Does Your Aortic Aneurysm Need Surgery?

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell & Arnold Miller Family Heart, Vascular, and Thoracic Institute. These podcasts will help you learn more about your heart, thoracic, and vascular systems, ways to stay healthy, and information about diseases, and treatment options. Enjoy.

Sean Lyden, MD:

Welcome, everybody. My name is Sean Lyden, I'm the Chairman of Vascular Surgery at the Cleveland Clinic, and I'm joined by one of my partners, and I'll let him introduce himself.

Francis Caputo, MD:

Hi, my name's Frank Caputo. I'm one of the vascular surgeons at the Cleveland Clinic. I'm also the Vascular Surgery Director of the Aortic Center here, as well as the Program Director of the Vascular Surgery Training Programs.

Sean Lyden, MD:

We're here to talk today a little about abdominal and thoracic aortic aneurysms, and sort of how we look at them, when we treat them, and how we decide to treat them.

Sean Lyden, MD:

So maybe, Dr. Caputo, if you want to talk a little bit about when the aneurysms are in the thoracic aorta in the chest, when do we decide to treat them, and then let's get to then how we treat them?

Francis Caputo, MD:

Yeah, sure. Aneurysms, generally, are defined by their anatomic borders, right, so when we talk about thoracic aneurysm, we're talking about anything above the diaphragm, and probably starting, from our standpoint, at the left subclavian artery, or the artery supplies the left arm.

Francis Caputo, MD:

Traditionally, this used to be all performed open surgery through an incision on the side, but we now have advanced endovascular techniques, or, I mean, even just basic endovascular techniques, where we're able to actually put a stent in those aneurysms.

Francis Caputo, MD:

The question is, "When do we do that?" The general consensus right now, according to our SVS, or Society for Vascular Surgery, we fixed them just about 5 1/2 centimeters, or 55 millimeters, or just about a little bit over 2 1/2 inches. The reason why we do that is, what we know is that once an aneurysm hits 5 1/2 centimeters, there is a increased chance of having a aortic emergency.

Francis Caputo, MD:

Now, in the thoracic aorta, an aortic emergency can be defined as either a rupture, or that means that the aneurysm blows up like a balloon, or we could talk about a dissection, where the aorta starts splitting along its layers, much like an onion has layers, an aorta has layers, and when those things start splitting, you can have a thing called an aortic dissection.

Francis Caputo, MD:

So when we hit about 55 millimeters, 60 millimeters, you have about a 30% chance per year of that happening.

Sean Lyden, MD:

I like to try and explain to patients, it's sort of like if you had a tire with a problem, you don't always have to get a brand new tire, so open surgery, you put a replacement piece of graft in, and this is really relining it from the inside, sort of like putting an inner tube within the tire to get that tire to last a whole lot longer.

Sean Lyden, MD:

I would say that we really used to only offer open surgery, and now, it's rare that open surgery is needed because the advances in the minimally invasive devices.

Sean Lyden, MD:

Dr. Caputo, why don't you talk about maybe some of the things that the patients can expect if they were to have a repair, in terms of the differences in what type of follow-up they need when we do these minimally invasive repairs, or thoracic endovascular aneurysm repairs.

Francis Caputo, MD:

The thing about endovascular is like Dr. Lyden said, it's literally like going inside of an inner tube, and in order to have that, we have to have good landing zones or good spots in the beginning or end of the tube.

Francis Caputo, MD:

We have to monitor those spots, because they're not sutured in by hand, and we monitor them generally in the beginning a little bit closer together, usually at one month and then one year, if everything looks good, and then, generally, we watch them yearly thereafter.

Francis Caputo, MD:

The reason why we do that is, A, aortas change, where we have aneurysmal disease, because we know the aorta can be diseased its entire length, and, B, we just want to make sure that seal sticks.

Francis Caputo, MD:

The other thing that we have to talk about is, a lot of times, we may have to do adjuncts or additional procedures, prior to that stenting. Now, this might be as simple as a little bypass in the neck to increase our landing zone, or it might be something even more, where we have to talk to our cardiothoracic colleagues to do something in the chest to give us a landing zone.

Francis Caputo, MD:

It's really, A, customized for every individual patient, and I think one of the things that we've come to realize at the Cleveland Clinic and what separates us apart a little bit, is a multidisciplinary approach, where we actually do talk to our cardiac colleagues, and we try to get the best approach for each individual patients.

Sean Lyden, MD:

The other place we see aneurysms is in the abdomen, below the kidney arteries or so called abdominal aortic aneurysm, and that also, traditionally, had been treated only with open surgery, and it is now probably 80% of cases in the United States are treated by a relining, as well, or minimally invasive surgery.

Sean Lyden, MD:

What are your thoughts, Dr. Caputo, when you see a patient of how you decide which way they should be treated, and what are some of the unique things, in terms of our offerings here for our patients, in terms of both what we see on a routine basis, and what we have available?

Francis Caputo, MD:

First and foremost, what we have available at the Cleveland Clinic is a very experienced cohort of surgeons, who deal with aneurysms on a daily basis, so that's number one.

Francis Caputo, MD:

Number two is, we have the expertise to treat both endovascular and open, both complicated endovascular and complicated open, so what that allows us is to offer you the best treatment for the patient.

