The Treatment of Abdominal Aortic Aneurysm

Intro: This is Weekly Dose of Wellness, brought to you by MemorialCare Health System. Here's Deborah Howell.

Melanie Cole (Host): Welcome. This is Melanie Cole, filling in for Deborah Howell today. Abdominal aortic aneurysms are relatively common and are potentially life-threatening. Aneurysms can develop slowly over many years and often with no symptoms. My guest to tell us about those today is Dr. Rahul Sharma. He's a vascular surgeon with MemorialCare Saddleback Medical Center and South Orange County Surgical Medical Group. Dr. Sharma, what is an abdominal aortic aneurysm, and do we know what causes them?

Rahul Sharma, MD: Yeah. Well, thanks for having me, Melanie. I appreciate it. And good morning to all those listening. So yeah, so abdominal aortic aneurysm, technically, it is a dilation of a blood vessel that's greater than 50% of what it should normally be. So when we're talking about abdominal aortic aneurysms specifically, in the majority of the population, the size is about two centimeters. So 50% greater than that is three centimeters. So anyone who has an aneurysm or a blood vessel that is greater than three centimeters, we consider that aneurysmal. There are different types of aneurysms, and for this, just to stay on topic here, involves all the layers of the actual blood vessel.

Melanie Cole (Host): So who would be most at risk for abdominal aortic aneurysms?

Rahul Sharma, MD: So there are a handful of patients and the general population that we look at. The things that put people at risk, at least the modifiable factors in life, is smoking. And I can't say it enough, and I'm sure you'll hear me say it over and over again, is smoking, smoking, smoking. In terms of the things that you can control in life, that is one of the biggest factors. The other things that do contribute, of course, being older age and people living longer, that's a factor. Also, being a male, have more risk for having an aneurysm. Caucasian males. Having hardening of your artery. High blood pressure. And actually even family history of having an aneurysm either in the abdomen or even in other locations in the leg or in the groin can put you at risk for having this also. Surprisingly, there is actually a decreased risk for patients who have diabetes, non-whites, and females. So typically it is male and elderly generation, and again just because I said it before I'll say it again, people who smoke cigarettes.

Melanie Cole (Host): So as we said also in the intro, sometimes there's no symptoms. So, would somebody, would there be anything that somebody would know about, and how is it diagnosed if it's asymptomatic, is it something that a physician might catch when they're looking for something else or doing a test for something else? What would we notice?

Rahul Sharma, MD: Right, well actually that's exactly it, Melanie. Most of the time patients don't have any symptoms at all and they're fine, they're found either by really good physical exam or just incidental finding. Patients who have belly pain or who are having tests for something else, that's really how we typically find them. So they're kind of, it's lurking beneath the surface. Typically what we tell people when we find it is that, "Hey look, this didn't sprout up overnight. It's kind of an unrealized risk that you've been living with, but now that we know it, here's how we manage it." There are a few scenarios in which patients would have symptoms because they're not all asymptomatic. But the patients who have symptoms, either if it's a rapidly growing aneurysm, they can cause pain. And typically that pain is in the abdomen, on the front, or even in the back, or on the flank. So anything like that with a history of aneurysm, or if the patients are in the ER, it becomes concerning because that becomes one of the higher or the highest acuity diagnosis that should be identified and treated right away. But again, like you said, most of the time it's without symptoms and we do find these incidentally all the time.

Melanie Cole (Host): Then let's talk about treatment options, Dr. Sharma. So, are treatment options always emergent? Are they always surgical? Or sometimes is it a medicational intervention, or a watch and wait? Tell us about how you determine the treatment options for a patient.

