In Health: Battling A Bulge
Albert Einstein …Laura Branigan …John Ritter ….
Drs. Matthew Namanny and Layla Lucas
What do a renowned physicist, a pop singer, and a comedic actor have in common? Each of them died from a rupture or dissection as the result of an aneurysm, a condition that most Americans know very little about — especially their individual risk factors.
By Marguerite Happe | Photography by James Patrick
Annually, about 13,000 people in the U.S. die from aortic aneurysms alone. That doesn’t take into account all those who are killed by aneurysms in the brain, intestine, spleen and other areas.
As grim as the statistics are, there is cause for optimism. In the past few decades, the medical community has made significant advances in treatments that can help to prevent aneurysms from rupturing or tearing loose and causing critical injuries or death.
We interviewed several local experts to discover what Tucsonans should know about this major medical condition, from prevention to diagnosis to treatment.
What Is an Abdominal Aortic Aneurysm?
Vascular surgeons agree that the majority of their patients with aneurysms have abdominal aortic ones. “We also see aneurysms of the thoracic aorta and in the extremities, such as the femoral or popliteal arteries,” says Layla Lucas, M.D., of Arizona Vascular Specialists. An aneurysm occurs when the arterial wall becomes weak and damaged. Then, the tension causes the wall of the vessel to bulge more than 1.5 times its normal diameter. For desert dwellers, Scott Berman, M.D., of Carondelet Medical Group Vascular Surgery, explains the intricacies of abdominal aortic aneurysms in easily understandable terms. “Everybody who lives in the desert knows that if you leave a garden hose out in the sun, it will develop a weakness, and it will blister. The blister will expand under pressure in the sun until it pops. That’s essentially what an aortic aneurysm is — an area in the aorta that weakens and expands until it might potentially rupture.”
Abdominal aortic aneurysms occur between the renal (kidney) arteries and the portion of the aorta that divides to carry blood to the legs. The number of these cases appears to be growing. “As the baby boomer population becomes older, we’re seeing more abdominal aortic aneurysms,” notes Eric Berens, M.D., F.A.C.S., of Arizona Endovascular Center. However, when it comes to cause, the answer is elusive.
There is no specific predictor that indicates who will and won’t develop an aneurysm. However, physicians have become more aware of risk factors that indicate the likelihood of one developing, says Dr. Berens: “Smoking is the highest contributor: It’s a habit that we strongly encourage our patients to quit.” Genetics also are a factor, and Dr. Berman notes that aneurysms can develop for unknown reasons. Lifestyle is the most significant correlative, but not the only one. “High blood pressure is a risk factor, and a sedentary lifestyle contributes to the entire spectrum of atherosclerosis. Having high blood pressure, being overweight, being diabetic, and/or smoking can all contribute.” Dr. Lucas notes the possibility of connective tissue disorders, infections, trauma, and other factors that might also play a role, and the limited ability of the patient to actually prevent an aneurysm from developing. “Avoiding tobacco and controlling high blood pressure and high cholesterol are the best things someone can do to prevent an aneurysm,” she notes.
What Happens When You’re Diagnosed? Screenings for aneurysms are more popular than ever before, but not all screenings are covered under Medicare. In fact, Dr. Berman notes that most people pay for screenings out of their own pocket. Many aneurysms are discovered when a patient undergoes a CAT scan for abdominal or back pain, and the doctors discover an aneurysm instead. “Screening in the general population is not very successful in finding many aneurysms,” says Dr. Berens. “The truth is that finding an aneurysm randomly by ultrasound is rare, which is why Medicare puts in specific category restrictions.”
Today, Medicare covers one screening exam in males between the age of 65 and 75 who have a significant history of cigarette use. It also covers the screening of patients who have a family history of abdominal aneurysms. Dr. Lucas notes that, “Most people don’t know that abdominal aortic aneurysms can be hereditary, especially in men. If someone in your family has an abdominal aortic aneurysm, everyone else in the family should be screened with a simple Doppler ultrasound.”
