July 3, 2025 • 38 mins
Understanding Aortic Aneurysms with Dr. Raghuveer Vallabhaneni
Host: Debra Schindler
Guest: Dr. Raghuveer Vallabhaneni, Director of Vascular Surgery, MedStar Health Baltimore Region
The aorta, your body’s largest blood vessel, acts like a fire hose — forcefully pumping blood from your heart to every part of your body. Over time, parts of the aortic wall can weaken and stretch, forming a bulge known as an aneurysm — a silent and potentially deadly condition. In this episode, Dr. Vallabhaneni explains the difference between aneurysms and aortic dissections, discusses risk factors such as high bloodpressure, smoking, and genetic predisposition, and emphasizes the critical importance of screening and early detection, especially for men over 65 who have smoked.
In this episode of DocTalk, Debra and Dr. Vallabhaneni discuss:
· Types of aneurysms (abdominal and thoracic)
· Who should be screened
· Warning signs and when to act
· How aneurysms are monitored
· Treatment options, from lifestyle changes to minimally invasive stent procedures (EVAR)
· Why lifelong follow-up care is vital after a repair
Dr. Vallabhaneni also shares remarkable cases, including treating a 13 cm aneurysm and how imaging advancements have revolutionized care.
Key Message: Most aneurysms grow slowly and can be safely monitored, but they become dangerous when undetected. If you or someone you love is at risk, screening can be lifesaving.
Baltimore-area listeners: To schedule an appointment with Dr. Vallabhaneni, call 410-554-2950.
For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.
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Episode Transcript
Available transcripts are automatically generated. Complete accuracy is not guaranteed.
(00:00):
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health DocTalk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland DC region.
The aorta is your body's largest bloodvessel To understand how vital and
(00:21):
vulnerable the aortais, picture a fire hose.
Imagine that the fire hose is connectedto your heart and with every beat,
every single second blood is rushingthrough it from the heart to every organ,
every limb, every inch of you travelingroughly at three feet per second.
A blood cell in the average person travelsthrough the entire body in about one
(00:43):
minute, which incredibly equates to 83gallons of blood an hour. Over time,
like a fire hose section of the aortacan weaken under the pressure the wall
stretches and thins out,and that's when an aneurysm can form
a bulge that may go unnoticed until itruptures. Today on doc talk, I'm
joined by Dr. Raghuveer Vallabhaneni,the Director of Vascular Surgery in
the Baltimore region of MedStar Health,to discuss the hidden
(01:07):
dangers of aortic aneurysms,the importance of finding them and
how they're treated. I'm your host,Deborah Schindler. Dr. Val Benini.
Thanks for being with me today.
Thank you, Debra.
I appreciate the opportunity todiscuss a topic close to my heart.
Literally. Right.
I think the first time I heard of anaortic aneurysm was when John Ritter from
(01:29):
the old TV show, three's companydied because of an aneurysm,
rupturing known as a dissection,something that also claimed the lives
of Albert Einstein and Lucille Ball.
Are they common?
That's a great question.
Deborah aneurysm and aorticpathologies are one of the leap in
men, especially over the age of 60.
(01:50):
They are quite common, andas we all speak about today,
I do refer them as the silentkiller because aneurysms can develop
and you don't really know that they'rea problem until they're about to burst,
which could be too late insome situations. Typically,
in most aneurysms are what we callasymptomatic or they don't produce
(02:11):
any symptoms until they get to a pointwhere there's a lot of tension on
the wall of the aorta. Like youmentioned, it's sort of like a fire hose.
So if that section of thefire hose begins to bulge,
you don't really feel that it'sabout to burst or cause a real
problem until it's stretched to thepoint where it's actually tearing.
(02:33):
So the symptoms of that late stagewould be things such as severe
back pain, abdominal painpressure in your abdomen.
It also could, depending on where inthe aorta the aneurysm is located,
caused chest pain as well. A lotof patients when they come in,
they feel like they're dyingand that's what they say.
(02:54):
They don't know what's going on.
So it's not something subtle.
It's not like an ache in your back,like if you have lower back pain,
don't be concern that that's an aneurysmbecause it is unlikely that that's what
it is. However,screening is a very important way of
detecting these aneurysms prior to thembecoming a problem.
We actually had a colleaguehere at MedStar Union
(03:18):
at his desk, just collapsed, fell over,and luckily he was in the hospital when
this dissection happened and they wereable to save him for him to share
his story and tell us about it.
But sitting at his desk andI mean that's pretty quick.
When.
This rupture happened.
It can happen.
And I just want to clarify a fewthings and different types of aortic
(03:40):
problems. So the first one is ananeurysm, which is the bulge in the aorta,
which is caused by theweakening in the wall,
which grows slowly over time andthen can rupture if it gets too large
and is untreated.
The other problem that could happen inthe aorta is something like you mentioned
called a dissection.
That's what John Ritter hadas well as Lucille Ball.
(04:03):
And what that is is a highblood pressure or a weakening of
the aorta from either a small aneurysm ora problem with the tissue of the
aorta causes a tear in the wall,which makes blood go in the wall of the
aorta as opposed to where it's supposedto go in the tube of the aorta
down to the vital organs.
(04:26):
This causes a tearing sensationand further weakening of the aorta,
which could cause bleeding and rupture.
So this isdefinitely something that has
certain risk factors that canbe treated and prevented
before they become a problem.
The risk factors for aorticdissection are the most common one is
(04:48):
very high blood pressure.
The high blood pressure causessuch a force in the aorta that it
can cause a tear or a holein the wall of the aorta.
The second most common reason forthis is a problem with the patient's,
what we call connective tissue orthe strength of the tissue that holds
everything together.
(05:09):
That can be from eithera genetic variation where
either someone in your family passedon something onto you that makes your
aorta weaker, or it could also befrom you having a small aneurysm,
which is weaker tissue by nature.
Those are the most commoncauses of an aortic dissection.
(05:32):
So along with the aortic dissection,there's also two different
kinds of maybe more,but let's talk about the two
different kinds of aortic aneurysms.
You have abdominalaortic aneurysm, the aaa.
Yeah. So let me talk aboutthe aortic dissections first,
then we'll talk more about the aneurysms.
And I want to make sure everyoneunderstands there are two separate things.
(05:54):
Dissections are the tear andthe aneurysms are the bulge.
So with dissections,they could start in your chest or
they could start in the back of youraorta and your upper chest,
and sometimes they couldbe a life-threatening
heart attack. If there is a tearthere. With the aortic aneurysms,
(06:15):
they could also be locatedanywhere along the whole
length of the aorta.
So it could be located right next toyour heart all the way down to in your
pelvis.
It could also be in the blood vesselsthat go to different organs as well as
even in your leg arteries.
How long is that aorta?
Well, the aorta goes rightfrom the heart and the chest,
(06:39):
and then it forms in the shape of acandy cane and it goes down to around the
area of your belly button,and that's where it splits and
it goes down into the leg artery.
So an aortic aneurysmcan form anywhere along
the aorta,but you could also have aneurysms in
any part of any artery in your body.
(07:00):
The most common aneurysmsthat people normally identify,
or you could hear a brain aneurysmswhere people have bulging of
an artery in their brainthat could rupture, could
But the aorta is actually one of themore common places that aneurysms occur
in the entire body. So it's veryimportant that people get screened,
(07:23):
especially if they're at risk fordevelopment of aortic aneurysms to try to
prevent them from occurringand growing and rupturing.
What is a thoracic aortic aneurysm?
So thoracic aortic aneurysm,it refers to an aneurysm that
would be in your chest cavity.
