M. David Tilson, MD
Professor of Surgery
Columbia University
New York City
I-way: [email protected]
ANEURYSM FAQ'S
An aneurysm is a dilation of a blood vessel (similar to a balloon) that poses a risk to health from the potential for rupture, clotting, or dissecting. Rupture of an aneurysm in the brain causes stroke, and rupture of an aneurysm in the abdomen causes shock. The abdominal aortic aneurysm (AAA) is the most common, and the rest of this discussion will focus on the AAA.
2. What causes aneurysms?
Several new theories have developed over the last 15 years. It appears that the disease probably requires a basic genetic susceptibility that may be traceable to a single major locus, probably an autosomal dominant gene. The disease unequivocally runs in families. In addition, there are probably other contributing causes, such as smoking and high blood pressure.
3. Who is at greatest risk?
White men over age 55 are at the greatest risk. In fact, aneurysms are among the top ten causes of death among this group. By about age 80, over 5% of white males will have developed an aneurysm. AAA's occur less frequently in white women, and they are relatively uncommon in African Americans of both sexes.
4. Why are aneurysms so dangerous?
AAA's cause many deaths because they are usually silent until a medical emergency occurs. One author has referred to an AAA as a "U-boat" in the belly, because they are silent, deep, and deadly.
5. How can I find out if I have one?
If you are thin and have a moderately large-sized AAA, you or your doctor may be able to feel it below your rib cage. Many are incidentally discovered as a result of medical imaging for other conditions, by ultrasound exams, CAT scans, MRI's, or even plain Xrays of the abdomen. If you are over 55 and other members of your family have had one or more AAA's, you should advise your doctor and have an ultrasound. It is safe, fast and painless.
6. If I have an aneurysm, what is the risk of death from
rupture?
If rupture occurs, few survive. Among celebrities, Roy Rogers survived a rupture, but he was the exception and not the rule. Albert Einstein, Lucille Ball, and Conway Twitty were not so fortunate. The best predictor of risk of rupture is the size of the aneurysm. The diameter of a normal aorta is about 2 centimeters (a little less than an inch). Once a AAA has reached 5-6 centimeters in diameter, about the size of an orange, the risk of rupture is very substantial, probably about 50/50 over the next few years. Most vascular surgeons would agree that a 5-6 cm aneurysm should be repaired, unless other medical factors in a patient make the operation too risky. There is less unanimity of opinion about smaller AAA's, since the risk of rupture is much lower. Some surgeons are now recommending repair of aneurysms over 3 centimeters, but others would advise watchful waiting for AAA's that small. There is presently a controlled, randomized, multi-center trial being carried out in the Veterans Administration Hospitals to try to answer the question as to when the size of the aneurysm indicates that the surgical risk for the patient has become less than the risk from rupture.
7. What is "watchful waiting?"
Most vascular surgeons feel comfortable following patients with small AAA's every six months with an ultrasound examination. The average rate of growth of an aneurysm is less than one-half of a centimeter per year, and some grow much slower, remaining relatively stable for fairly long periods of time. Others may enlarge rapidly, and a "growth spurt" is a serious warning sign.
8. Is there anything one can do while "waiting"?
Giving up tobacco, making sure of reasonable blood pressure control, and improving physical fitness with a mild exercise program are all prudent. So far, no medication has been proven in a prospective scientific experiment to reduce the growth rate of AAA's in people, although propranolol (a beta-blocker) has been shown to reduce the incidence of ruptured aneurysms in turkeys and to delay the growth of aneurysms in mice. Retrospective studies at Yale and at the University of Vermont have suggested thatp ropranolol might be beneficial in people, but proof will await a prospective trial. Such a trial is now being planned by surgeons at the University of Vermont.
9. What are the risks of surgical repair?
The risk of death from surgery is related to hospital expertise and experience, the skill of the surgeon, and the basic underlying health of the patient. Mortality rates are frequently reported to be as low as 0 to 2% in academic medical centers with vascular specialists and superior intensive care. Rates may be higher in small community hospitals without dedicated vascular specialists. Patients without any history or signs of heart disease generally do very well, because heart attack postoperatively is the leading cause of surgical mortality. Patients with known coronary artery disease should have a thorough cardiological evaluation prior to surgery.
10. How long does it take to recover, and what is the likelihood of returning to a normal life?
The average hospital stay is 7-10 days, and most patients take about 6 weeks off before returning to work. By that time, they have usually regained their sense of well being, although some bounce back much faster. The vast majority of patients are back on a normal survival curve for life expectancy, consistent with their cohort of persons of similar age and with similar underlying health (e.g., heart condition, renal function, etc.). One unfortunate complication, about which male patients should be forewarned, is the possibility of sexual dysfunction. If this occurs, it usually takes the form of "retrograde ejaculation", not impotence. For more information, please consult with your doctor.
11. I've heard of "minimally invasive surgery". Does this work for AAA?
There has been recent progress toward this goal. An "endovascular" repair (e.g., using tubes, stents, and wires threaded up into the aneurysm from leg arteries) was developed by a surgeon in Argentina and is presently coming into use in the United States. This procedure is presently considered to be in its developmental stages, and it is offered only in selected centers.
[Addendum to this FAQ, April 30, 1995: Dr. Juan Perodi has just published an account of the first 50 of these aneurysm procedures, reviewed by mdt in the April Papers of the Month section in the Aneurysm Information Project Home Page.]
12. What can I do to join others to fight aneurysm disease.
The American Aneurysm Foundation is dedicated to increasing public and physician awareness of the importance of early detection. This non-profit charity also promotes research aimed at developing better methods for early detection and treatment. It is possible that methods may be discovered in due course for preventing the disease in susceptible people. You may send a tax deductable contribution, or request additional information from:
Mary Lapham, President
American Aneurysm Foundation
PO Box 1051
Solana Beach, CA 92075
Fax: 619-774-5811
Checks should be made payable to the American Aneurysm Foundation.