If an aneurysm is found during the screening, the doctor will first evaluate it in terms of size and treat accordingly. “Most aneurysms have a size threshold that triggers the surgeon to treat it,” says Dr. Lucas. “If an aneurysm is below that threshold and is not causing symptoms, it usually can be kept under close surveillance. If the aneurysm reaches a certain size threshold or is symptomatic, it can be treated.” And although smaller aneurysms do indeed rupture, if the risk of surgery exceeds the risk of rupture, doctors will recommend leaving the aneurysm in place sans treatment. According to Dr. Berman, this diagnosis may cause its own psychological anxiety. “The most common thing that patients worry about when they find out that they have an aneurysm is their risk. When you have patients who have an aneurysm and it’s not big enough to fix, some of them feel as if they have a time bomb sitting in their bodies. We occasionally see what I have termed ‘aneurysm dysfunction,’ when patients become so obsessed with worrying about an aneurysm that they can’t function.”
A New and Improved Treatment
If the swelling passes the size threshold for surgery, there are two treatment options. “When I was training in the 1980s, we did a procedure through a major abdominal incision, three to four hours with the help of one to two other surgeons and required 10 days in the hospital,” explains Dr. Berens. “Fast-forward to the present day — we can perform a painless endovascular (inside the vessel) procedure to place a covered stent or stent graft, which acts as an inner tube that lines the artery and prevents rupture. Rather than open the patient’s abdomen, we enter the body through an artery in the groin using a catheter,” he explains. From hours of surgery to a painless outpatient procedure under local anesthetic, the ability of the medical community to prevent aneurysms from rupture has spectacularly shifted.
When treated with a stent graft, the less-invasive method comes with an accompanying caveat — more extensive follow-up is required. Doctors will check the graft at one month, six months, a year, then annually to make sure it is functioning normally.
As with many procedures, no treatment is one-size-fits-all. “One of the things we’ve always believed in is being able to tailor treatment to what’s most appropriate for that patient’s specific clinical scenario,” says Dr. Berman. “We think we offer a better service by looking at a patient and deciding if his treatment should be a stent, which is the less-invasive way, or if his body composition is better suited to the more invasive procedure.”
Cerebral aneurysms, which involve the blood vessels of the brain, have many distinctive features and are treated by a different group of specialists, namely neurosurgeons and interventional neuroradiologists.
“Unruptured brain aneurysms usually are clinically silent, which means that they frequently do not cause symptoms unless they rupture,” explains David Jeck, M.D., Interventional Neuroradiologist with Radiology Ltd. “At Radiology Ltd., we have three physicians who specialize in the endovascular treatment of brain aneurysms: myself, Dr. Creed Rucker, and Dr. Andrew Gyorke. We are senior members of the Society for Neurointerventional Surgery with many years of experience in the endovascular treatment of brain aneurysms. Collectively, we have treated more than 1,000.”
The risk of a brain aneurysm rupturing is influenced by factors such as its size and location. Risk factors for likely candidates of a brain aneurysm may vary from those in the rest of the body. Women are much more likely to experience a brain aneurysm and, as Dr. Jeck explains, “The vast majority of [them] are seen in adults.” However, lifestyle choices that contribute to the likelihood of developing a brain aneurysm remain similar — smoking, high blood pressure and certain genetic conditions all make the list.
After a patient is diagnosed with an unruptured brain aneurysm, additional tests often are necessary to determine the best treatment. If treatment is recommended, there are two options, similar to bodily aortic aneurysms: open surgery and endovascular treatment. “Endovascular treatment of brain aneurysms involves advancing catheters under X-ray through the blood vessels into the brain to treat the aneurysm in a minimally invasive manner,” Dr. Jeck says. “In traditional open surgery, a neurosurgeon performs a craniotomy, where a piece of skull is removed and a clip is then placed across the aneurysm neck (the area where the aneurysm attaches to the blood vessel). At Radiology Ltd., we work very closely with many excellent neurosurgeons in the Tucson community to determine the best treatment option for each patient.”
In the event an aneurysm ruptures, though, it may be fatal. A ruptured aneurysm releases blood into the spaces around the brain, called a subarachnoid hemorrhage, a life-threatening type of stroke. “Patients who survive the initial rupture and present to the hospital are frequently critically ill,” Dr. Jeck states. These aneurysms are unstable, so the doctor must treat the aneurysm aggressively to prevent it from rupturing again. According to the Brain Aneurysm Foundation, “Ruptured brain aneurysms are fatal in about 40 percent of cases. Of those who survive, about 66 percent suffer some permanent neurological deficit. Approximately 15 percent of patients with aneurysmal subarachnoid hemorrhage (SAH) die before reaching the hospital.” TL