Question on Abdominal Aortic Aneurysm

[bstratt]

While my Dad is still undergoing tests to determine what treatment, if any, is applicable to his Abdominal Aortic Aneurysm, the meeting with the vascular surgeon was anything but reassuring.

His aneurysm is 5.9

Doctor said IF they could do it by a stent they would consider it but otherwise he would be better off just living with it - he quoted the odds of it blowing in the next 5 years at around 40% whereas the odds of him dying "under the knife" if they had to do more invasive surgery than a stent was 70%.

I find the 70% figure hard to believe. Is this true?

 

[river_rat]

While my Dad is still undergoing tests to determine what treatment, if any, is applicable to his Abdominal Aortic Aneurysm, the meeting with the vascular surgeon was anything but reassuring.

His aneurysm is 5.9

Doctor said IF they could do it by a stent they would consider it but otherwise he would be better off just living with it - he quoted the odds of it blowing in the next 5 years at around 40% whereas the odds of him dying "under the knife" if they had to do more invasive surgery than a stent was 70%.

I find the 70% figure hard to believe. Is this true?

Not a doctor but I found this.

http://www.surgery.usc.edu/divisions/vas/abdominalaorticaneurysm.html

and this

http://linkinghub.elsevier.com/retrieve/pii/S1078588497802870


greg

 

[Capt. Geoffrey Thorpe]

Well, I ain't no doctor...

But, given the kind of odds you are being quoted, I would think that you would really want to get another opinion or two.

The other thing is that if some of his other conditions get sorted out, his chances for successful surgery could get better as well.

Praying for you and your dad...

 

[twdeckard]

Barry,

Abdominal Aortic Anuerysms are not uncommon and you are lucky to have discovered it. A number of famous folks have them. Bob Dole and Bob Euchre both had stent repairs of their anuerysms. Albert Einstein died of a AAA rupture however his surgical intervention of that time consisted of wrapping the ballooning vessel in a sort of cellophane.

Many can be treated with a graft which is inserted thru a vessel in your groin and deployed in the aorta like ship-in-a-bottle assembly. There are conditions which preclude the use of an endograft. The graft never really "cures" the condition but just acts to take the blood pressure from the vessel deformity. The recovery is pretty quick and you must be regularly monitored to make sure the graft has not slipped, or failed, and continues to protect the vessel. As with all these things, you want someone who is well practiced in the method.

Otherwise they use an external surgical repair. Its a more grueling procedure and often done in the case of an emergency rupture. Here I have heard doctors use the "rule of 50s" 50% make it to the table and 50% of those make it off. But that is the case where it is done as an emergency. Perhaps you misheard the grim 70% figure. I know two folks who had external repair and they both survived so my statistics are more encouraging.

There is some debate about the long term outcomes of the two techniques. If you will take it with a grain of salt and promise to only trust advice from your physicians; the short term <2 year outcomes strongly favor the graft but after two years then surgical repair may have a statistical edge. This may be colored by the age of the data and not reflect recent advances in the grafting technology or the surgical methods.

I do know that they are generally monitored if below a certain dimension, while perhaps blood pressure control is used. Then a decision is made about an endograft, the choice of graft, or the decision to go to surgery.
Your doctors practice patterns may contain a prejudice towards a particular graft or technique.

If you want to PM me I can give you any other information and perhaps drum up a surgeon reference. Again, its a common condition (its the fifteenth leading cause of death in the US) so you can find an expert in any metropolitan area.

I am not a doctor but I have worked on software which assists in planning for the graft procedure.

Todd

 

[twdeckard]

One thing, as I read my post. The grim surgical repair statistics pertain to treating an emergent rupture. I think if you get to mark the surgury on your calendar the mortality might be 5%.

 

[bstratt]

Angiogram gave him the "all clear" - no significant blockages or other issues. He is back in sinus rhythm and heart rate normal. They apparently have to wait at least 24 hours for the dye from the angiogram to clear before getting a CAT scan to more accurately assess the aneurysm. From what I know at the moment, it appears the aneurysm is below the renal arteries branch - does that make it more difficult?

We have been in touch with various stent experts around the world, including what I understand to be the pioneer in the process in Germany. The "younger" surgeons are saying the stent can be done - the "older" surgeons are saying no.

Apparently the issue with the invasive surgery is a combination of having to stop the heart and my Dad's bad asthma (i.e. very possible side effects from the anesthesia).

 

[steingar]

How old is your father? My mother in law had an aortic stenosis. While it could have been corrected surgically, she was sufficiently old to be a poor surgical candidate. It stayed, she lived with it and died from it at the ripe age of 89. Gotta die of something.

Better a year or two of good living than dying in surgery or in recovery, as far as I'm concerned.

 

[bstratt]

he's only 78

 

[AcroBoy]

Aortic stenosis is a narrowing of the aortic valve in the heart, a AAA is in the abdomen.

 

[steingar]

Aortic stenosis is a narrowing of the aortic valve in the heart, a AAA is in the abdomen.

