Aortic Dissection: From Acute Dissection to Life-Long Care

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.

Sean Lyden, MD:
Welcome, everybody. My name's Sean Lyden. I'm the current Chair of Vascular Surgery at the Cleveland Clinic, and I have two colleagues here with me today to talk about aortic dissection. We'll introduce ourselves. Next to my left is?

Milind Desai, MD, MBA:
Hi, everybody. I'm Milind Desai. I'm the Medical Director of the Aortic Center and Director of Clinical Operations for the Department of Cardiovascular Medicine.

Sean Lyden, MD:
And to my right?

Scott Cameron, MD, PhD:
Hi, my name's Scott Cameron. I'm a vascular medicine physician and cardiologist, and I serve as the Section Head of Vascular Medicine at Cleveland Clinic.

Sean Lyden, MD:
So at the Cleveland Clinic, we actually see a large number of aortic dissections, both from small hospitals, mid hospitals, and even large hospitals. Milind, I'd maybe ask you to talk about first, so when someone calls with aortic emergency, an aortic dissection, how do they get to us? And then how do we actually start out by evaluating the patients, and where do they go?

Milind Desai, MD, MBA:
So it is all about teamwork and very coordinated, synchronous teamwork. So if there is a smaller institute, or an affiliate program that has a patient that presents to the emergency room with a suspected acute aortic emergency, and they do the initial set of testing that confirms the possibility of aortic dissection or any acute emergency, then there's an emergency phone line that they can get in contact with us. They are connected straight to our critical care team of physicians, fellows, et cetera, here at the main campus.

Milind Desai, MD, MBA:
And essentially, then the process starts really quickly. Depending upon the circumstances, we could send our air support or ambulance support to, the patients can be transferred via air helicopter or ground ambulance. They come to our ICU. But there's an important thing also, that happens concomitantly. We have developed a robust cloud-based system, where the images are transferred as the patient is still en route, so that we can have an evaluation of these images and have a game plan, before the patient ever reaches the Cleveland Clinic. And we can mobilize and assemble the team, so that essentially, everybody's waiting. Because time is money, as we all know.

Milind Desai, MD, MBA:
Once the patient gets here, they end up in our ICU, depending upon if there's a call that the patient needs to go to the OR emergently, then so be it. But majority of the patients end up in our ICU, have a quick evaluation. If there's some confirmation testing that needs to be done, that happens. If some stabilization needs to happen, that happens. And if a decision is made to initiate transportation to the OR, as I've alluded to, everybody has a game plan, to a point where it happens fast and very synchronous. And it works really well.

Milind Desai, MD, MBA:
We have established a robust system, including a robust support system and it is basically become a stellar organization, in terms of receiving acute aortic care.

Sean Lyden, MD:
I think that's one. And, to me, one of the amazing things is that before a patient comes, we'll use Epic as our electronic medical record system and we'll have a chat. And in Epic that one alerts anybody involved in aortic care that a patient's coming. It'll usually one of our cardiologists who does imaging will actually pre review the imaging once we have them electronically to let people know they're there. It allows the cardiac surgery team, the cardiology team, and the vascular surgery team, all to pre-review the images and so if someone had a ruptured dissection or had a ruptured aneurysmal dissection, or has a Type A dissection, we can get the OR teams ready to go. And the amazing thing is we're all expected to sort of coalesce at the patient's bedside upon arrival and sort of figure it out.

Sean Lyden, MD:
There's times when patients will be sent to us and they're not sure if it's a Type A or a Type B, and instead of sitting there and saying, well, you'll start on this service and then maybe you'll have to go to that service, or I have to make 12 phone calls. The key thing that we really tried to do is we tried to see it through the eyes of the referring clinicians in that, the patients, the answer is always yes, and there's always a bed. And so when we became an Institute back in 2008, the first head of the Institute, Dr. Lytle said, the answers will never be a no for an aortic catastrophe and I don't know how our Cardiac ICU always does it, but with only 26 beds, they are always able to make a bed for any time of the day, 24 hours a day to get those patients here. And I think then the other key thing is that we continue to do the care all the way through after they go home.