Francis Caputo, MD:

When we talk about aneurysm in the belly, or what they call infrarenal, or pararenal, where the renal arteries, or involving the renal arteries, it comes down to anatomy of the aneurysm, and it comes down to the physiology of the patient, or the morbidity of the patient, or how sick the patient is.

Francis Caputo, MD:

Nowadays, we are seeing an epidemic of endovascular repairs that are being done in 80% of the patients, where they're failing. They're failing short-term, they're failing long-term, and being at the Cleveland Clinic, we see a lot of these patients being referred to us, and a large part of this is where literally, people are trying to fit these devices into anatomy that won't accept them.

Francis Caputo, MD:

And so I think the number one thing I do when I look at an aneurysm, is what the anatomy of that aneurysm is, it has good anatomy for an EVAR? If it is, then we can look at the patient. If the patient is young and healthy, and is it better to get fixed open? I mean, Sean, we talk about this all the time. Is it better to get fixed open, where we have the durability for decades, without having to worry about getting radiation from a CAT scan every year, or additional procedures? Or, is it better to do an EVAR on these patients?

Francis Caputo, MD:

I think, right now, the data is sussing out that in a young, healthy patient, even with good anatomy, it's better to undergo an open operation.

Francis Caputo, MD:

Don't you think?

Sean Lyden, MD:

Yeah, and the way I try and explain to my patients, is that both repairs, if you're chosen appropriately, can work wonderful, and have only a 1% chance in your lifetime that you'll need something else done. Both repairs, if not in skilled hands and chosen appropriately, can have an issue.

Sean Lyden, MD:

I always tell patients, some people like to buy cars, some people like to lease cars. Either way, you can get a really nice car, you're either going to pay cash up front, and take all the risks up front, and then do great in the long-term, or you're going to pay a little bit over time but be paying forever.

Sean Lyden, MD:

Each way, you can have a great car that lasts a long time, or you can have a lemon, and so you really want to pick a reputable car, a reputable dealer, a reputable surgeon, and you want to make sure that they're going to do the right thing.

Sean Lyden, MD:

The downside of the minimally invasive repair is that they're going to get imaging in a month, at one year, and, then, usually, every one to two years, for as long as they're alive. With the open surgery, they'll get imaging at a year. They'll generally get imaging every three to five years, and the likelihood of need further surgeries is less.

Sean Lyden, MD:

As Dr. Caputo said, so if you're a younger person taking that a little bit longer recovery on the early side, so you have a lot less follow-up on the late side, tends to make a lot more sense.

Sean Lyden, MD:

I think that's where we look at it very simply, "How sick are you, and how straightforward is the option?" When it's really straightforward, and you're sick, always the minimally invasive repair makes sense.

Sean Lyden, MD:

If you're really young, even if you have good anatomy, the downside is you're going to have to come back with a lot more CAT scans and have the risks of always needing that checked on, because we can't see inside of you.

Francis Caputo, MD:

With that being said, as the anatomy gets more and more complicated, the healthier and healthier you have to be, as a person.

Francis Caputo, MD:

If you have a very complicated aneurysm you have to, and undergo an open operation, be healthy enough to tolerate that open operation. Luckily, we have the ability and the technology here where we have advanced devices and trial devices, where we're able to address some of these complicated aneurysms, minimally invasive.

Francis Caputo, MD:

We have fenestrated grafts, we have branch grafts, so we're able to provide that for our patient and those patients that can't necessarily undergo the complicated open repair.

Francis Caputo, MD:

The caveat is, and I always say caveat emptor, is when you do not have great anatomy, and people try to use a less than successful repair, using a standard endovascular device, and that leads into problems. I mean, how many failed EVARs do we see here a year?

Sean Lyden, MD:

At the Cleveland Clinic, we do about 1300 open aneurysm and endovascular aneurysm repair a year. It's the most in the entire country, and most surgeons may never have to take care of a minimally invasive failure. We see one about every seven days, and so the problem is that as more surgeons become less comfortable doing larger open surgeries, they may try and push the limits of what a minimally invasive repair can do, and when they fail, they tend to refer them here.

Sean Lyden, MD:

I try and explain to patients, we have a tube on the top, we can reline a tube on the bottom we can reline, but then, in the middle is where all your intestinal kidney areas come off, and that's where we have options for very advanced, difficult, open surgeries or minimally invasive relinings, and that's what a branch endograft is. We're putting branches into those kidney vessels, to those intestinal vessels, to try and still allow us to do it in a minimally invasive fashion. Either way, that takes a lot more expertise, a lot more training, a lot more experience, and that's something unique that we've had here for a long time at the Cleveland Clinic.

Sean Lyden, MD:

With that, maybe we'll draw our time to close. We'll recommend that you can look on our website, we'll have information you can see for resources, and we'd love to take care of you, here, at the Cleveland Clinic.

Announcer:

Thank you for listening. We hope you enjoyed the podcast. We welcome your comments and feedback. Please contact us at heart@ccf.org. Like what you heard? Subscribe wherever you get your podcast, or listen at clevelandclinic.org/loveyourheartpodcast.