So anywhere from around your diaphragmright around where the bottom of your rib
(07:44):
cage is to your heart along the aorta,they're a little bit more complicated
to take care of because they're in yourchest and not necessarily in your belly.
So especially with open surgical repair,it could be a much more
complicated repair. Thankfully,over the past several decades,
we've made huge advances in thetreatment of aortic aneurysms.
(08:07):
To give an example, AlbertEinstein, you mentioned earlier,
he had an aortic aneurysm and youwould never guess how they treated it.
He choose not to havetreatment or surgery anyway.
Well, they originally, oneof the things they did,
and they thought thatthis was going to cure it,
is they wrapped it withsaran wrap cellophane.
Oh my goodness.
(08:27):
And they did that to induce inflammationsort of and scar tissue around the
aorta to hold it inplace. Needless to say,
it didn't work.
So that was in the fifties.
We made a lot of advances since thattime in the treatment of aortic surgery,
Michael DeBakey, one of theforefathers of cardiovascular surgery,
(08:49):
was one of the first people to usean aortic graft, which he actually,
this is an interesting story too.
He was trying to find a goodmaterial to use for the graft,
and back then he thought thatpolyester might be a great
material to use, but there weren't asmany rules and regulations in the fifties.
(09:09):
So he went to Sears Roebuck.
For those of you old enough toremember what that store is?
I sure do.
And he bought a roll offabric called Dacron,
and he took the bolt of fabric to hiswife who sewed an aortic graft for
him. He took it to the hospitalthe next day, sterilized it,
(09:31):
and then implanted it in a patient.
And that was the first aortic graftthat was done in Texas in the fifties.
Was it at all successful even?
Yes, it was a success. Wow. Andit was the birth of real aortic,
open aortic surgery in theUnited States and the world.
That's amazing. That's amazing.
The innovation of medicine.
Yeah, thankfully, since that time,open aortic surgery
(09:53):
requires large incisions.
So for an abdominal aorticsurgery in the belly region,
typically it would either involvea long incision from your rib cage
down to your pelvis and stayingin the hospital for about a
week. We still do thosesurgeries in certain situations,
(10:14):
but a lot of times we try todo less invasive procedures.
The early nineties,there was something called the
endovascular revolution that occurred withaneurysms.
And what endovascular meansis instead of taking a
bulge in that fire hose wewere talking about before,
(10:34):
there are two ways to fix it.
You could either cut out a pieceof hose and sort of sew in a new
piece of hose that's open aortic surgery.
The other option would be to slide in aslightly smaller hose through the hose
and redirect the waterthrough it without putting any
pressure on that weakened areathat's minimally invasive surgery.
(10:59):
So basically what we do is we puta tube or a stent in the aorta
to redirect the flow away from theweakened walls of the normal blood vessel
and with a tube coveredwith graft material,
the blood will travel through the weakenedarea to areas of normal artery to the
legs and every other organ.
(11:20):
So you're bypassing.
It's sort of an internal bypass with thestent and it doesn't require opening up
the belly.
It requires just typically keyholes in the groin arteries
right under in the groin area.
So it doesn't even require anincision most times these days.
When you said one option was toremove the bulge from the fire
(11:43):
hose and then sew inanother piece of fire hose,
I thought you were just going to say toremove the bulge and then reconnect them
and sew them together, that not possible?
Or would that make the aorta too short?
The aorta is connected tolots of different organs.
Sometimes in areas in the leg artery orin the carotid artery in the
(12:05):
neck. That is possibility,but there's usually not enough extra
length of the aorta to bring themback together. That is a good question,
but just technically it's not possible.
So we need to have somethingto fill that space up,
so we have to sew a newpiece of hose in there.
Okay. I want to come back to optionsfor treatment, but to get to that,
(12:30):
I want to know if there are nosymptoms where the symptoms are absent,
how do patients usually get diagnosed?
How do they come to see you?
So most times these days it'swhen someone gets a CAT scan
for any number of reasons, abdominal pain,looking at their spine, they're trying
to figure out some other problem.
(12:51):
And this is found what we callincidentally by accident Because of
the seriousness of this. Whenthe Welcome to Medicare package,
there was a law passedthat actually allowed
screening for abdominal aorticaneurysms in anyone who meets a
select criteria, which isa large amount of people.
(13:13):
What this criteria is is in anyone who is65 years old male and has smoked more than
five packs of cigarettesin their lifetime,
males traditionally have higherrisk factor for developing
abdominal aortic aneurysmsthan women do. That being said,
(13:36):
in my practice,any woman or male who has
ever smoked and is over theage of 65,
they should be screened foran abdominal aortic aneurysm.
And usually that's done withan ultrasound, which is a
Noninvasive takes about20 minutes to perform and
(13:57):
you'd be good to go just putting anultrasound probe on your abdomen and
looking.
Is there a family history for this?
Should John Ritter's kids be screened?
Should they go and get an ultrasound?
It sounds like a pretty easy.
Step.
To take.
So if anyone has a familyhistory of aneurysms or aortic
disease,they should also be screened pretty
much 10 years prior to the diagnosis ofthe other person.
(14:23):
So we're at the very leastby the age of 50 years old,
if they've had a history of someonewho has died or had a significant
aortic problem.
Do all aneurysms need to be treated?
What's the threshold fortreatment and not treatment?
No, that's a good question. Sowhenever I see patients in the clinic,
everyone thinks that ananeurysm is a ticking time bomb,
(14:47):
and generally when they come to me,the aneurysms have been slowly
growing for years and years and years.
So they grow slowly and we normally stud.
Large studies have shown that you don'tneed to have a repair of an aneurysm
until of meet certain sizecriteria in men in an abdominal
aneurysm, in most instancesit's about 5.5 centimeters.
(15:11):
In women,it's about five centimeters
just in general because general.
So the relative risk of a five centimeteraneurysm is higher than that of a
male.
So once it's five centimeters,you're saying that's when.
That's when it should be repaired. Andthankfully, aneurysms for the most part,
grow quite slowly, onlya few millimeters a year.
(15:34):
So if someone has a threeand a half centimeter
aneurysm, it can be severalyears before a repair is needed.
And sometimes a repair is notneeded because if someone has other
illnesses,we want to make sure that we're actually
going to extend someone's life byfixing this aneurysm.
(15:55):
So if they have severe lung disease orheart disease or they have a cancer,
it may not make sense to fix an aneurysm,especially if it's probably not going to
be the thing that harms them. However,anyone with an aneurysm should be followed
very closely by a vascular surgeon.
It seems though, everytime we talk about disease,
(16:17):
that early detectionmeans better outcomes,
survival. If I had an aneurysm, Ithink I just want to get it fixed.
That's a good point.
You could just wrap that Dacronaround it and send me home.
With any surgery there is risks,and even though surgery
is very safe these days,even open or minimally
(16:37):
invasive aortic stem surgery,the risk of a rupture in most patients
if it doesn't reach a certain thresholdis still very low.
What is the process ofmonitoring an aneurysm?
How often do you have to check it,and how fast does the bulge
typically grow or worsen?
(16:58):
So typically they tend to grow abouttwo to three millimeters a
year, which is not that big.
If you look at a ruler andlook what three millimeters is,
it's really not that much larger a year.
And that's determinedpurely by ultrasound.
Purely by ultrasound,or if it's closer to needing a repair.
(17:21):
If it's in the four and a halfcentimeter, four centimeter range,
it could then be followed with a CATscan to get more precise measurements and
see also help with planning of repair.
Have you ever seen it where itwent from a non concerning size to
suddenly becoming very perilous?
I have, and that's why wefollow patients pretty closely.
(17:45):
So generally,especially if it's above four centimeters,
you want to see that patient every sixmonths to a year, depending on the size.