Sean Lyden, MD:
One of the things that we realized in the last couple of years is that when patients go home say they had a Type B and they're just undergoing medical management with impulse control, that the ongoing care of those patients is critical. And that if you don't see them early, to make sure that need adjustments of their medicines, they bounce back. So maybe Dr. Cameron, you want to talk about some of things we've initiated here to try and capture those patients who might otherwise not be ready to go all the way back to their internist or their referring physician, but need something on the interim way that we can help transition them back to the people who referred them to us.

Scott Cameron, MD, PhD:
Sure. And that's a really great question, Dr. Lyden. Having worked in other institutions that are perhaps a little bit less cohesive, one of the things that I thought was fantastic about the aortic program is that complete ownership is assumed for the patient, not only just at the time of the procedure, but then also wherever they happen to go back into their home environment. Now, one of the issues that we're always concerned about as you well know, is that patients who have aneurysms, the wall of that part of the blood vessel is a little bit weaker than the rest of the blood vessel. And so you really don't want to be in a situation where a patient is exposed to excess pressure in that area either before the surgical procedure or even after the surgical procedure.

Scott Cameron, MD, PhD:
And what we've found is that, if you look at the data, and I think nationwide hospitals would admit this, patients that have undergone surgery for aortic dissection or rupture, a lot of them have blood pressure excursions when they leave the hospital environment. It may be low blood pressure. It may be elevated blood pressure. And both of those are just as harmful as each other because we know that in a patient who's undergone a major aortic surgical procedure, there are blood vessels that come off of that main aorta into the spinal column. You certainly don't want the blood pressure to be too low. That can be dangerous. But similarly, when there's a fresh surgical site, you don't want the blood pressure to be elevated. And so patients they can perceive if their blood pressure is elevated or if it's too low and when the patient doesn't feel well, then actual thing we tell them is they should go to the emergency department.

Scott Cameron, MD, PhD:
One of the initiatives that we've now engaged in is that the patients will be pre-screened before they leave the hospital after surgery. They're given a blood pressure cuff. They're given a very clear algorithm and they're plugged into vascular medicine physician or vascular cardiologist, even before they've seen them, they're able to follow up with them by telephone and sometimes we can actually make medication changes over the telephone that prevents a patient from having to go to the emergency room. And then sometimes inevitably, particularly if it's in a rural area, the emergency departments will certainly say, well, this is a major procedure that the patients had, perhaps we should just transfer them back to Cleveland Clinic. And a lot of that creates undue anxiety for the patients as well as their families. So I think in taking care of patients carefully in the backend, we can prevent a lot of these re-hospitalizations.

Sean Lyden, MD:
So I think the other thing that from taking care of a lot of patients comes a lot of research. And maybe Milind, you can talk about some of the things we've looked at in the ICU in terms of our research initiatives to try and look at the patients we care for, how we understand our patient populations and how we've improved or altered our care. I mean, I know the one thing that we've all seen in last 5 to 10 years is shortage of medicines and pricing increases. And I know we've struggled a lot with what we best use to impulse control our patients. And you want to talk about maybe some things we looked at in the ICU phase of care in terms of how we better understand our patients and how that's altered our approaches based on our research.

Milind Desai, MD, MBA:
I mean and I think as we have discussed a few minutes ago, it is not just one thing. It is a lot of things. It is a combination of a lot of things. It is pivoting from if one particular medicine is not available. If things are more expensive, if the generic brand all of a sudden gets to be astronomical, then recognizing that and pivoting to a cheaper version or a more effective version. And we've done it really well. The story on the nitrates or the beta blockers. We continue to evolve and it's just not one little thing. It is a combination of many things.

Milind Desai, MD, MBA:
The other aspect I am particularly intrigued is what Sean mentioned. The cloud-based image assessment, that the time-saving, that the data that we publish on saving time in terms of when a patient is identified to when the patient comes here and we are not wasting time repeating scans. We are not wasting time trying to make a diagnosis or getting the ubiquitously missing disc that the transfer service forgot to bring to us. So it is this cloud-based image assessment that chat, the simple things, that we have done have made a tremendous dent in form of communication, in form of image transfer, and then once the patient gets in, the pivoting to utilizing the best possible available therapies and pivoting when there is a supply shortage, then pivoting to alternative solutions very quickly.

