This is the Ascension “Vital Signs” (peer) podcast. We welcome Dr. Atif Baqai, Division Chief of Vascular Surgery at Ascension Illinois, Chair of the Ascension Vascular Medicine Subcommittee and Associate Professor of Surgery at the University of Illinois, Chicago – here to discuss abdominal aortic aneurysms, a condition that can be difficult to diagnose, repair, and may be life threatening. Dr. Andrew Wilner discusses aortic aneurysms with Dr. Atif Baqai.

Host: Dr. Baqai, to begin, could you give me a quick definition of abdominal aortic aneurysm and how common a problem it is?

Dr. Baqai: So, abdominal aortic aneurysm, is a dilation of the abdominal aorta that's more than 50% compared to the expected normal diameter. An aneurysm by definition can occur in any artery in the body. But the abdominal aortic aneurysm is one of the most common aneurysms and life-threatening conditions.

Host: So, I guess the question is who gets these and is there any way to prevent them?

Dr. Baqai: Right. So, that's a great question. There's many risk factors that are associated with abdominal aortic aneurysms, age, gender, smoking. Smoking is probably the biggest modifiable risk factor. And smoking is in itself associated with a five times higher association with aneurysms. There's other risk factors involved including race. This tends to be more common in Caucasian population, positive family history, if they have high blood pressure, high cholesterol, coronary artery disease, and other peripheral vascular disease.

Host: Well, you're a vascular surgeon, and I know that your job is to fix these, but patients probably don't just find you when they have one. It must be up to somebody else to find these aneurysms and send them to you. Is that right?

Dr. Baqai: Yeah, that's exactly right. So, a big portion of changing the paradigm for aneurysms is appropriate screening. And that's really the most important thing that we can do for patients that have risk factors, which would be susceptible for them developing an aneurysm. So, therefore this, this is up to the primary care physicians who are seeing patients, this is up to other providers to find them and appropriately screen them. Because unfortunately, many times the first time that the patient finds out that they have an aneurysm is when they are symptomatic or it has ruptured.

Host: Now, primary care physicians are I guess pretty busy with all the routine screenings they have to do, for prostate and breast cancer. And, I don't know, there's all these mandated screenings and. How do they figure out who are the ones they should screen? And then what should they actually do?

Dr. Baqai: So Medicare has some clear guidelines in terms of the patients that should be appropriately screened. So, Medicare says that anybody that has a positive family history or any male over the age of 65 who has ever smoked a hundred cigarettes in their lifetime, gets a free ultrasound screening for an abdominal aortic aneurysm. So, we can start with that, and make sure that when we find people that have a family member, a relative or someone that has had an abdominal aortic aneurysm a known abdominal aortic aneurysm, they should be screened. And any male over the age of 65 who's ever smoked a hundred cigarettes in their lifetime, which is not very much, they should be screened with an abdominal ultrasound. And ultrasound is a very noninvasive test. Doesn't involve them getting any radiation. And it's a very quick tool to being able to diagnose this condition.

Host: Wow. Well, I think it's important to emphasize that adult male 65 and older who've smoked a hundred cigarettes or more. I think that describes about 99% of my patients at the VA.

Dr. Baqai: That's, that's exactly right.

Host: I mean, there should be sort of admit the patient, get a CBC and chemistry test and an abdominal aortic aneurysm screening.

Dr. Baqai: Right. And, you know, this is one of those conditions that is treatable. And, when it comes to the mortality associated with abdominal aortic aneurysms, this is probably one of the single most diseases that we can really change the mortality of these patients, if they're appropriately screened and diagnosed early.

Host: Now you mentioned smoking as a modifiable risk factor. is it about cigarettes? Even a hundred cigarettes that's gonna damage your aorta? I think. Do we know that?