I didn't say they were the same. I told my own personal story about how I responded to a medical problem in a relative who was a poor surgical candidate, which is really the salient issue in this case.

 

[AcroBoy]

The relative risk of any procedure is multifactorial, including age and other co-morbidities- there are no absolute percentages. However, an acutely ruptured AAA has a bad prognosis. Below the renals has a better prognosis than if the AAA involves the renals.

 

[twdeckard]

From what I know at the moment, it appears the aneurysm is below the renal arteries branch - does that make it more difficult?

It is common for the anuerysm to be below the renal arteries. All things considered this is a good thing. The question is how far below and is there enough apposition for the "landing zone" for the endograft. Otherwise you use a fenestrated graft (with holes in it) and overlap the kidney branches.

Grafts can be contraindicated for a number of reasons

The CT Angiogram generates an exquisite 3D picture of the aorta and can provide a lot of detail to make the decision about grafting, choice of graft, or external repair. Normally you would do the CTA first, and then go to the angio suite but again I am not a doctor, nor do I play one on TV.

What city are you in? I'll look up some contacts for you and PM you if your interested.

 

[bbchien]

Barry, the younger guys can do amazing things with a stent. If the rest of your dad is pretty intact, 6.0 she's surely gonna blow (30% in two years) and the mortality from that is 70-75% ON THE TABLE. When it blows you WILL WANT TO DIE.

Get the stent. The elective operation when it's greater than 6.0 is about 10-15% morbid.

 

[bstratt]

That's what I thought Bruce.

He's still in the hospital and they are keeping him in until they get the new CAT scan and MRI next week sometime. After that we'll be discussing possible treatments.

 

[bstratt]

CAT scan and MRI completed. Aneurysm is 6.9. The aneurysm is too close to the Renal areteries to do a stent. He will be going under the knife first thing Monday morning. Time on the table is estimated to be 4 to 6 hours.

I'm going up Saturday to stay until after the surgery.

 

[gismo]

CAT scan and MRI completed. Aneurysm is 6.9. The aneurysm is too close to the Renal areteries to do a stent. He will be going under the knife first thing Monday morning. Time on the table is estimated to be 4 to 6 hours.

I'm going up Saturday to stay until after the surgery.

Wishing for the best possible outcome.

 

[Capt. Geoffrey Thorpe]

Wishing for the best possible outcome.

Amen.

 

[Skip Miller]

Barry, I wish your Dad and you the best possible outcome! Prayers in your direction.....

-Skip

 

[Doggtyred]

His aneurysm is 5.9

he quoted the odds of it blowing in the next 5 years at around 40% whereas the odds of him dying "under the knife" if they had to do more invasive surgery than a stent was 70%.

I find the 70% figure hard to believe. Is this true?

Depends on your fathers age and medical history. 70% "under the knife" might be a bit extreme but it might be more accurately a predictor of never leaving the hospital alive.

If he is a heart patient with CHF or poor ejection fraction he very well COULD die on the table. Those guys have very little cardiac reserve to undergo anesthesia.

If he has bad emphysema or COPD he may not ever come off the breathing machine after surgery, particularly if its severe COPD.

If he's old with a bad heart and bad lungs, I'd think very hard about quality of life before I went cutting on someone. Is this AAA actually causing a problem or is it an "incidental finding" where they just happened to notice it and have been monitoring it?

The stenting procedure would be something inserted through a "large IV" in the femoral artery in the groin, for lack of a better lay term, and requires minimal anesthesia/sedation compared to an open abdominal procedure (the traditional repair for a AAA)

If his renal function is crappy to poor, the use of xray dye in the stenting procedure could result in acute renal failure that might require dialysis, and might get better and might not.

Take the doc at his word. If he's scared to cut on your dad, that means he's got a good reason to be scared. Doc's dont want your dad to die during or as a result of a procedure more than you, so they will steer you away from it unless they have no choice.

If it was actively growing, or starting to "dissect" then they WOULD have their backs against the wall. Then it approaches one of those situations where you probably will die WITH surgery, but WILL die without very soon..

 

[Doggtyred]

6.0 she's surely gonna blow (30% in two years) and the mortality from that is 70-75% ON THE TABLE. When it blows you WILL WANT TO DIE.

Having taken care of the train wrecks who have survived such an emergent surgery, I have to say... I concur wholeheartedly.

 

[EdLarkin]

I thought I'd update this thread with my experience with a AAA.

BACKGROUND: 65 year old male, private pilot. Herniated disc (L5) known and reported to FAA. Five years ago diagnosed as Type II diabetic (medication and diet controlled - metformin), hypertension (medication controlled-lisinopril), with open angle glaucoma (medication controlled). SI for diabetes and hypertension, annual renewal (May).

A MRI on my spine in early September found (direct from the MRI report) Aneurysmal dilation of the infrarenal aorta. Maximum diameter 6.36 cm with lumen measuring approximately 4.3 cm. In other words, an abdominal aortic aneurysm. I had no symptoms. Vascular surgeon referred me to cardiology for a full workup before surgery.