Sean Lyden, MD:
Having been here 20 years, when I first got here, for minimally invasive treatment for dissections was taking devices and making them on the back table. Since then, we first started with physician sponsored research studies to use commercial devices, and then have been participated in thoracic trials, leading to the approval of all the devices. Now we have trials for treating non-operative patients for Type A's with dissection devices. We now have arch branch trials. And so we've really tried to innovate in our technique of who we do and the best timing to do it has continued to evolve over time. I think one of the things we know is that we first only waited till someone who was really bad mal-perfused they were either having visceral ischemia, renal ischemia, or limb ischemia, and their mortality was better with endovascular therapy than nothing and better than open surgical mortality, but it was still 40%.

Sean Lyden, MD:
And so now we've really worked hard to see what are high risk features. And so we have patients who might come in with a Type B dissection or impulse controlled by the cardiologists and vascular medicine colleagues, but we know that they're likely to grow. And so we'll wait to an opportune time, about six weeks down the road to treat him and to seal up their anterior to have better long-term outcomes. But I think the one thing that we still don't have the best idea on is who to then to use that in the connective tissue patients and how likely they are to have dissection. So maybe Dr. Cameron, you want to comment on-

Milind Desai, MD, MBA:
Before Scott goes, I would like to make one comment. Sorry, Scott, to steal your thunder for a second, but one of the things that we have evolved, and again, I'm not a surgeon but, dealing with these patients a lot is the business of complete repair in the midst of an emergency. So it is not when the patient is in the middle of a catastrophe. It is at least at the Cleveland Clinic, we have access to fantastic cardio aortic surgeons who are skilled at doing a complete job. So it is no longer okay to just replace a portion of the mid ascending aorta with a short supracoronary graft. There are patients where we would do a complete job, including a root repair, root operation, ascending aorta operation, as well as a frozen elephant trunk operation with side branches that Dr. Lyden alluded to. And these are complete operations that reduce, repeat, unnecessary procedures with excellent, excellent outcomes. So evolution, so it is no longer just a small operation and get out of dodge, but do a complete operation. And this has been a very successful strategy. Sorry, Scott.

Sean Lyden, MD
: So, we're basically getting to the connective tissue patients, patients with Ehlers-Danlos or Marfan's and whether or not they're at risk for developing a dissection, or if they've had a dissection, at what threshold for be repaired. And so maybe Dr. Cameron, you can talk about some of the services we have available here to sort of look, if people don't know they have a connective tissue disorder, services we've had to figure out, do you have one? And then how we coordinate care amongst all the different specialties in terms of when and how to coordinate a repair.

Scott Cameron, MD, PhD:
That's right. So I think we're pretty good in terms of imaging modalities to know exactly what a patient has, and clearly the surgical and endovascular therapies have advanced, but two questions are always asked by patients. Number one question is this disorder that I might have in my blood vessel, is it something that I inherited or is it something that I can pass on to my children? Or is it something that my brothers and sisters have? That's an excellent question. And there are certain considerations for that group of patients. And then the second thing is, are there any medical therapies that could be adjuncts to surgery to prevent a surgical procedure, to delay a surgical procedure, or even to be used after it? And the answer to that question is also yes. I specifically for the patients who may have a heritable disorder, those that we probably hear most about are Marfan syndrome and Ehlers-Danlos syndrome.

Scott Cameron, MD, PhD:
And so those are two very specific disorders of blood vessels, where some of the structural proteins that give the blood vessel its strength are slightly different and there's a mutation in the gene. And so the proteins that are involved in those two disorders, don't behave the same way in the blood vessel wall. And we know from history and by looking at data that anybody who's got those disorders, if there's an aneurysm, it's statistically more likely to grow a little bit faster. And so if we're able to identify that patient has one of those particular genes, then influences how often we will image the patient. And it also influences when we should say now is the time for surgery. Now, if you're talking about the top part of the aorta that's coming out of the heart and the bottom part of the aorta, the number that everyone usually adheres to in most guidelines is 5.5 centimeters.