Generally, if a patient grows morethan half a centimeter in one year,
that's another indication torepair it regardless of the size,
because then in that patientit's growing too fast.
(18:07):
Is that a decision thatyou make for the patient?
It's always a discussion.
We give patients ouropinions on when these
aneurysms should berepaired to help prevent it.
It's one of the few prophylacticsurgeries that we do as vascular ss.
I mean, I'm trying to Is it elective?
(18:27):
Is.
It still elective at that point?
Yeah, generally it's elective untilit's causing pain or a problem,
then it's an emergency. So I alwaystell my patients I'm not God.
If I was, I would call them the daybefore they were about to rupture,
then I would tell them thatit's time to get it fixed.
Get in.
Here, because without thatknowledge, you have no idea.
(18:49):
And patient's aneurysm sizes vary.
I've had patients with sixcentimeter aneurysms rupture,
and I've had patients show up in my clinicwith 10 centimeter aneurysms who have
not ruptured and someone just found it.
So it's very difficult to predict.
There's a lot of research tryingto figure out different prognostic
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indicators of what makes ananeurysm more likely to rupture,
and we're making some progress with it,but it's still imperfect science,
so it's pretty safe.
We don't put patients' lives at risk.
When we wait till fiveand a half centimeters,
we know that it's the likelihoodversus the risk of the
(19:35):
procedure. It really meetsthat minimum around that size.
So a patient comes to you,you do the ultrasound,
you determine they have aaneurysm, maybe it's not ready,
it's not severe enough for surgery.
What would be the first step then?
Walk me through the stages of treatment.
So the first thing is Ihad to get a full history.
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I ask them about their family,ask them if anyone's ever died of sudden
death where they didn't really knowwhat was happening.
Because a lot of times,especially if people didn't really
get an autopsy or know why theydied, it could have been an aortic
problem. They just didn't know about it.
And after the history, we get imaging,so whether it be an ultrasound or
(20:17):
if they show up already having a CTscan, we could look at it together.
And then we talk about a plan where wetalk about a follow-up plan and also
signs and symptoms that we mentionedabout that would make you seek a
comeback earlier than ourregular scheduled intervals.
(20:38):
And that would be thingslike increasing pain,
just not feeling well. Again,it's very unlikely in someone who's
followed regularly for them to rupture,but we have to just educate the patient
just for that off chance that somethingcould happen.
How would you describe theaorta? I mean, how big is it?
So normal aorta is anywherefrom about two to two and a half
(21:01):
centimeters in diameter. It.
Seems very small then.
Yeah.
And an aneurysm that needs to be repairedis about five and a half centimeters,
so it's about double that size.
The definition of ananeurysm is any blood vessel.
That's one and a half times itsnormal. Size is an aneurysm.
It's not necessarily an aneurysmthat needs to be repaired.
(21:22):
It's just one that needs to be followedbecause it's weakened from the bulging.
So it sounds like it would be very easyfor you to see that on an ultrasound.
You wouldn't likely miss it. It's.
No.
Pretty pronounced.
If you get a screening, most people,you're able to see a pretty clearly,
but if not,there are other alternatives such as CT
scans or MRIs or different things youcould do to follow it.
(21:44):
What's the worst one you ever saw?
The worst.
The worst one.
Aneurysm?
Yeah.
The biggest aneurysm I'veever seen was 13 centimeters.
And it didn't rupture.
Well, that one was causingpain and I had to fix it.
Oh, wow. It was in a mail?
It was in a mail, yes.
See, we did a story someyears ago, many years ago,
and the patient was a very young manand he was getting a physical and they
(22:08):
heard something, can you hear something?
The cardiologist didn't think it soundedright. Sent this young man for imaging,
and that's when he found out that hehad an aneurysm that required surgery.
Yeah, you could hear whatwe call a brewery sometimes,
which is an abnormalflow with a stethoscope,
which could tell you that somethingis off with the blood vessel.
(22:30):
Generally on physical exam,it's feeling the mass,
a pulsitile mass is the giveawaythat someone has an aneurysm.
You can feel it through the skin.
You can feel it through the skin,and the people who are thin enough
and it's large enough aneurysm,you could actually, if they're
laying flat, it's pretty common,especially when I'm fixing large
aneurysms that they're lying flat inthe operating room and you could just
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see their belly rising with every pulsefrom the aneurysm pulsating
through their skin.
I think it sounds like a hernia.
Could it be mistaken for a hernia.
Except with the pulseis what gives it away.
So a pulsitile mass anywhere in your body,you got to be concerned of an aneurysm.
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Are there medications?
Oh yeah.
So medical management is very importantfor a treatment of aortic aneurysms to
try to prevent rapid growth rates,and those include blood pressure
control being on a statin,which is a very common medication
that a lot of our listeners may be onthat helps prevent growth
of aneurysms. Also,just decreasing everyone's stress level.
(23:43):
Quit smoking.
Quit smoking.
Smoking is definitely a bigrisk factor for aneurysm growth,
and it definitely increases the rateof growth. So even quitting smoking,
even though you have an aneurysmpotentially from smoking,
quitting smoking could reduce your riskof that aneurysm growing at a rapid
rate.
Okay. Medical treatment monitoring,lifestyle changes, endovascular repair,
(24:06):
EVAR. Tell me about that.
So the minimally invasive approachwith the stent for the abdominal aortic
aneurysm,we use the acronym EVAR for
endovascular aortic aneurysmrepair.
That's normally where weslide a tube or stent into the
abdominal aorta and rightbelow the kidney arteries,
(24:28):
we land our stent and wego into the iliac arteries,
which are the arteriesunderneath the belly button,
which split and go to the legs.
So this is thrown incision in the belly?
No, this goes just througha small pinhole needle hole.
Needle stick in the groinarteries, the femoral.
Artery, the femoral. Oh, okay.
(24:49):
Can.
You do it through the radial.
That we cannot do throughthe radial at this time? No.
The stents are too large to travelthrough there. When they go in,
when they're not deployed,they're about the size of a thin
marker is about the size of astent that is non-deployed, and
then when you deploy the stent,it opens up to be about
(25:16):
two and a half to three and ahalf centimeters in diameter.
It's on the inside of the artery.
It's on the inside of the artery, sorelining the inside of the artery,
redirecting the blood flow.
So that technologystarted around the early
nineties, but even since then,we've even become more advanced.
(25:37):
So the problem is just putting astent across an artery. That's fine.
If there are not that many importantbranches coming off that artery and in the
abdominal aorta belowyour kidney arteries,
there's not that many importantblood vessels coming off of it,
so you could block those vessels offand not really having too many problems.
The problem occurs when you havesignificant important blood vessels
(26:00):
coming off the aorta. So bloodvessels like the kidney arteries,
intestinal artery, the arterygoing into your liver and stomach,
those are very important. If youblock any of those arteries off,
you could have a significant problemwith your health and even your life for
those reasons.
There's been more advanced developmentof minimally invasive techniques.
(26:21):
Previously you'd have to do big opensurgeries where we make a really long
incision from your shoulder, shoulderblade to below your belly button.
Oh my.
Open you up, go through yourribs, go through your diaphragm.
It sounds medieval.
And we still do it sometimesin certain patients,
but it does have an increased risk ofcomplications the bigger the surgery
(26:42):
is.
Infection. Sure.
Yeah. Infection wound complications.
Just being able to do it,especially as patients get older and as
generally older patients who have theseaneurysms,
it definitely becomes more of a problemdoing these bigger operations on them.
For that reason, thesestents have been a lifesaver.
(27:02):
We've really been able to extend thisoperation to patients who we never
would've thought of previously.