Dr. Baqai: Yeah. So, it's funny you ask that because many of my patients bring up the same question and are surprised when I tell them that their smoking is associated with the development of their aneurysm. When patients smoke or when people smoke, it damages the lining of the arteries within the body. And when that lining is damaged and the artery is pulsating, it's like weakening your dry wall, and when you're trying to put up a house and you keep pushing on it, over time, will just start bowing out. And that's essentially what happens is that you weaken the lining of the artery and with your blood pressure, especially if it's not controlled, this causes the weakened artery to then start bowing out and becoming aneurysmal. And the more it bows out, the thinner, the lining of the artery gets, and the more prone it is to rupturing.

Host: Right. So the bigger it gets, the bigger it gets, right? Because it's less able to contain itself.

Dr. Baqai: Correct.

Host: You mentioned earlier, symptoms. What are the symptoms and how often do patients have them?

Dr. Baqai: So, unfortunately, the time that patients develop symptoms is a sign that they could have already ruptured or be a sign of impending rupture, but many of the symptoms that patients can develop, the common things are back pain, severe back pain. They can have chest pain, they can have pain in their groin, pain in their buttocks. And so any severe pain, that's unrelenting and if the patient has a known abdominal aortic aneurysm, and they have these symptoms, it can be a very dangerous sign that they are about to rupture, or they already have ruptured.

Host: So, let's suppose we identify an aneurysm in a patient. And, I know you have an example of a patient who had a very large aneurysm. Can you tell us about that and what you did about it?

Dr. Baqai: So, we had a very rare, but very interesting case of a patient that presented to the hospital with severe bilateral lower extremity leg swelling, and that was the presenting symptom. And it was pretty sudden in onset and you don't usually associate a leg swelling with a sign of an abdominal aortic aneurysm. But he had severe leg swelling and on his laboratory work, he was in renal failure and he had never had any diagnosis of renal failure in the past.

So, the primary care physician who had admitted the patient, given that the patient had leg swelling and was having renal failure, had ordered a ultrasound of his kidneys to look and evaluate the renal failure the patient had. And on that ultrasound, it was picked up that the patient had a 14 centimeter, abdominal aortic aneurysm. And that's how it was found, which was obviously a very nerve wracking experience because when you get that phone call that somebody has a 14 centimeter aneurysm, your first thought is well, is he ruptured? But interestingly, in his situation, he had a contained rupture, but he had a contained rupture into the vena cava where he had formed a connection, an abnormal connection between the aorta and the vena cava. And that's what was causing the severe leg swelling and renal failure that he was exhibiting.

Host: But it was also kind of a pressure valve that let some of the blood leak out into the vena cava so that the artery didn't keep expanding. Is that what prevented the rupture you think?

Dr. Baqai: Yep. Exactly. So it was a, essentially it had found a place where it can somewhat decompress and not rupture into the retroperitonium, which is where the aorta lies. And those are the ones that are usually lethal. However, a connection between the aorta and vena cava is very, very lethal because your veins aren't used to having the same pressure as your arteries. And when you have such high pressures in your veins, it causes people to go into rapid renal failure and heart failure, which is what was happening in this patient. The patient was starting to deteriorate pretty rapidly, and ended up needing to be started on dialysis right away to try to help decrease the amount of volume overload, which he was exhibiting, just so we can get him optimized somewhat and take him to surgery.

Host: Now you mentioned that the aneurysm was 14 centimeters. How big should the aorta be in diameter? And, when is it problematic?

Dr. Baqai: So, the abdominal aorta is obviously different in males and females, but, it can vary anywhere from being 10 millimeters to up to 24 millimeters. That's kind of the normal diameter. So, that's 2.4 centimeters. So, in this situation, the aorta was seven times the normal size of a normal aorta, which is very large.

Host: When you are presented with a patient with an aneurysm; I'm in my office, I have a 70 year old guy who smokes and has hypertension and diabetes, and I examined him and I don't know, maybe there's something there. Maybe not. I can't really tell if there's a pulsating mass or, he's kind of big. So, it's hard to tell. I do the ultrasound and there's a five centimeter aneurysm. So, I make an urgent appointment to see you. So, it's not six months from now. So, he sees you in a couple of days. What do you tell him?

