Quick Questions Abdominal Aortic Aneurysm

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. This podcast will explore disease prevention, testing, medical and surgical treatments, new innovations and more. Enjoy.

Dr. Francis Caputo:

Hello, everyone. My name is Frank Caputo. I am the Aortic Director of Vascular Surgery here at the Cleveland Clinic, as well as a professor of surgery at the Cleveland Clinic Lerner College of Medicine. Today, I'll be answering some questions that we get about abdominal aortic aneurysms that you guys have reached out to us about, and some that are just common that people want to know.

So just to start right off, when we find an abdominal aortic aneurysm, when do we figure out when to operate on it and when to just watch it? So, a lot of times, people with aortic aneurysm say, "Yeah, I got one. Just fix it." Well, aortic aneurysm surgery is much like gambling or doing odds. It's a risk-benefit ratio. What is the risk of this aortic aneurysm rupturing versus what is the risk of surgery or the procedure?

Now, current endovascular surgeries have mortalities of 1 to 2%, but when you look at rupture risks of a small aneurysm of less than 4.5, 4 centimeters, the rupture risk is much even smaller than that, so the risk of rupture is still less than the risk of operating. Conversely, if you have a large aneurysm, say 7 or 8 centimeters, your risk of rupture is much higher than that risk of surgery, so that's when we fix the aneurysm.

Generally speaking, our current guidelines recommend fixing an abdominal aortic aneurysm in a healthy individual for a male at 5.5 centimeters and for a female at 5 centimeters. Now, my caveat is there's always some nuance to that. If you have a saccular aneurysm, just consider that as a funny-shaped aneurysm, or if you consider ones that are in your common iliac aneurysm, which are a little bit lower than your aorta, then we might lessen that threshold. Conversely, if the aneurysm's higher up by your vessels that supply your intestines and your kidneys, we might make the threshold six centimeters because the surgery's much higher risk. It all depends. It really comes down to what they consider patient-centered determination of medical outcomes, meaning how do we make these decisions together between me as your physician and you as my patient?

Now, I get asked all the time, what is the difference between an abdominal aortic aneurysm and a thoracic aortic aneurysm or an aorta that's in the heart, or what they call an ascending aortic aneurysm? It really comes down to different thresholds because there are different complications. Now, I am not a cardiac surgeon by any stretch of the imagination, but I work very closely with some close partners of mine, and we do a lot of combined cases together. If the aneurysm is in the thoracic aorta, distal to what they consider your arch, or if you consider the aorta a candy cane or distal to the curve, then the thresholds are very similar, particularly if we can fix them with a stent. If we can say 55 millimeters or 5.5 centimeters in the thoracic aorta and you are a healthy individual, we'll consider fixing that with an endovascular stent. Now, ascending, I am not going to speak to that because again, that is not my area of expertise. We're going to stick to the thoracic aorta and the thoracoabdominal aorta today.

Now, aneurysms again get more complicated, meaning aneurysms that stretch the chest and the abdomen, what they consider a thoracoabdominal aneurysm, we sometimes push that threshold to 6 centimeters because the surgery sometimes is a little bit more involved and the complication risk profile is much higher.

With that all being said, here at the Cleveland Clinic, we have experts in both endovascular and open surgery, and again, using those decisions with the patient together, patient-centered care, we come up with the best way to fix your aneurysm that you have.

Now, there's a whole different world of people with aneurysms, and that's patients with connective tissue disorders. We often hear about patients with Marfan's disease, Loeys-Dietz, Ehlers-Danlos, and they tend to run in families, they can be hereditary. They can also be spontaneous, but a lot of times they're hereditary. We often get asked, how do we screen these patients? Well, if we know a patient has one of these kinds of tissue disorders, like I just mentioned, and there's a whole host of them, we generally recommend the initial person getting genetically screened and their first-degree relatives. It's as simple as getting a little counseling from our excellent genetic counselors here at the Cleveland Clinic, and getting a blood test to see if you fall into that hereditary category.

Now, regular aneurysms are mostly attributed to atherosclerotic disease, or the same disease that's caused by smoking, hypertension, all the other stuff that we know is bad for us. Sometimes they cause blockages, and sometimes they cause an aneurysm. We don't really know why that is, but those aneurysms also can run in families. We don't necessarily know the exact, precise mechanism of it, but we do know there's a genetic component of it.

Well, are there any warning signs that an aneurysm is getting worse or at risk of rupturing? Well, we call it the quiet killer. We know it's a problem when you have an aneurysm, or you don't know you have an aneurysm, and you don't get it watched, you don't get it surveilled. You have an aneurysm at 3 centimeters, 4 centimeters, and you say, "Ah, forget it, put it on the back burner," and you haven't followed up for 5, 6, 7 years, that aneurysm now could be a 9-centimeter ticking time bomb. What you really have to do is, once you have an aneurysm, establish care with a vascular surgeon that you feel comfortable with, and make sure that you are on a surveillance protocol to monitor that aneurysm to see if it's going to grow.