When I was in training 20,30 years ago,
I remember calling up patients intheir eighties who've had an aneurysm,
which was involving some of thesemajor blood vessels and telling them,
we can't really tolerate an open surgery,so there's really nothing
(27:23):
we could do for you.
That was a very common thing that occurredunfortunately for patients because
aneurysms grew as they grew older.
That had to be a horrible part of the job.
Yeah, it was unfortunate,but we were doing what was in the best
interest of the patient because theopen surgery in patients in their
eighties is very hard for them totolerate in some instances. So
(27:45):
with minimally invasive techniques,we're able to treat aneurysms
that we weren't able to before,including aneurysms that include
the major arteries of the body,like the kidney arteries, the intestinal
arteries, and the liver artery,including the arteries that go near,
(28:06):
go to your brain,even into your arms in the chest with
these minimally invasive techniques.
So some of the advances have been whatwe call fenestrated technology where
there are holes that arecustom made for the patient's
individual anatomy to cover them and putstents in them so they're getting blood
(28:27):
flow even though the aneurysmis covered with a stent.
And there's also a branch technologybranched endovascular repair
where we actually have a tube withbranches that come off of it where
we're able to put stents in toall the different blood vessels.
Both of those operations.
We do quite a few of at MedStarhospitals throughout the region.
(28:52):
The case that you said was the biggestaneurysm that you did that you said it
was what, 15.
13 Or 15 centimeters? Yeah.
13 Centimeters.
Yeah.
How did you treat that? One.
That was minimallyinvasively with a stent.
And the patient recovered well.
Patient did well.
If a patient has an aneurysm like that,is it likely that they're
going to develop another one?
They can. That's whyif someone is repaired,
(29:15):
especially with a minimally invasiveaneurysm, is very, very, very important.
And I always really drive this homewith point home with our patients that
they need to be followed for the restof their life because with the stent,
although it's very secure, we'renot curing aneurysm disease,
we're treating a specific aneurysm.
(29:36):
Whatever factors led them to developthis aneurysm could develop weakening in
another portion of their aorta,and if that happens, the seal,
which is basically just the force of thestent against the artery could become
compromised and then they arenot a fully repaired aneurysm
if they develop a leak potentially.
(29:58):
I was going to ask how doesit not move inside the vessel?
It is basically there'ssome hooks, internal hooks,
and also radial force are the main waysthat these stents stay in the blood
vessel, which is different thanwhen we do open surgical repair.
We're actually using suture tosew the graft to the patient's
(30:18):
aorta.
How do you discern who should getthe endovascular repair versus
surgery?
Like I mentioned before,it's always a joint decision.
A lot of times youngerpatients may be better
served by an open surgerybecause although there are higher
(30:39):
risks associated with it when comparedto the minimally invasive surgery,
it's also better toleratedbecause they're relatively
younger and also it could bemore durable in the long-term.
So long-term being potentiallydecades if they're in their fifties
now with minimally invasive approaches,typically they have a higher
(31:01):
rate of reintervention,meaning that you might need another
procedure to keep your aneurysmrepaired in the future,
but that could be several years downthe road and most likely in the future,
that will also be anotherminimally invasive procedure,
not a big open procedure. So itdepends on the patient's anatomy,
(31:25):
where exactly their aneurysmis and also their other health
problems when deciding.
So it's always a veryindividualized approach.
That being said, the vastmajority of patients generally
desire the minimally invasive procedurewhen they're given all options and
(31:46):
when they ask my opinion ofwhat would be best for them,
especially because it's in most commonlyin patients in their seventies and
eighties.
So once you come to the decision withyour patient that surgery is needed,
what happens next?
Based on the size of theaneurysm patient's symptoms?
If it is elective,meaning that they aren't
having any symptoms,we want to make sure that they're
(32:09):
able to tolerate the surgery well.
So I will contact theirprimary care doctor and their
cardiologist.
They have one to make sure theirheart could tolerate the procedure.
They may need some diagnostic testing toverify that they don't need anything to
optimize them for the surgery.
Are there surgical options.
(32:30):
Following their medical clearanceonce they're scheduled for surgery?
Typically,a hospital stay for a straightforward
abdominal aortic aneurysmusing a stent is only overnight,
so they go home the next day.
A lot of times the patients have no pain.
They don't even need pain medicationsjust because it's a very small
(32:53):
needle hole incision that maybe hasone stitch, and that's about it.
So the more complicated operationsthat usually incorporate
blood vessels in the kidneyarteries, the intestinal arteries,
and the liver artery,they typically may stay a few more days
just to make sure that everything isokay. As I mentioned before, if
someone requires open surgery,they likely will be in the
(33:16):
hospital for about a week.
It'll still take time toheal after they get home,
and they probably won't be feeling backto their full normal self for about
three to six months.
What do you call the surgery to repairan aortic aneurysm or a dissection?
Are they different surgeries?
So for aortic dissection, if someonecomes in with tearing chest pain,
(33:40):
tearing back pain, havevery high blood pressure,
typically the way we repairthat is we seal the tear.
So depending on where the tearis, if it's by right by the heart,
for the most part these days,cardiac surgeons would have to open up
the chest and replace that portion of theaorta. If it is not in that area,
(34:01):
if there's an area furtheralong the pathway of the aorta,
we are able to fix it with a stentwhere we're able to tack the tear
along the wall and preventblood flow from going in the
wall of the aorta. The acronymwe use for, that's called tbar,
which is thoracicendovascular aortic repair.
(34:24):
That's just a larger stentin the aorta in the chest,
which is called the thoracicaorta. There is, again,
lots of advances in this field,and we are treating more and more
aortic problems closer to theheart with stents.
So my guess in the next 10 or 15 years,a lot of these therapies that
(34:45):
were previously required openheart surgery potentially
could be repaired with a stent.
It looked like there wasa lot of excitement online
about this approach called tbi.
Yes. So the gore.
Tell me about that. So.
The GORE TBI is a newcommercially available device,
(35:08):
which was recently becameFDA approved this last
year, and we are one of the fewinstitutions in the region that are
performing that repair.
That repair requires patients withmore complicated aneurysms that extend
from chest into the abdomenand cross that delicate area
(35:30):
where the kidney arteries and theintestinal arteries come off of.
We're able to use branch stents tomaintain blood flow to those vital
organs while repairingthe aneurysm. Typically,
we use an approach where westill don't make any incisions,
but just may go through needle holesin the upper arm on the left side
(35:51):
and both groins.
So it's a remarkable new technologythat enabled us to treat a lot more
patients, includingpatients in their eighties.
And I assume they're undergeneral sedation for that?
Yeah,typically it's under general
anesthesia for those just because we ofthe careful imaging required to
make sure we're in those vitalorgans.
(36:15):
How long are you usually in the labwith a case like a Tam ABI case?
Yeah, so with those TAM ABI cases,we're pretty expert at those,
but it's a very complicated case.
So it still takes about three hours,three to four hours, I'd say,
which is very good for thattype of complicated repair.
And the patient can gohome maybe a day later.
(36:35):
Generally, for those patients,they're in the hospital for two nights
just to make sure that everything'sworking okay.
Do your patients feel differentlyafter they've had an aneurysm repaired?
That's one of the hardthings about an aneurysm,
especially if it's electiveand they found it by accident.
I'm repairing somethingthat doesn't make them feel.
(36:55):
Badly that they didn't know they had.
So no matter how minor the repair is,they're likely going to feel a little
bit worse than they did just because theyhad surgery.
Understood.
