and I'm a cardiologist and vascular medicine physician at the Cleveland Clinic, and I'm joined today by Dr. Sean Lyden, who's the chair of vascular surgery. And we're going to talk a little bit today about aneurysms, particularly aneurysms in the aorta, and just to kind of give the awareness of what we do as a center, some of the patients that typically might fall within screening guidelines, and just really give the awareness that we're here to care for the patients. And I might just ask Dr. Lyden, what kind of patients do you think you'd like to discuss with healthcare providers? Those patients that they may see every day, but not necessarily think they have an aneurysm. What should we tell them?
Dr. Sean Lyden:
I think the key thing is, there's a lot of societal guidelines and national guidelines and so if you have patients above the age of 65, that have ever smoked, part of their welcome to Medicare physical, they should have their abdominal aorta screened. And then as you see your patients in your office, if they have a family history of aneurysms, if it's a thoracic aneurysm, they have a 50% chance that they may have one. If it's an abdominal area, it's a 15%. So it's really patients who have risk factors of either smoking or age above the age of 65, or have a family history of aneurysm, those are the patients really would concentrate on saying, "Hey, could they have one as well?" And if it's something you feel comfortable ordering screening, that should be done, if not, then sending it to someone like Dr. Cameron or myself to evaluate those patients for those types of problems.
Dr. Scott Cameron:
You know, one of the things that I'm always struck by when you're examining patients, and certainly there are many medical specialties, and in North America, we do tend to be a little bit more specialized than maybe some other countries, is sometimes providers, physicians for example, say, "Well, the physical exam is enough. I don't really need a screening guideline." And one of the things I usually say is what turns out that's been studied as you well know, and the physical examination, particularly for the infrarenal aortic aneurysms is actually not sensitive at all. And that's one of the reasons why we do have very specific screening guidelines. And I think everybody would know, that if it's an older male, most patients would be aware that there's probably a guideline at some point. And certainly if you're a male 65 to 75, if you're actively smoking, heaven forbid, or if you have a history of smoking, you should be screened at least one time.
But some of the other patients sometimes can fly below radar. And I always encourage physicians, when you're doing a physical exam, if you see something that's a little bit unusual that might be a patient you'd like to refer to a specialist, Dr. Lyden or myself, who maybe sees a lot of aneurysms. And a couple of things that come up is if you're looking in the mouth, certainly for the aneurysms, most of them are atherosclerosis, or hardening of the artery, that causes the remodeling and causes aneurysm. But certainly there are collagen vascular diseases.
If you just look at the uvula and you see there's two lobes there, that's a telltale sign that, that patient could have an intrinsic heritable collagen vascular disorder, because most patients don't have two lobes to their uvula. Another thing is if they have a very high palate, or if they have a cleft palate, we sometimes say that that can signify it. If they have hyper extensibility in the joints, particularly in the intrinsic areas of the hand, we sometimes that's a warning sign. For our colleagues in the community, Dr. Lyden, how often do you think they should consider referring? Should it be, as soon as they've detected an aneurysm is a certain size, or do you think that they should always be seen by specialists? What's your feeling based on what you've seen at Cleveland Clinic?
Dr. Sean Lyden:
So I think a lot of it depends on the comfort level of the physician and whether or not they see this as part of the routine practice. I think were both vascular medicine and vascular surgery are a little different, is that we act as primary care providers for many patients with vascular disease, and so we feel very comfortable being referred patients from the time it just becomes big enough to call an aneurysm, all the way through treatment, as well as just checking in with the family doctor or whether you're a cardiologist or another specialist. And so there are guidelines of when people should get examined first and how often they should get rechecked. It depends if it's in the chest or in the abdominal aorta.
And so I really talked to the providers who are sending me somebody and say, "Is this something you feel comfortable seeing." If not, unlike many other surgeons, you have a gallbladder problem, general surgeon takes out your gallbladder and never sees you again. We're primary care providers of our vascular patients and we follow them longitudinally over time. So I'm happy to see a patient any time along that time point from both when it's first diagnosed well through treatment in lifelong follow-up because when patients have an aneurysm in one location in the body of the aorta, they're much more likely to have it somewhere else. So if someone has an abdominal repair over the next decade, 30% will develop in the chest. If someone has in the chest, 30% over the next decade, will have it in the abdomen. So in follow up, after your fixed part of it, there's other areas you have to go and consider, and worry about.