Scott Cameron, MD, PhD:
Everyone will universally agree that that's a reasonable time to correct that particular aneurysm before there's an issue. We certainly know between 5 and 5.4 centimeters, that's also considered very reasonable. But if you have a patient that has Ehlers-Danlos syndrome, for example, or Marfan syndrome or Loeys-Dietz syndrome, and I see all of those patients, we know that those patients would benefit from having intervention earlier, before they actually develop a tear, a dissection or even worse or rupture, which is life-threatening. Now, the other thing that's also important is to always individualize it to the patient. And I'll give you an example. If I have a patient who has Ehlers-Danlos syndrome and they happen to find out they're pregnant, we have to personalize care to that patient because we know that the hormonal changes during pregnancy, there are certain increased risks. We know that the hemodynamic forces, the mechanical forces on the aorta, they're going to change during pregnancy.

Scott Cameron, MD, PhD:
We know that blood volume increases by 50% during pregnancy. So these are all those things that we're thinking about when we see patients really trying to personalize the care. We have a cadre of highly qualified genetic counselors who understand anatomy and physiology of blood vessels, as well as most physicians. And quite often I find patients can be referred for a certain disease and one disease I'll just mention this fibromuscular dysplasia. I've had several referrals for that and I find out they don't have fibromuscular dysplasia, they actually have a mutation in some of these genes. In one case it was Loeys-Dietz syndrome and that completely changes the management of that patient. Once we realize they have that, and it changes the type of conversation we'll have not only with the patient, but also what I may relay to my surgical colleagues.

Sean Lyden, MD:
I think the other thing we hear a lot is how then coordinate, you know, follow up with the physician who sent them to us. And I'd say in the last a year and a half with COVID, we've had the great explosion of virtual care, both by using video chat, as well as phone chat. And we've seen escalation then deescalation of where and how we're allowed to do it too. But once typically it is a patient that we've engaged with for that problem, we can do some remote follow-up. And so, I don't know if either one of you to one, I sort of talk about how we've sort of done that. And some of the lessons we've learned over the last year and a half.

Milind Desai, MD, MBA:
I mean, and this, thanks, Sean. This is not necessarily only related to aortic aneurysm or dissection patients. This is healthcare delivery in general cardiovascular medicine in particular, and maybe even specific to the dissection patients who require careful follow-up. So yes, some sort of telehealth has become a very crucial aspect of our taking care of patients. So in my role in operations, one of the things we have made sure in cardiovascular medicine is if you are an inpatient, getting discharged, everyone is offered at least a virtual visit or an in-person visit with a provider at one week in follow up. So if you are from a catchment area, you want to come in, you will have an appointment in person. If you want to do a virtual visit, you will have an appointment within one week. This helps alleviate anxiety from the patient. If they have any lingering questions that have come up, some lifestyle adjustment question. Very often medication questions. A lot of times the readmissions happen because of volume overload, because of hypertension, so all these things can be addressed during these followup.

Milind Desai, MD, MBA:
And then there's, after that appointment, there's always a follow-up either with your local providers or if you choose to continue care with us, that is also offered at about 4 to 6 weeks. And for the dissection folks, especially if they've had any surgical or percutaneous therapies, there are established guidelines of follow-up imaging to establish a timeframe based progression, or make sure there is no progression of disease. So we have robust plans basically to make sure there's a continuity of care. At least in our practice, for aortopathy, if the patients are coming from outside of our Cleveland Clinic catchment area, they should continue care with the local providers and/or cardiology, local primary care providers and/or cardiologists. But we also recommend some element of followup care with us on an ongoing basis. And with telehealth, it has made things substantially more feasible.

Sean Lyden, MD:
Any, any other comments in terms of the telehealth initiatives that we haven't brought up already there? Dr. Cameron?