That being said,that's why it's very important to
follow up with your primary care doctor,get the abdominal aortic surveillance,
especially if you're having riskfactors such as smoking, family history,
(37:19):
and make sure that you keep on followingwith your vascular surgeon even after
you have it repaired, because it is very,very important just to make sure
that this stays not causing symptoms.
We want having an aneurysmto be as boring as possible.
Right? Absolutely.
The aortic aneurysm isn't usually aheadline condition, but it should be.
(37:41):
Awareness and screening can changethat. If you or a loved one is at risk,
talk to your doctor. Thatconversation could save a life.
If you're in the Baltimore area and wouldlike to make an appointment with Dr.
Vallabhaneni,call 4 1 0 5 5 4 2 9 5 0.
If you would like to provide feedback onthis podcast or get more information on
(38:05):
aortic aneurysms,send me an email schindler@medstar.net.
Comprehensive,relevant and insightful conversations
about health and medicine happen here onMedStar Health DocTalk.
These are real conversations withphysician experts from around the largest
healthcare system inthe Maryland DC region.
The aorta is your body's largest bloodvessel To understand how vital and
(00:21):
vulnerable the aortais, picture a fire hose.
Imagine that the fire hose is connectedto your heart and with every beat,
every single second blood is rushingthrough it from the heart to every organ,
every limb, every inch of you travelingroughly at three feet per second.
A blood cell in the average person travelsthrough the entire body in about one
(00:43):
minute, which incredibly equates to 83gallons of blood an hour. Over time,
like a fire hose section of the aortacan weaken under the pressure the wall
stretches and thins out,and that's when an aneurysm can form
a bulge that may go unnoticed until itruptures. Today on doc talk, I'm
joined by Dr. Raghuveer Vallabhaneni,the Director of Vascular Surgery in
the Baltimore region of MedStar Health,to discuss the hidden
(01:07):
dangers of aortic aneurysms,the importance of finding them and
how they're treated. I'm your host,Deborah Schindler. Dr. Val Benini.
Thanks for being with me today.
Thank you, Debra.
I appreciate the opportunity todiscuss a topic close to my heart.
Literally. Right.
I think the first time I heard of anaortic aneurysm was when John Ritter from
(01:29):
the old TV show, three's companydied because of an aneurysm,
rupturing known as a dissection,something that also claimed the lives
of Albert Einstein and Lucille Ball.
Are they common?
That's a great question.
Deborah aneurysm and aorticpathologies are one of the leap in
men, especially over the age of 60.
(01:50):
They are quite common, andas we all speak about today,
I do refer them as the silentkiller because aneurysms can develop
and you don't really know that they'rea problem until they're about to burst,
which could be too late insome situations. Typically,
in most aneurysms are what we callasymptomatic or they don't produce
(02:11):
any symptoms until they get to a pointwhere there's a lot of tension on
the wall of the aorta. Like youmentioned, it's sort of like a fire hose.
So if that section of thefire hose begins to bulge,
you don't really feel that it'sabout to burst or cause a real
problem until it's stretched to thepoint where it's actually tearing.
(02:33):
So the symptoms of that late stagewould be things such as severe
back pain, abdominal painpressure in your abdomen.
It also could, depending on where inthe aorta the aneurysm is located,
caused chest pain as well. A lotof patients when they come in,
they feel like they're dyingand that's what they say.
(02:54):
They don't know what's going on.
So it's not something subtle.
It's not like an ache in your back,like if you have lower back pain,
don't be concern that that's an aneurysmbecause it is unlikely that that's what
it is. However,screening is a very important way of
detecting these aneurysms prior to thembecoming a problem.
We actually had a colleaguehere at MedStar Union
(03:18):
at his desk, just collapsed, fell over,and luckily he was in the hospital when
this dissection happened and they wereable to save him for him to share
his story and tell us about it.
But sitting at his desk andI mean that's pretty quick.
When.
This rupture happened.
It can happen.
And I just want to clarify a fewthings and different types of aortic
(03:40):
problems. So the first one is ananeurysm, which is the bulge in the aorta,
which is caused by theweakening in the wall,
which grows slowly over time andthen can rupture if it gets too large
and is untreated.
The other problem that could happen inthe aorta is something like you mentioned
called a dissection.
That's what John Ritter hadas well as Lucille Ball.
(04:03):
And what that is is a highblood pressure or a weakening of
the aorta from either a small aneurysm ora problem with the tissue of the
aorta causes a tear in the wall,which makes blood go in the wall of the
aorta as opposed to where it's supposedto go in the tube of the aorta
down to the vital organs.
(04:26):
This causes a tearing sensationand further weakening of the aorta,
which could cause bleeding and rupture.
So this isdefinitely something that has
certain risk factors that canbe treated and prevented
before they become a problem.
The risk factors for aorticdissection are the most common one is
(04:48):
very high blood pressure.
The high blood pressure causessuch a force in the aorta that it
can cause a tear or a holein the wall of the aorta.
The second most common reason forthis is a problem with the patient's,
what we call connective tissue orthe strength of the tissue that holds
everything together.
(05:09):
That can be from eithera genetic variation where
either someone in your family passedon something onto you that makes your
aorta weaker, or it could also befrom you having a small aneurysm,
which is weaker tissue by nature.
Those are the most commoncauses of an aortic dissection.
(05:32):
So along with the aortic dissection,there's also two different
kinds of maybe more,but let's talk about the two
different kinds of aortic aneurysms.
You have abdominalaortic aneurysm, the aaa.
Yeah. So let me talk aboutthe aortic dissections first,
then we'll talk more about the aneurysms.
And I want to make sure everyoneunderstands there are two separate things.
(05:54):
Dissections are the tear andthe aneurysms are the bulge.
So with dissections,they could start in your chest or
they could start in the back of youraorta and your upper chest,
and sometimes they couldbe a life-threatening
heart attack. If there is a tearthere. With the aortic aneurysms,
(06:15):
they could also be locatedanywhere along the whole
length of the aorta.
So it could be located right next toyour heart all the way down to in your
pelvis.
It could also be in the blood vesselsthat go to different organs as well as
even in your leg arteries.
How long is that aorta?
Well, the aorta goes rightfrom the heart and the chest,
(06:39):
and then it forms in the shape of acandy cane and it goes down to around the
area of your belly button,and that's where it splits and
it goes down into the leg artery.
So an aortic aneurysmcan form anywhere along
the aorta,but you could also have aneurysms in
any part of any artery in your body.
(07:00):
The most common aneurysmsthat people normally identify,
or you could hear a brain aneurysmswhere people have bulging of
an artery in their brainthat could rupture, could
But the aorta is actually one of themore common places that aneurysms occur
in the entire body. So it's veryimportant that people get screened,
(07:23):
especially if they're at risk fordevelopment of aortic aneurysms to try to
prevent them from occurringand growing and rupturing.
What is a thoracic aortic aneurysm?
So thoracic aortic aneurysm,it refers to an aneurysm that
would be in your chest cavity.
So anywhere from around your diaphragmright around where the bottom of your rib
(07:44):
cage is to your heart along the aorta,they're a little bit more complicated
to take care of because they're in yourchest and not necessarily in your belly.
So especially with open surgical repair,it could be a much more
complicated repair. Thankfully,over the past several decades,
we've made huge advances in thetreatment of aortic aneurysms.
(08:07):
To give an example, AlbertEinstein, you mentioned earlier,
he had an aortic aneurysm and youwould never guess how they treated it.
He choose not to havetreatment or surgery anyway.
Well, they originally, oneof the things they did,
and they thought thatthis was going to cure it,
is they wrapped it withsaran wrap cellophane.
Oh my goodness.
(08:27):
And they did that to induce inflammationsort of and scar tissue around the
aorta to hold it inplace. Needless to say,
it didn't work.
