Managing Aortic Aneurysms

Podcast Transcript

Announcer:

Welcome to Love Your Heart, brought to you by Cleveland Clinic's Sydell and 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.

Francis Caputo, MD:

Good morning and greetings from the Cleveland Clinic. My name's Frank Caputo. I'm the Vascular Surgery Director of the Aortic Center here at the Cleveland Clinic, and I am joined with Dr. Marijan Koprivanac.

Marijan Koprivanac, MD:

I'm Marijan Koprivanac. It's a little bit hard to pronounce, but I'm a cardiac aortic surgeon here at the Cleveland Clinic and Frank, a vascular surgeon here obviously. We do a lot of aortas. We're going to talk to you a little bit about aortic surgery and different types of aneurysms and pathologies, the sections that we treat here and different kind of anatomy kind of situations.

Francis Caputo, MD:

I think this is a unique situation that we could talk about this morning because you're dealing with a heart surgeon here who deals with aneurysms in the chest and you're dealing with a vascular surgeon here who tends to deal with complicated aneurysms in the belly and as they enter the chest. Just to start off, to you, what is the most common aneurysm you treat, Marijan?

Marijan Koprivanac, MD:

This is interesting. From my standpoint, of course it's the one in the chest. That would include aortic root, ascending aorta arch, and potentially beginning of the aortic distal, descending aorta, proximal descending aorta. The interesting thing is when you already touch base is the different types of aneurysms in different location, but it's all the same organ. This is something that we started to talk more about in the aortic community worldwide, more commonly that aorta is one organ. As one organ we have vascular surgeons treating one part, the cardiac surgeon treating the other part, and quite commonly we have to come together to actually fix the whole organ at the end. This is where this, I think integration and working together is critical.

Francis Caputo, MD:

Yeah, definitely. The one thing about the Cleveland Clinic. I think we are the largest aortic center in the Western Hemisphere and we do a lot of aortas and we do it really well here. The question is though, that I often get asked by everybody that I first see is, what is an aneurysm? Sometimes the CAT scan report just says "aneurysm" and you get frantic phone calls from doctors and patients. In the chest, what is an aortic aneurysm?

Marijan Koprivanac, MD:

When you talk to the patient, what is the aneurysm? You kind of try to describe what the aorta is and you try to start talking about, well, it's a pipe, the main supply of blood that distributes the blood to the whole body. When you have a dilation of that pipe, when the pipe is getting bigger and bigger, that eventually tends to burst. This is how we discuss it. When we talk about the numbers, which it is always a numbers game, quite commonly. They come either with the echo or with the CT scan where they start talking, "Well, they say it's five centimeters, four centimeters, what do we do?" One of the standard numbers when we talk about the thoracic aneurysms and aneurysms that are primarily root ascending in the arch, the numbers that we start to talk about when we need to do interventions is about 5 centimeters to 5.5 centimeters, we say we need to do surgeries.

Now this is not in every patient. Some patients need to have surgeries sooner if they have certain risk factors, potentially connective tissue disorders that we know very well or maybe some other family history without necessarily an obvious sign of or history of connective tissue disorders. But they have possible family history that their fathers, mothers, or any kind of relatives who died from sudden cardiac death potentially caused by aorta.

Francis Caputo, MD:

I think the one thing that we've known about aortic surgery or aortic aneurysms, we have to tailor it to the individual. In the abdomen, it's very similar. 5.5 is generally the accepted threshold for males and 5 centimeters for females. What we say is it's because of the risk of rupture. I always say to my patients, aortic aneurysms, it's all about what is the risk of it being in your body versus the risk of surgery. The nice thing about working here at the Cleveland Clinic is not only do we have experts in the field of identifying, we also have experts of treating, so the risk of surgery is low. If you look at the STS Database as well as you look at VQI, which is the vascular surgery equivalent, we are way below the national threshold of mortality and morbidity after surgery. In fact, we get three stars (highest) across the board. Why do you think that is?