Scott Cameron, MD, PhD:
No, I agree with Dr. Desai. I'll tell you one thing that I have found helpful and in one case was availability of imaging data, as well as telehealth. And in one case, I was able to be pretty sure that a patient had a genetic disorder that happens to involve the aorta as well as blood vessels in the brain. And the telehealth was actually sufficient for us to get all the information needed, to know that the patient required a genetic test. The patient then presented for it and actually had it. It was Type 2 Loeys-Dietz syndrome. And I think what the patient indicated is they lived very, very far away, but they were satisfied with the quality of the service and our ability to pre-evaluate all the scans. And so we're very clear with patients that we'll evaluate data that's perhaps from outside our institution and it's oftentimes quite helpful. And a lot of times we don't need to repeat that imaging. And in conjunction with telehealth, I'll tell you that the patients with aortic disease, particularly, I find it very helpful.

Sean Lyden, MD:
And, and I think the one thing that we've learned is still one the difficulties from the acute event, where we've been able to establish with the hospital that's trying to send the patient, the ability to electronically transfer images. Once the patient's in the outpatient setting and there may be 5, 7 different, 8 locations, they might get imaging at it. I think one of the difficulties we're still working through is how to get those scans and followup sent to us electronically. And I think that's one of the difficulties is that the patient wants to have a virtual visit and you've done an implant of some kind or you're watching something. And it's really to make sure we have those actual images before you do the virtual visit and so we continue to try and improve those events.

Sean Lyden, MD:
And so we like working very well with our clinicians to sit there and say, hey, if you don't know how to order the scan, we can send to you exactly how the radiologist had set the scan up so it meets our needs, so we don't have to repeat that, but we still struggle with having more and more institutions who can electronically transfer us the data. And I think that's still one of the difficulties we've not yet ironed out in the virtual care, in the telehealth systems. And I think as our government mandates, the hospitals, the EMRs to talk to each other better, hopefully that'll improve. But otherwise it's an institution by institution event and then filling out a lot of release forms to get those sent to us.

Milind Desai, MD, MBA:
And also it is important, not just the process of image transfer, but homogenization of image acquisition, especially, for aortic imaging that is beyond the front, beyond close to the heart. So in front of, diaphragmatic, it is relatively easy, but it to be challenging when you have to establish imaging protocols for the ascending aorta or the thoracic aorta in general, because of significant risk of motion artifacts and so use of different techniques, including gating, et cetera, is crucial in these patients. And education of folks, becomes, in different centers, becomes important as it relates to making sure imaging is standardized, transfer of data is standardized, and that way patients are well taken care of. There's not an angst and there is a uniformity of care and care delivery.

Sean Lyden, MD:
So I want to welcome a latecomer, this is Dr. Roselli who's the Surgical Director of the Aortic Center, just like always, he was involved, delayed in patient care. So a little late in getting here.

Eric Roselli, MD:
Hi everyone.

Sean Lyden, MD:
And so we're just doing the discussion with physicians about aortic dissection and we were talking a little bit out of how we've used telehealth to help ease the ability of patients to get remote care with us after we've either set on a medical pathway of followup or they've had a surgical repair.

Eric Roselli, MD:
Yeah. I appreciate you guys being patient and allowing me to jump in, but I did come straight from the OR as you know. Yeah. I think the keen, that lesson that we learned about this disease process over the last decade and a half, is that it requires lifelong care and exactly how and when, and the cadence of imaging is still something we're figuring out, but none of the literature is going to help us because none of the literature only gives us 5 or 10 years of followup. And our patients are surviving into their second decades and beyond. So even somebody who's 10 or 15 years out from a dissection and things look stable, they still need to have an imaging study every year or two or something, at least every couple of years, if even if it's been stable for a long time.

Eric Roselli, MD:
And to ask those people to travel a long way to an aorta center might be difficult. It's been really nice to work with the partners that are taking care, the medical part, the medical health care partners that are taking care of these patients at home to coordinate getting the images transferred and having those conversations with the patients and letting them know that, there's, they still have access to some of the really complex care that we deliver, even though it might not be now. You can't just forget these people and say, it's been good for a long time. You're done.

Sean Lyden, MD:
So with that, maybe we'll draw our session to close. And if you guys ever want to find out more, please come to the Cleveland Clinic website, to the Aortic Center website, and we're happy to help serve your patients in any way we can.

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