So that was in the fifties.
We made a lot of advances since thattime in the treatment of aortic surgery,
Michael DeBakey, one of theforefathers of cardiovascular surgery,
(08:49):
was one of the first people to usean aortic graft, which he actually,
this is an interesting story too.
He was trying to find a goodmaterial to use for the graft,
and back then he thought thatpolyester might be a great
material to use, but there weren't asmany rules and regulations in the fifties.
(09:09):
So he went to Sears Roebuck.
For those of you old enough toremember what that store is?
I sure do.
And he bought a roll offabric called Dacron,
and he took the bolt of fabric to hiswife who sewed an aortic graft for
him. He took it to the hospitalthe next day, sterilized it,
(09:31):
and then implanted it in a patient.
And that was the first aortic graftthat was done in Texas in the fifties.
Was it at all successful even?
Yes, it was a success. Wow. Andit was the birth of real aortic,
open aortic surgery in theUnited States and the world.
That's amazing. That's amazing.
The innovation of medicine.
Yeah, thankfully, since that time,open aortic surgery
(09:53):
requires large incisions.
So for an abdominal aorticsurgery in the belly region,
typically it would either involvea long incision from your rib cage
down to your pelvis and stayingin the hospital for about a
week. We still do thosesurgeries in certain situations,
(10:14):
but a lot of times we try todo less invasive procedures.
The early nineties,there was something called the
endovascular revolution that occurred withaneurysms.
And what endovascular meansis instead of taking a
bulge in that fire hose wewere talking about before,
(10:34):
there are two ways to fix it.
You could either cut out a pieceof hose and sort of sew in a new
piece of hose that's open aortic surgery.
The other option would be to slide in aslightly smaller hose through the hose
and redirect the waterthrough it without putting any
pressure on that weakened areathat's minimally invasive surgery.
(10:59):
So basically what we do is we puta tube or a stent in the aorta
to redirect the flow away from theweakened walls of the normal blood vessel
and with a tube coveredwith graft material,
the blood will travel through the weakenedarea to areas of normal artery to the
legs and every other organ.
(11:20):
So you're bypassing.
It's sort of an internal bypass with thestent and it doesn't require opening up
the belly.
It requires just typically keyholes in the groin arteries
right under in the groin area.
So it doesn't even require anincision most times these days.
When you said one option was toremove the bulge from the fire
(11:43):
hose and then sew inanother piece of fire hose,
I thought you were just going to say toremove the bulge and then reconnect them
and sew them together, that not possible?
Or would that make the aorta too short?
The aorta is connected tolots of different organs.
Sometimes in areas in the leg artery orin the carotid artery in the
(12:05):
neck. That is possibility,but there's usually not enough extra
length of the aorta to bring themback together. That is a good question,
but just technically it's not possible.
So we need to have somethingto fill that space up,
so we have to sew a newpiece of hose in there.
Okay. I want to come back to optionsfor treatment, but to get to that,
(12:30):
I want to know if there are nosymptoms where the symptoms are absent,
how do patients usually get diagnosed?
How do they come to see you?
So most times these days it'swhen someone gets a CAT scan
for any number of reasons, abdominal pain,looking at their spine, they're trying
to figure out some other problem.
(12:51):
And this is found what we callincidentally by accident Because of
the seriousness of this. Whenthe Welcome to Medicare package,
there was a law passedthat actually allowed
screening for abdominal aorticaneurysms in anyone who meets a
select criteria, which isa large amount of people.
(13:13):
What this criteria is is in anyone who is65 years old male and has smoked more than
five packs of cigarettesin their lifetime,
males traditionally have higherrisk factor for developing
abdominal aortic aneurysmsthan women do. That being said,
(13:36):
in my practice,any woman or male who has
ever smoked and is over theage of 65,
they should be screened foran abdominal aortic aneurysm.
And usually that's done withan ultrasound, which is a
Noninvasive takes about20 minutes to perform and
(13:57):
you'd be good to go just putting anultrasound probe on your abdomen and
looking.
Is there a family history for this?
Should John Ritter's kids be screened?
Should they go and get an ultrasound?
It sounds like a pretty easy.
Step.
To take.
So if anyone has a familyhistory of aneurysms or aortic
disease,they should also be screened pretty
much 10 years prior to the diagnosis ofthe other person.
(14:23):
So we're at the very leastby the age of 50 years old,
if they've had a history of someonewho has died or had a significant
aortic problem.
Do all aneurysms need to be treated?
What's the threshold fortreatment and not treatment?
No, that's a good question. Sowhenever I see patients in the clinic,
everyone thinks that ananeurysm is a ticking time bomb,
(14:47):
and generally when they come to me,the aneurysms have been slowly
growing for years and years and years.
So they grow slowly and we normally stud.
Large studies have shown that you don'tneed to have a repair of an aneurysm
until of meet certain sizecriteria in men in an abdominal
aneurysm, in most instancesit's about 5.5 centimeters.
(15:11):
In women,it's about five centimeters
just in general because general.
So the relative risk of a five centimeteraneurysm is higher than that of a
male.
So once it's five centimeters,you're saying that's when.
That's when it should be repaired. Andthankfully, aneurysms for the most part,
grow quite slowly, onlya few millimeters a year.
(15:34):
So if someone has a threeand a half centimeter
aneurysm, it can be severalyears before a repair is needed.
And sometimes a repair is notneeded because if someone has other
illnesses,we want to make sure that we're actually
going to extend someone's life byfixing this aneurysm.
(15:55):
So if they have severe lung disease orheart disease or they have a cancer,
it may not make sense to fix an aneurysm,especially if it's probably not going to
be the thing that harms them. However,anyone with an aneurysm should be followed
very closely by a vascular surgeon.
It seems though, everytime we talk about disease,
(16:17):
that early detectionmeans better outcomes,
survival. If I had an aneurysm, Ithink I just want to get it fixed.
That's a good point.
You could just wrap that Dacronaround it and send me home.
With any surgery there is risks,and even though surgery
is very safe these days,even open or minimally
(16:37):
invasive aortic stem surgery,the risk of a rupture in most patients
if it doesn't reach a certain thresholdis still very low.
What is the process ofmonitoring an aneurysm?
How often do you have to check it,and how fast does the bulge
typically grow or worsen?
(16:58):
So typically they tend to grow abouttwo to three millimeters a
year, which is not that big.
If you look at a ruler andlook what three millimeters is,
it's really not that much larger a year.
And that's determinedpurely by ultrasound.
Purely by ultrasound,or if it's closer to needing a repair.
(17:21):
If it's in the four and a halfcentimeter, four centimeter range,
it could then be followed with a CATscan to get more precise measurements and
see also help with planning of repair.
Have you ever seen it where itwent from a non concerning size to
suddenly becoming very perilous?
I have, and that's why wefollow patients pretty closely.
(17:45):
So generally,especially if it's above four centimeters,
you want to see that patient every sixmonths to a year, depending on the size.
Generally, if a patient grows morethan half a centimeter in one year,
that's another indication torepair it regardless of the size,
because then in that patientit's growing too fast.
(18:07):
Is that a decision thatyou make for the patient?
It's always a discussion.
We give patients ouropinions on when these
aneurysms should berepaired to help prevent it.
It's one of the few prophylacticsurgeries that we do as vascular ss.
I mean, I'm trying to Is it elective?
(18:27):
Is.
It still elective at that point?
Yeah, generally it's elective untilit's causing pain or a problem,
then it's an emergency. So I alwaystell my patients I'm not God.
If I was, I would call them the daybefore they were about to rupture,
then I would tell them thatit's time to get it fixed.
Get in.
Here, because without thatknowledge, you have no idea.