Marijan Koprivanac, MD:

Well, it's all of us. You cannot treat such a complex problem just with one treatment modality. When a patient comes in first, you can already touch base with his diagnosis. That's the first step. The patient needs to know that he has a problem. We have expert imaging, we have our dedicated aortic cardiologists that will read the aortic CT scans and they look at it and measure them and they measure them accurately. Measuring aorta is not as simple. Sometimes you have to do certain cuts and kind of manipulate the imaging to get a true size of the aorta.

So, it starts with them, then it gets to our cardiologists who start working up these patients and then sending them to us. Then we try to see what kind of treatment is the best. Is open-heart surgery better? Is vascular treatment better? Or is it the hybrid approach, where we have to do both? Sometimes at the same time, sometimes sequentially, with the vascular first, then the open or open and then the endovascular. It's really the team play of these really high functioning people that we have, from cardiologists, the radiologists to cardiac surgeons, and of course our support teams, nursing, perfusionists and so on.

Francis Caputo, MD:

I think you're touching on, it's multidisciplinary here. No one's operating in circles. The one thing that we have, we have experts in cardiology for our preoperative risk stratification for our preoperative imaging surveillance. We have experts in the surgical fields. We can't forget our anesthesia colleagues that take such good care of our patients intraoperative, as well as our ICU care where we're seeing the whole gamut of experts. There are complications that can happen, but it's our ability to rescue here that I think makes this place very unique in our ability to really take care of patients.

Marijan Koprivanac, MD:

This ability to rescue is very important, very important.

Francis Caputo, MD:

Now the other thing you mentioned is open versus endovascular techniques. Can you describe that?

Marijan Koprivanac, MD:

Well, these waters are getting a little bit muddier and muddier. Before, traditionally, as you well know, we treated a lot of these things open. That was the standard of care from 50 years ago, but recently, we started to develop better and better endovascular techniques to treat these aneurysms. They started the first primarily with the belly, as you know well, and then started to spread more into the chest. Now we actually have devices that can effectively treat or fenestrate that kind of a TEVARS (Thoracic Endovascular Aortic Repair), as we call them and so on. We can treat not just the straight line of the aorta, but we can also treat the lines of the aorta that have certain branches. We can endovascularly treat those branches too.

Now as we're getting more and more technology and skill and experience with those things, we can even treat something that before we would not consider, treating even the thoracic arch and belly branched part of the aorta with the completely endovascular approaches. Now when the patient comes in, we have the ability to offer few ways to treat the same problem. This is, as you mentioned, the cardiologist risk stratification. We look at every patient individually and see what would be the best thing short-term and long-term for this patient? What are the pros and cons of each of the approach?

Francis Caputo, MD:

I think we would be remiss not to say that we're leading some of this research. If you look at our thoracic component or ascending component, we are not only participating in the trials, we're leading the trial in both the ascending graft and thoracic grafts. Now in the belly, we just got approved for a physician-sponsored IDE, which means that we can custom make grafts for people in the abdomen that sometimes has to go a little higher up to branch out into the branch vessels. The reason why I am saying all this advanced stuff is because straightforward endovascular techniques, just to break it down a little bit ,is literally just sealing a normal aorta or normal seals in above and below the aneurysm. Well, not everything is a straight tube. There's a lot of side roads that lead to the kidneys, lead to the intestines that we would never want to cover.

We use advanced techniques to potentially provide blood flow to these organs, even with stents. The same thing is happening in the arch providing blood flow to the head vessels. I think it's one of these things where talking as a team between, not just the medical and the surgical teams, but the individual surgical disciplines, cardiac and vascular and working together. We come up not only with the best approach, endo versus open or stenting versus open, but we're also deciding what should go first? What stages? You alluded to it and it's almost playing chess, not checkers.