Cardiology did CAT scan (which detected two kidney stones – again no symptoms), ultrasound on leg and neck arteries (OK) and a nuclear stress test. Nuke results were “no significant findings”. A quick visit with a urologist got me a return visit scheduled after the AAA surgery.

I underwent endovascular stent emplacement surgery 10 days ago. Two and a half hours on the table, overnight stay in the hospital and I was discharged. No additional medications (other than the ones I already take). I have an appointment for another CAT scan and vascular surgeon visit in a month to ensure the stent isn’t leaking and hasn’t slipped, then annual repeats of the scan and visit forever.

I'm working on determining what I need to do to reinstate my medical.

FYI: I learned this is the white man's disease, 50 to 80 year old, current or former smoker, history of (or family history) cardiac issues. According to my surgeon there's less than .1% (one tenth of 1 percent) chance of dying in OR for this surgery. Less than .3% for the 'split him open from top to bottom' aortic graph surgery. 'Split him open' surgery gets you up to a week in ICU, a week or so in hospital then 3 months when you feel like a truck ran over you (that's exactly what the surgeon said - word for word).

 

[Kelvin]

Good deal...

I thought I'd update this thread with my experience with a AAA.

BACKGROUND: 65 year old male, private pilot. Herniated disc (L5) known and reported to FAA. Five years ago diagnosed as Type II diabetic (medication and diet controlled - metformin), hypertension (medication controlled-lisinopril), with open angle glaucoma (medication controlled). SI for diabetes and hypertension, annual renewal (May).

A MRI on my spine in early September found (direct from the MRI report) Aneurysmal dilation of the infrarenal aorta. Maximum diameter 6.36 cm with lumen measuring approximately 4.3 cm. In other words, an abdominal aortic aneurysm. I had no symptoms. Vascular surgeon referred me to cardiology for a full workup before surgery.

Cardiology did CAT scan (which detected two kidney stones – again no symptoms), ultrasound on leg and neck arteries (OK) and a nuclear stress test. Nuke results were “no significant findings”. A quick visit with a urologist got me a return visit scheduled after the AAA surgery.

I underwent endovascular stent emplacement surgery 10 days ago. Two and a half hours on the table, overnight stay in the hospital and I was discharged. No additional medications (other than the ones I already take). I have an appointment for another CAT scan and vascular surgeon visit in a month to ensure the stent isn’t leaking and hasn’t slipped, then annual repeats of the scan and visit forever.

I'm working on determining what I need to do to reinstate my medical.

FYI: I learned this is the white man's disease, 50 to 80 year old, current or former smoker, history of (or family history) cardiac issues. According to my surgeon there's less than .1% (one tenth of 1 percent) chance of dying in OR for this surgery. Less than .3% for the 'split him open from top to bottom' aortic graph surgery. 'Split him open' surgery gets you up to a week in ICU, a week or so in hospital then 3 months when you feel like a truck ran over you (that's exactly what the surgeon said - word for word).

 

[bbchien]

I thought I'd update this thread with my experience with a AAA.

BACKGROUND: 65 year old male, private pilot. Herniated disc (L5) known and reported to FAA. Five years ago diagnosed as Type II diabetic (medication and diet controlled - metformin), hypertension (medication controlled-lisinopril), with open angle glaucoma (medication controlled). SI for diabetes and hypertension, annual renewal (May).

A MRI on my spine in early September found (direct from the MRI report) Aneurysmal dilation of the infrarenal aorta. Maximum diameter 6.36 cm with lumen measuring approximately 4.3 cm. In other words, an abdominal aortic aneurysm. I had no symptoms. Vascular surgeon referred me to cardiology for a full workup before surgery.

Cardiology did CAT scan (which detected two kidney stones – again no symptoms), ultrasound on leg and neck arteries (OK) and a nuclear stress test. Nuke results were “no significant findings”. A quick visit with a urologist got me a return visit scheduled after the AAA surgery.

I underwent endovascular stent emplacement surgery 10 days ago. Two and a half hours on the table, overnight stay in the hospital and I was discharged. No additional medications (other than the ones I already take). I have an appointment for another CAT scan and vascular surgeon visit in a month to ensure the stent isn’t leaking and hasn’t slipped, then annual repeats of the scan and visit forever.

I'm working on determining what I need to do to reinstate my medical.

FYI: I learned this is the white man's disease, 50 to 80 year old, current or former smoker, history of (or family history) cardiac issues. According to my surgeon there's less than .1% (one tenth of 1 percent) chance of dying in OR for this surgery. Less than .3% for the 'split him open from top to bottom' aortic graph surgery. 'Split him open' surgery gets you up to a week in ICU, a week or so in hospital then 3 months when you feel like a truck ran over you (that's exactly what the surgeon said - word for word).

Gunbunny, it's the CAD workup:
Stress treadmill
Cardiologist's letter
Lipid profile, fasting glucose creatinine.
PLUS
Stent procedure note
Echo of the abdominal aorta (current, and can be a CT).