And the other thing is that every time it's a touchpoint, these patients die from cardiovascular and cerebrovascular causes, so every touch point is another time to get them to stop smoking, to work with us and with the referring physicians about cholesterol control and then blood pressure control because I think that's the thing that sometimes the patients just don't hear enough of how important the benefits from smoking sensation happened immediately on aortic disease. It's not like your cancer risk, which may be fixed from your point of smoking prior, and every time you see them, their blood pressure control and cholesterol control should be assessed because many of these are atherosclerotic based. And if you can control their risk factors, their overall longevity be improved.
Dr. Scott Cameron:
You know, it's a really interesting point you make. An I have to say, without us ever really discussing this, I've sort of felt the same way. And one of the reasons I decided to do subspecialty in vascular medicine, is I actually enjoy the longitudinal care and the blood vessels unite every organ. And because they unite every organ, that has to bring a certain amount of comfort with issues that can happen in all those different organs. And those are things that we're quite used to seeing over a period of time. And I have to say, that I find caring for patients, with vascular disease, tremendously rewarding. And more often than not, and I would wager about 80% of the time, if I see a patient with a vascular disorder in an artery, I also noticed that they have a disorder in the veins.
I'd say those that have atherosclerosis and hardening of the arteries, I'd say about 25% of them I find that they carry atypical lipoproteins that don't respond to conventional medical therapy. But those are things that we happen to see a lot of here. And we're very fortunate that we know the outcome and we know some newer ways that we can maybe help some of those patients. And so, sometimes I like to say, the patients is kind of like when you hand your car into the mechanic. If you come to a vascular specialist, you might ask them to look at the muffler, but they say, "Well, while you're here, I also noticed this with the brakes." And lot of the things that we see in vascular care actually happen that way and it's just that we quite often find out there's issues in other parts of the body and we can serve the patient with that as well.
Dr. Sean Lyden:
I think the other key thing is that we work very well collaborative together. If we're going to intervene on an aortic disease, whether it's a dissection or an aneurysm, to make sure the risk factors are controlled, that we've addressed all their other issues so we can bring them through treatments as safely as possible. We have some of the most complicated patients in terms of overall risk. If you look at the [inaudible 00:07:47] health consortium, and observed expected ratio, we're treating some of the sickest patients for any like size institution with a very, very low morbidity. And in almost every patient, we consider both minimally invasive as well as traditional open options. And when there's a minimally invasive option that can have great longevity, we have great success doing that. Leading treatments of all the current trials for branch vessel disease of the arch, the thoracoabdominal aorta, but really also treating patients who might've had a treatment somewhere else that now is having an issue and failing.
And so we work very well together to make sure the patients get evaluated on the front end. And then part of... many times when they come from out of town or out of state, before they can get back home, we work really well with the vascular medicine department to get them a portable blood pressure monitor. So they can have remote checks to make sure by the time they're ready to get back to their home state or their home doctor that they're really doing well so they don't have to make a bunch of trips back to see us. And I think that's been a really new collaboration that's worked really well between our departments.
Dr. Scott Cameron:
Yeah, definitely. Just as you said, is one of the benefits and the joys of working here is like Dr. Lyden, is a surgeon. He does very complicated open procedures, but also very experienced in endovascular care where sometimes if a physician or a medical provider sending a patient here, the care can be fragmented. Maybe some people will do one thing, but not the other. In the case of myself, I do see patients with vascular disease, but also take care of their heart issues while they're there and so it can sort of save the patient time. And the fact that we're sort of in this unified vascular care umbrella, it really makes things faster for the patient. And we have a policy that we communicate very, very closely and very quickly back with referring providers. So I think it works quite well.
Dr. Sean Lyden:
Well, thanks everybody for joining us. And, we look forward to providing future updates on how we can educate on our vascular disease patients and consider joining in on some of our tall rounds.
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