Rahul Sharma, MD: Typically, once we identify that the patients have this, everything is a risk and benefit in terms of the medical field, especially in regards to surgery. So we balance the risk of surgery with the risk of just waiting and watching. So for men, it is generally accepted that five and a half centimeters is the diameter at which you would offer treatment, because at that diameter the risk of rupture exceeds the risk of surgery. And that's not to say that you know aneurysms bigger than that will be, will rupture or they'll be okay, and something smaller won't. But it's all about risk assessment for the patients and then assessing what they will go under if they have to have surgery. In terms of females, for them it's at five centimeters is kind of the number. But then again it's also individualized to the patient. So if the patient has a rapidly growing aneurysm, that is of concern to us also. Of course, any diameter with symptoms we typically treat. And then I guess going from there in terms of treatments that we offer, for the last, I'd say, almost 20 years or a little longer actually, we've been doing a lot of these procedures by minimally invasive methods, which are only getting better over time. And these are done through small incisions in the groin where we navigate the stents and the grafts inside the patient, almost like lining a tire from the inside to fix a bubble in the tire or to repair a hole. And so that's a good majority of how we do these procedures today. One of my partners actually was one of the first to do something called a fenestrated graft in Southern California. And so these are advancing rapidly. And there is of course the old-school open surgical repair which takes a little more investment from the patient. We certainly have to ensure that their body and their physiology is able to undergo a large operation. But these are good, durable procedures, and for the right patient, it can be the right procedure. So typically we discuss options with patients so that there's full transparency so they understand how the preoperative course will go and how the post-op course will go. But yeah, so there's a mixture of things and they are both good, durable options.

Melanie Cole (Host): What's recovery like? If you have to do one of those procedures, then is the person's, because I think Doctor, one of the big things with an aneurysm such as this is the anxiety that the person might have that this could rupture or cause issues. So if you've done one of those procedures afterward, do they still have to be worried about a recurring one? Do they still have to be anxious?

Rahul Sharma, MD: Yeah, now those are great questions. I think, from the time that we meet the patients, from the very first visit, we kind of establish what, you know, again, as unrealized or un-realized risk that they've been living with. Um, and then we kind of give them an idea so, for a five and a half centimeter aneurysm, the risk of rupture for there is anywhere from 5 to 11% per year. So when you couple that with, "Hey, surgery has a risk of 1 to 2%," then you can kind of see where things are gonna go. So when we do these procedures by endovascular means or the minimally invasive means, they still do require maintenance. It's just like a car. You can't just take it in one time for an oil change. You kind of have to have these things maintained. So what we do over time, once the stents and grafts are placed, we do continue surveillance on these things. Because they are, it's a dynamic process. It can move, it can shift. Um, and the whole purpose for doing these procedures is to reduce or to eliminate the risk of rupture for these patients. So certainly, again, with counseling starting from the very first time we encounter this disease with the patient, we let them know that it's not something where you get this fixed and you ride off into the sunset. It's something that does take a team approach between the patient and the physician, and that we do have to monitor these over time to make sure that there's no complications from them. Typically, at least for the endovascular arm of treatment, these patients come in one day in the morning or in the afternoon. Procedure can take anywhere from an hour to a few hours. And typically, as long as they do well and they're without pain and discomfort and they can eat, typically our patients go home the following day within about 24 hours from the time of the surgery. If you were to undergo a larger open surgery, this can take a little more investment from the patient, which can take anywhere from five days in the hospital to a week and sometimes more, barring if there's no complications. But again, we look at these things to say, "Hey look, again, it's nothing that you just have and you walk away," but the main thing is alleviating the risk of rupture and of course the anxiety that's coupled with that for the patients.

Melanie Cole (Host): So wrap it up for us then, Dr. Sharma, with your best advice. If there is anything that people can do to prevent abdominal aortic aneurysm and what you would like the take-home message to be today.

Rahul Sharma, MD: Oh, well I think, you know, I said it earlier and I'll say it again, is that if there are things in life you can control, you should control them. And we do have good evidence that smoking is one of the highest things and the highest risk things that you can control and modify to stop the growth of aneurysms. Even for the patients that we look for, if you've ever been a smoker and you're a male and you're greater than 65 years old, you should have screening to make sure that you don't have an aneurysm. And there's other risk factors such as high blood pressure, hardening of the arteries. So when you have any of these things, just be comfortable and if it sounds like you, discuss with your primary care physician and let them know, at least so you can have the surveillance. And then from there, you know, we walk the patients comfortably with decisions that we can carry, carry on that relationship forward from there.

Melanie Cole (Host): Thank you so much for joining us today, Dr. Sharma, and sharing your expertise and explaining abdominal aortic aneurysm so very well for us. Thank you again. You're listening to Weekly Dose of Wellness. For more information or to listen to more podcasts in these series, please visit memorialcare.org. That's memorialcare.org. I'm Melanie Cole, thanks so much for tuning in.