Marijan Koprivanac, MD:

Correct, correct. It's very deep thought and I think this is the communication between you, me, all of the other teams to see what is the best for the patient. Is a patient younger, a little bit older, more comorbidities, sicker patient, less sick patient and what is really the goal here? It's a unique place here. We're connected to so many, as I said, functioning highly skilled people on all cross of the branches come together to just to choose. We don't care what we do. We are not, "I want to do only TEVARS. I want to do only open stuff." We just want to do, I always say to my patient, "We don't care what you get, we just want what's best for you." We come as a team. We construct this plan that we think is going to be the best short and long term. We do it regardless of what it is because we have ability to do all of these things at the same time.

Francis Caputo, MD:

Yeah. Not only do we have the wide breadth of techniques available here and the expertise here, we do a lot of it. What we know with aortic volume is the more you do aortic surgery, the better your outcomes. Again, I want to just allude to our outcomes here. If you look at open aortic surgery, particularly in the abdomen for me, our mortality is 0% for the last three years. Which again, it's not surgeon based, it's team based. This is compared to national averages that are three, four times that. It's the same thing with the STS Database.

Marijan Koprivanac, MD:

Same thing with the STS. When you look at, for example, we published the data on the valve sparing root replacements and ascending and replacement hemi-arches, our David [procedure] replacement mortality on elective repairs is 0%. You never say to the patient 0%, but you say less than 1% risk of mortality. You can never guarantee 0%. But this is what we have so far. So these are remarkable numbers. I don't think these numbers are achievable, it's hard to say, anywhere else, but these are pretty much outstanding numbers. I actually presented recently in one of the conferences where I compare this. If you drive from New York to LA, you have a higher risk of getting in a car accident than actually dying or having something happen in heart surgery, for example, proximal aortic surgeries. We are getting there also with the arches and so on.

We are single percentage mortality for these selective cases. I think this is something that is remarkable. If you look at the other centers, and if you look at the outcomes about 10, 15 years ago, where the mortality for elective arch cases and things like that was about 5, 6, 7% and higher and this was in big centers. With this experience, high volume in these high-level interactions that we have and some things that maybe other cardiac surgeons are not even aware that exists. High-risk features, distances of the vessels on the arch, landing zones and things like that, which are not necessarily common things for people who do just general surgery. In general, these discussions are unbelievable.

Francis Caputo, MD:

We are talking about surgery here and patients always ask, "What can I expect after surgery?" I always say, "For endovascular EVARs, you're looking at a one to two-day stay." They love that idea.

Marijan Koprivanac, MD:

Oh, they love it.

Francis Caputo, MD:

Sometimes, we can't offer that. I would say a large part of my practice is doing open surgery, open abdominal aortic surgery where we had to make an incision. A large part of my practice is actually when EVARs have failed and I have to take them out and actually convert. I start saying, "Yes, your length of stay is longer. Yes, it's about five days. You're going to feel a little under the weather for a couple of weeks, but you're buying all your risk up front." That's one thing that's important to realize when we compare open and endovascular techniques. There are benefits to both and there are cons to both. One of the benefits of open surgery tends to be you're buying your risk up front. It tends to be a little bit more durable than a endovascular techniques. What do you tell your open heart patients? How long are they staying for?

Marijan Koprivanac, MD:

You touched a lot of stuff here. When you have a complex patient, maybe not so healthy, not necessarily so physically strong, durable, and then you have a complex aneurysm close to, I don't know, renal or any kind of a branch vessels in the arch and so on. You know the open heart surgery is not going to be a great thing because he won't be able to recover. Or the belly surgery, we always say with open surgery, the surgery makes you a little bit worse before it makes you better. That's kind of the way it is. What we do here, you stretch the limitations of each of the approach. Sometimes maybe the endovascular is not perfect, but it's good enough to temporize you, maybe bridge you to something better and down the line.

But anyways, to go back to your question is the open heart. Nothing, I mean, exactly what I mentioned. With open heart, we have a little bit less options maybe in terms of, for example, root for now and ascending, even though we are doing of course the ARISE trial that we can potentially use in some selected cases, ascending stent grafts. It makes you worse. You do have to open the chest, which is usually more traumatic than your belly when you open it, because we do have a bone and of course every breath hurts. You can't really say, "I will stop breathing so I have less pain." You kind of have to breathe. That's a problem with open heart surgery in general, not just aortic surgery. So we always go and talk, "You will feel worse. We'll give pain medication, try to bridge you through. You got to move, you got to walk, but then you're going to get better and you have a long durable [outcome] for the rest of your life hopefully. The repair should not cause any troubles depending on which side we are."