(18:49):
And patient's aneurysm sizes vary.
I've had patients with sixcentimeter aneurysms rupture,
and I've had patients show up in my clinicwith 10 centimeter aneurysms who have
not ruptured and someone just found it.
So it's very difficult to predict.
There's a lot of research tryingto figure out different prognostic
(19:12):
indicators of what makes ananeurysm more likely to rupture,
and we're making some progress with it,but it's still imperfect science,
so it's pretty safe.
We don't put patients' lives at risk.
When we wait till fiveand a half centimeters,
we know that it's the likelihoodversus the risk of the
(19:35):
procedure. It really meetsthat minimum around that size.
So a patient comes to you,you do the ultrasound,
you determine they have aaneurysm, maybe it's not ready,
it's not severe enough for surgery.
What would be the first step then?
Walk me through the stages of treatment.
So the first thing is Ihad to get a full history.
(19:56):
I ask them about their family,ask them if anyone's ever died of sudden
death where they didn't really knowwhat was happening.
Because a lot of times,especially if people didn't really
get an autopsy or know why theydied, it could have been an aortic
problem. They just didn't know about it.
And after the history, we get imaging,so whether it be an ultrasound or
(20:17):
if they show up already having a CTscan, we could look at it together.
And then we talk about a plan where wetalk about a follow-up plan and also
signs and symptoms that we mentionedabout that would make you seek a
comeback earlier than ourregular scheduled intervals.
(20:38):
And that would be thingslike increasing pain,
just not feeling well. Again,it's very unlikely in someone who's
followed regularly for them to rupture,but we have to just educate the patient
just for that off chance that somethingcould happen.
How would you describe theaorta? I mean, how big is it?
So normal aorta is anywherefrom about two to two and a half
(21:01):
centimeters in diameter. It.
Seems very small then.
Yeah.
And an aneurysm that needs to be repairedis about five and a half centimeters,
so it's about double that size.
The definition of ananeurysm is any blood vessel.
That's one and a half times itsnormal. Size is an aneurysm.
It's not necessarily an aneurysmthat needs to be repaired.
(21:22):
It's just one that needs to be followedbecause it's weakened from the bulging.
So it sounds like it would be very easyfor you to see that on an ultrasound.
You wouldn't likely miss it. It's.
No.
Pretty pronounced.
If you get a screening, most people,you're able to see a pretty clearly,
but if not,there are other alternatives such as CT
scans or MRIs or different things youcould do to follow it.
(21:44):
What's the worst one you ever saw?
The worst.
The worst one.
Aneurysm?
Yeah.
The biggest aneurysm I'veever seen was 13 centimeters.
And it didn't rupture.
Well, that one was causingpain and I had to fix it.
Oh, wow. It was in a mail?
It was in a mail, yes.
See, we did a story someyears ago, many years ago,
and the patient was a very young manand he was getting a physical and they
(22:08):
heard something, can you hear something?
The cardiologist didn't think it soundedright. Sent this young man for imaging,
and that's when he found out that hehad an aneurysm that required surgery.
Yeah, you could hear whatwe call a brewery sometimes,
which is an abnormalflow with a stethoscope,
which could tell you that somethingis off with the blood vessel.
(22:30):
Generally on physical exam,it's feeling the mass,
a pulsitile mass is the giveawaythat someone has an aneurysm.
You can feel it through the skin.
You can feel it through the skin,and the people who are thin enough
and it's large enough aneurysm,you could actually, if they're
laying flat, it's pretty common,especially when I'm fixing large
aneurysms that they're lying flat inthe operating room and you could just
(22:53):
see their belly rising with every pulsefrom the aneurysm pulsating
through their skin.
I think it sounds like a hernia.
Could it be mistaken for a hernia.
Except with the pulseis what gives it away.
So a pulsitile mass anywhere in your body,you got to be concerned of an aneurysm.
(23:16):
Are there medications?
Oh yeah.
So medical management is very importantfor a treatment of aortic aneurysms to
try to prevent rapid growth rates,and those include blood pressure
control being on a statin,which is a very common medication
that a lot of our listeners may be onthat helps prevent growth
of aneurysms. Also,just decreasing everyone's stress level.
(23:43):
Quit smoking.
Quit smoking.
Smoking is definitely a bigrisk factor for aneurysm growth,
and it definitely increases the rateof growth. So even quitting smoking,
even though you have an aneurysmpotentially from smoking,
quitting smoking could reduce your riskof that aneurysm growing at a rapid
rate.
Okay. Medical treatment monitoring,lifestyle changes, endovascular repair,
(24:06):
EVAR. Tell me about that.
So the minimally invasive approachwith the stent for the abdominal aortic
aneurysm,we use the acronym EVAR for
endovascular aortic aneurysmrepair.
That's normally where weslide a tube or stent into the
abdominal aorta and rightbelow the kidney arteries,
(24:28):
we land our stent and wego into the iliac arteries,
which are the arteriesunderneath the belly button,
which split and go to the legs.
So this is thrown incision in the belly?
No, this goes just througha small pinhole needle hole.
Needle stick in the groinarteries, the femoral.
Artery, the femoral. Oh, okay.
(24:49):
Can.
You do it through the radial.
That we cannot do throughthe radial at this time? No.
The stents are too large to travelthrough there. When they go in,
when they're not deployed,they're about the size of a thin
marker is about the size of astent that is non-deployed, and
then when you deploy the stent,it opens up to be about
(25:16):
two and a half to three and ahalf centimeters in diameter.
It's on the inside of the artery.
It's on the inside of the artery, sorelining the inside of the artery,
redirecting the blood flow.
So that technologystarted around the early
nineties, but even since then,we've even become more advanced.
(25:37):
So the problem is just putting astent across an artery. That's fine.
If there are not that many importantbranches coming off that artery and in the
abdominal aorta belowyour kidney arteries,
there's not that many importantblood vessels coming off of it,
so you could block those vessels offand not really having too many problems.
The problem occurs when you havesignificant important blood vessels
(26:00):
coming off the aorta. So bloodvessels like the kidney arteries,
intestinal artery, the arterygoing into your liver and stomach,
those are very important. If youblock any of those arteries off,
you could have a significant problemwith your health and even your life for
those reasons.
There's been more advanced developmentof minimally invasive techniques.
(26:21):
Previously you'd have to do big opensurgeries where we make a really long
incision from your shoulder, shoulderblade to below your belly button.
Oh my.
Open you up, go through yourribs, go through your diaphragm.
It sounds medieval.
And we still do it sometimesin certain patients,
but it does have an increased risk ofcomplications the bigger the surgery
(26:42):
is.
Infection. Sure.
Yeah. Infection wound complications.
Just being able to do it,especially as patients get older and as
generally older patients who have theseaneurysms,
it definitely becomes more of a problemdoing these bigger operations on them.
For that reason, thesestents have been a lifesaver.
(27:02):
We've really been able to extend thisoperation to patients who we never
would've thought of previously.
When I was in training 20,30 years ago,
I remember calling up patients intheir eighties who've had an aneurysm,
which was involving some of thesemajor blood vessels and telling them,
we can't really tolerate an open surgery,so there's really nothing
(27:23):
we could do for you.
That was a very common thing that occurredunfortunately for patients because
aneurysms grew as they grew older.
That had to be a horrible part of the job.
Yeah, it was unfortunate,but we were doing what was in the best
interest of the patient because theopen surgery in patients in their
eighties is very hard for them totolerate in some instances. So
(27:45):
with minimally invasive techniques,we're able to treat aneurysms
that we weren't able to before,including aneurysms that include
the major arteries of the body,like the kidney arteries, the intestinal
arteries, and the liver artery,including the arteries that go near,
(28:06):
go to your brain,even into your arms in the chest with
these minimally invasive techniques.