Now, we know that smaller aneurysms get surveilled less frequently, and as we approach that threshold, 5 centimeters, 5.5 centimeters, 4 centimeters, we monitor it much more closely. With that being said, I would say if you find out you have an aneurysm, make sure that you have it watched.

Now, again, while the rupture risks of small aneurysms are small, there is always a rupture risk. We do know that. What are the signs of rupture? The classic signs of rupture are severe back pain as well as a feeling of not feeling well, feeling unsettled. If you do know you have an aneurysm, familiarize yourself and have a plan in place to know what you are going to do in case you do have that sudden pain. How are we going to have that plan in action? Let your family know. Don't live in a black box, but be proactive with your care.

And what can you do to prevent aneurysms from growing? Well, I always tell my patients, the worst thing you can do is do dishes at home, and I'm just joking with that. But the reality is, when it comes down to lifestyle changes, we know blood pressure being high is not good for anything, so that's one thing. One of the greatest risk factors that people don't attribute it to and they don't want to stop is smoking. Smoking is one of the number one things you can do to make your aneurysm grow, so if you want to really be proactive in having that aneurysm stop growing, stop your smoking. That'll be the best thing you can do for you and your lungs, and if you ever do need surgery, for the surgical outcomes to be the best they can potentially be.

We talked a little bit about stenting and a little bit about open surgery, and what is the main difference? Well, endovascular surgery is, if you break down the word, that’s just what it is: within the blood vessel. We do a combination of stenting, and sometimes it's very straightforward, sometimes it's not. Much like you can patch a tire from the inside, we fix an aneurysm from the inside. The reality is it's very well tolerated, people go home usually the next day or the following day. The downside is it's lifelong surveillance of that stenting, meaning we have to watch it. They're not always the best in patients with connective tissue disorders. If you're young and healthy, it might be better off talking about open surgery.

Now, when it comes down to endovascular repair, it really comes down to what kind of anatomy you have. The worst thing you can do in a patient that does not have an anatomically favorable aneurysm for an EVAR, or endovascular repair, is try to fit it. It's like trying to fit a square peg into a round hole. We know those aneurysm repairs fail, and sometimes fail as early as one year. The key is to really have a talk with a surgeon who is comfortable doing both and realizing that are certain anatomies that open repair is a better-suited solution.

Now, with that being said, you want to make sure that your surgeon is comfortable doing open surgery repair, because a lot of times, these are the aneurysms that are closer to your renal arteries, you have smaller iliacs, so there is some nuance to that surgical skillset. But again, the key is, how do we decide? Well, we take the patient's anatomy into place and we take the patient's physiology into consideration. Meaning, if you are a young, healthy person, late 50s, early 60s, you work out and you have an aneurysm, you still have a life expectancy that's quite long, 30, 40 years. An open repair is much more durable, there's less surveillance. You will have a little bit rougher time in the beginning. You'll be in the hospital four or five days, you'll be a little uncomfortable for a month, but once you're done, you're fixed. You get checked every five years.

But not everyone is that healthy patient. Sometimes, there are patients who are not as healthy, meaning they have some lung disease from years of smoking, they have some heart disease, so endovascular repair might be their only option. But again, the key is to get the right endovascular repair. We have the skillset to do fenestrated repairs, branch repairs, and these are all just complicated endovascular repairs that not everyone does, but we do offer here at Cleveland Clinic. So, if you're unable to undergo that open repair, we still have a good solution that is not only good for your physiology and will allow you to live the life you're living, but also to fix your aneurysm in a durable way.

So, that's how we decide. We sometimes have a multidisciplinary approach, sometimes I talk to the cardiac surgeons. Sometimes we do things in stages, but again, that's where the difference is. When you go to an aortic surgeon or aortic center, you're getting that expertise that sees aneurysms all day, every day.

The reality is, life after an aneurysm repair, you should return back to the lifestyle you had. Now again, if you have an open repair, it might take you two to three weeks to get back to that. Endovascular might be a couple of days, but the reality is the whole goal of aneurysm surgery is prophylaxis- prophylactic from that aneurysm rupturing and allowing you to get back on that life-year chart to resume a normal health life expectancy. I really want to say that when it comes to aneurysm repair, the whole goal is to prevent that rupture risk and just maintain a healthy lifestyle.

So, as we wrap up here, the final take-home message is if you do have an aneurysm, continue getting it checked. If you have any aneurysms running in your family, make sure you don't have one. If you do ever have a CAT scan done for whatever other reason and it says that word aneurysm on the CAT scan or MRI or ultrasound, get it checked out, because that's what saves lives: early detection, surveillance, and repair electively.

I want to thank you for listening to the Love Your Heart podcast. I hope you enjoyed listening as much as I enjoyed talking to you. If you have any further questions, you can always come see us. All right, thank you very much.

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