That's kind of how it goes. We always give a little bit of a hard talk to our patients. I always mention that the key for the open heart surgery is you got to move, you got to walk, you need to get out of the bed. Human beings are not designed to be in the bed. If you're in a bed, not breathing, shallow breaths, then you have a high risk of pneumonia, complications and issues. I always say, "We'll make sure that you get the surgery that you need, that everything goes perfectly, but it's actually on you to get out of the bed and do well."

It's staving off those complications in those rescue situations because whenever you do everything perfectly, not necessarily everything always goes perfect. The patient might get an infection, might get some PEs (pulmonary embolism) or clots, who knows. Any kind of a weird thing can happen, even though rarely. But when they happen we have ability to rescue these patients out. But for the patients, the key point is always that our focus is rehab. They got to get out of that bed right away. We'll make sure we do everything surgically that we need to do and then afterwards, for them to get back on the field.

Francis Caputo, MD:

You mentioned the ARISE trial, which is a newer trial that's for the ascending aorta or the beginning of the right side of the aorta.

Marijan Koprivanac, MD:

That's the one I mentioned, that we are leading the pack.

Francis Caputo, MD:

Correct. The national PI (primary investigator) for that is Eric Roselli. Now, one thing that you may or may not know is that the Cleveland Clinic is the birthplace of pretty much advanced endovascular techniques under the guidance of the late Roy Greenberg who Dr. Lyden, the Chairman of Vascular Surgery, was partners with. Roy Greenberg was a vascular surgeon. Dr. Roselli trained with him. I think we see this line of pedigree of people leading innovation. Dr. Roselli has a physician-sponsored IDE for the arch. Dr. Lyden and me, myself have a sponsored IDE for the infrarenal and the pararenals. What do you think is the benefit of coming to a place with that heritage?

Marijan Koprivanac, MD:

Well, we already touched base. You have an opportunity to use every possible means to help the patient. Everything is on a table. It's not that you cannot provide certain aspects of surgery or treatment that exist, you have everything available for the patient. But also expectations are higher. You're standing on the shoulders of giants, as they always say, and there is more truth here than anywhere else. With Greenberg and everyone that you mentioned and Dr. Roselli and Dr. Svensson all of these big names, that expectations are higher from technical expertise, but also to continue to think and innovate. How can you make things better? It only gets harder of course as you go higher and higher into these details. But just the expectations are sometimes a little bit scary when you look on the outside, what you got to do to make sure you stand up to expectations, what needs to be and continue the legacy because it's on us to continue that.

Francis Caputo, MD:

It would be foolish just not to mention, yes, we have expertise in endovascular and we are on the giants of endovascular surgeons in the forefront of it, but we are led by Dr. Svensson who is a giant of open surgery. He trained with the forefathers of thoracoabdominal surgery. We are held to a high standard in both open and endo and we better choose right, I feel.

Marijan Koprivanac, MD:

That's that. I got a little chill here when you think about all of that. You never think about, you just keep going. But when Dr. Svensson started, he learned from the guy who wrote the book on open thoraco, Crawford and everything else. You can talk to him here, about how they did this stuff back then and how it is now. It's absolutely unbelievable. Then you have Greenberg and the guys who did endovascular, so it's basically the birthplace of almost all of these things. It's right here. Everything is concentrated in this one spot and just unbelievable.

Francis Caputo, MD:

Well, Marijan, it was a pleasure doing this podcast with you. I hope that if there's any questions, please feel free to reach out to either of us or get a hold of Love Your Heart, and we can follow up with those questions.

Take home message: if you are at risk of having an aneurysm, if you have a family history of having an aneurysm, if you've been recommended to get screening, get your screening, find out.

Thank you for listening to Love Your Heart.

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