So some of the advances have been whatwe call fenestrated technology where
there are holes that arecustom made for the patient's
individual anatomy to cover them and putstents in them so they're getting blood
(28:27):
flow even though the aneurysmis covered with a stent.
And there's also a branch technologybranched endovascular repair
where we actually have a tube withbranches that come off of it where
we're able to put stents in toall the different blood vessels.
Both of those operations.
We do quite a few of at MedStarhospitals throughout the region.
(28:52):
The case that you said was the biggestaneurysm that you did that you said it
was what, 15.
13 Or 15 centimeters? Yeah.
13 Centimeters.
Yeah.
How did you treat that? One.
That was minimallyinvasively with a stent.
And the patient recovered well.
Patient did well.
If a patient has an aneurysm like that,is it likely that they're
going to develop another one?
They can. That's whyif someone is repaired,
(29:15):
especially with a minimally invasiveaneurysm, is very, very, very important.
And I always really drive this homewith point home with our patients that
they need to be followed for the restof their life because with the stent,
although it's very secure, we'renot curing aneurysm disease,
we're treating a specific aneurysm.
(29:36):
Whatever factors led them to developthis aneurysm could develop weakening in
another portion of their aorta,and if that happens, the seal,
which is basically just the force of thestent against the artery could become
compromised and then they arenot a fully repaired aneurysm
if they develop a leak potentially.
(29:58):
I was going to ask how doesit not move inside the vessel?
It is basically there'ssome hooks, internal hooks,
and also radial force are the main waysthat these stents stay in the blood
vessel, which is different thanwhen we do open surgical repair.
We're actually using suture tosew the graft to the patient's
(30:18):
aorta.
How do you discern who should getthe endovascular repair versus
surgery?
Like I mentioned before,it's always a joint decision.
A lot of times youngerpatients may be better
served by an open surgerybecause although there are higher
(30:39):
risks associated with it when comparedto the minimally invasive surgery,
it's also better toleratedbecause they're relatively
younger and also it could bemore durable in the long-term.
So long-term being potentiallydecades if they're in their fifties
now with minimally invasive approaches,typically they have a higher
(31:01):
rate of reintervention,meaning that you might need another
procedure to keep your aneurysmrepaired in the future,
but that could be several years downthe road and most likely in the future,
that will also be anotherminimally invasive procedure,
not a big open procedure. So itdepends on the patient's anatomy,
(31:25):
where exactly their aneurysmis and also their other health
problems when deciding.
So it's always a veryindividualized approach.
That being said, the vastmajority of patients generally
desire the minimally invasive procedurewhen they're given all options and
(31:46):
when they ask my opinion ofwhat would be best for them,
especially because it's in most commonlyin patients in their seventies and
eighties.
So once you come to the decision withyour patient that surgery is needed,
what happens next?
Based on the size of theaneurysm patient's symptoms?
If it is elective,meaning that they aren't
having any symptoms,we want to make sure that they're
(32:09):
able to tolerate the surgery well.
So I will contact theirprimary care doctor and their
cardiologist.
They have one to make sure theirheart could tolerate the procedure.
They may need some diagnostic testing toverify that they don't need anything to
optimize them for the surgery.
Are there surgical options.
(32:30):
Following their medical clearanceonce they're scheduled for surgery?
Typically,a hospital stay for a straightforward
abdominal aortic aneurysmusing a stent is only overnight,
so they go home the next day.
A lot of times the patients have no pain.
They don't even need pain medicationsjust because it's a very small
(32:53):
needle hole incision that maybe hasone stitch, and that's about it.
So the more complicated operationsthat usually incorporate
blood vessels in the kidneyarteries, the intestinal arteries,
and the liver artery,they typically may stay a few more days
just to make sure that everything isokay. As I mentioned before, if
someone requires open surgery,they likely will be in the
(33:16):
hospital for about a week.
It'll still take time toheal after they get home,
and they probably won't be feeling backto their full normal self for about
three to six months.
What do you call the surgery to repairan aortic aneurysm or a dissection?
Are they different surgeries?
So for aortic dissection, if someonecomes in with tearing chest pain,
(33:40):
tearing back pain, havevery high blood pressure,
typically the way we repairthat is we seal the tear.
So depending on where the tearis, if it's by right by the heart,
for the most part these days,cardiac surgeons would have to open up
the chest and replace that portion of theaorta. If it is not in that area,
(34:01):
if there's an area furtheralong the pathway of the aorta,
we are able to fix it with a stentwhere we're able to tack the tear
along the wall and preventblood flow from going in the
wall of the aorta. The acronymwe use for, that's called tbar,
which is thoracicendovascular aortic repair.
(34:24):
That's just a larger stentin the aorta in the chest,
which is called the thoracicaorta. There is, again,
lots of advances in this field,and we are treating more and more
aortic problems closer to theheart with stents.
So my guess in the next 10 or 15 years,a lot of these therapies that
(34:45):
were previously required openheart surgery potentially
could be repaired with a stent.
It looked like there wasa lot of excitement online
about this approach called tbi.
Yes. So the gore.
Tell me about that. So.
The GORE TBI is a newcommercially available device,
(35:08):
which was recently becameFDA approved this last
year, and we are one of the fewinstitutions in the region that are
performing that repair.
That repair requires patients withmore complicated aneurysms that extend
from chest into the abdomenand cross that delicate area
(35:30):
where the kidney arteries and theintestinal arteries come off of.
We're able to use branch stents tomaintain blood flow to those vital
organs while repairingthe aneurysm. Typically,
we use an approach where westill don't make any incisions,
but just may go through needle holesin the upper arm on the left side
(35:51):
and both groins.
So it's a remarkable new technologythat enabled us to treat a lot more
patients, includingpatients in their eighties.
And I assume they're undergeneral sedation for that?
Yeah,typically it's under general
anesthesia for those just because we ofthe careful imaging required to
make sure we're in those vitalorgans.
(36:15):
How long are you usually in the labwith a case like a Tam ABI case?
Yeah, so with those TAM ABI cases,we're pretty expert at those,
but it's a very complicated case.
So it still takes about three hours,three to four hours, I'd say,
which is very good for thattype of complicated repair.
And the patient can gohome maybe a day later.
(36:35):
Generally, for those patients,they're in the hospital for two nights
just to make sure that everything'sworking okay.
Do your patients feel differentlyafter they've had an aneurysm repaired?
That's one of the hardthings about an aneurysm,
especially if it's electiveand they found it by accident.
I'm repairing somethingthat doesn't make them feel.
(36:55):
Badly that they didn't know they had.
So no matter how minor the repair is,they're likely going to feel a little
bit worse than they did just because theyhad surgery.
Understood.
That being said,that's why it's very important to
follow up with your primary care doctor,get the abdominal aortic surveillance,
especially if you're having riskfactors such as smoking, family history,
(37:19):
and make sure that you keep on followingwith your vascular surgeon even after
you have it repaired, because it is very,very important just to make sure
that this stays not causing symptoms.
We want having an aneurysmto be as boring as possible.
Right? Absolutely.
The aortic aneurysm isn't usually aheadline condition, but it should be.
(37:41):
Awareness and screening can changethat. If you or a loved one is at risk,
talk to your doctor. Thatconversation could save a life.
If you're in the Baltimore area and wouldlike to make an appointment with Dr.
Vallabhaneni,call 4 1 0 5 5 4 2 9 5 0.
If you would like to provide feedback onthis podcast or get more information on
(38:05):
aortic aneurysms,send me an email schindler@medstar.net.
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