Dr. Baqai: So, the anatomy is very important in these patients. And what I tell them that number one, they're really lucky that they got to their primary care provider, found this aneurysm before it became problematic. So, that's very encouraging, but this is something that's very treatable. You know, this is something that people can have treated and then go on and live a normal life. But the anatomy is very important and depending on their anatomy, we can decide whether they would be a candidate for a minimally invasive repair, an endovascular repair, where we put stents in from inside the artery to help exclude the aneurysm, or if they can undergo an open aneurysm repair, which entails us resecting that portion of the artery, which is aneurysmal and replacing it with a graft, and sewing a graft in. So, depending on their anatomy, we have options. As a vascular surgeon, I can present them with both options and give them the risks and benefits from each one, whether we do the endovascular or the open, and then allow the patients to decide on which avenue they want to take.

Host: Well, I guess if I was the patient, I'd kind of lean towards the endovascular approach.

Dr. Baqai: Yeah. Well, you know, there's pros and cons to each. And one of the things that patients don't understand when it comes to the endovascular approach, is that when people have endovascular treatments, they have to be followed lifelong for surveillance, and they have to get repeat imaging, whether it's a CAT scan or an ultrasound, they have to get repetitive imaging lifelong to make sure that they don't have any leaking around the stent graph. And so there is about 10 to 15% of people that end up requiring additional procedures after an endovascular repair. And many times patients, when they hear that will opt to wanting to just get the open repair. Because when we repair it open, you don't require that subsequent imaging surveillance. And so, each one you have to kind of look at the patient, you have to look to see what risk factors they have, how sick are they at baseline. But for a patient that's in their fifties that has a six centimeter abdominal aortic aneurysm, many times people will opt for the open approach because they just don't want to have to deal with it anymore.

Host: That's interesting. Have there been any changes in the techniques that you use in the last 30 years in terms of, since I was in med school, in how you fix these things, or you just chop it out and put a little Dacron tube there and sew it up and that's it?

Dr. Baqai: No, that's exactly how we do it. And so, in terms of the open approach, it's pretty much done exactly in the manner you just described. It requires just resecting the diseased portion of the aorta and replacing it with a Dacron graft. There's a couple ways in which you can do that. You can go through the abdomen, like from an anterior approach. And then there's another way that it's done where we do it through a retroperitoneal approach and that's more through a flank incision. And those are the two approaches that we'd use for the open approach. Now, on the endovascular, yes, there has been a lot of changes that have occurred.

The grafts have gone through some different configurations and there's multiple grafts on the market. And depending on the patient's anatomy, you kind of decide which one would be best suited for the repair. We now have grafts that we can actually make holes in and, either they come pre-made with holes in them, or we make holes in them to account for the branches of the abdominal aorta. So, the endovascular has certainly significantly evolved over the last 30 years, but I can tell you that the open one, it's pretty standard and it's standard because there's really not many changes that have occurred to it.

Host: As a medical student, I remember during my surgical sub internship, rushing a patient to the operating room from the ER who had a ruptured abdominal aortic aneurysm. And when I read up on it, the mortality of that scenario, I think was at least 50%. Now what about in an elective situation like we described, patient sees you in the office and I guess you do an angiogram so you can see all the little branches and everything.

Dr. Baqai: Yeah. So, our imaging technology has gotten a lot better. So, we have very sophisticated CT scans, which will give us all the information that we need. And so typically would they'll get a CT angio of their abdominal aorta, which lets us size the aorta and identify exactly where all the branches are located. But you're right, this is a very bad problem, when they become symptomatic. In fact, the statistics will show that 50% of people die before they even make it to the hospital. And then of the 50% that make it to the hospital only about 50% survive. And those numbers, even with the advances that we've made in the endovascular approach and whatnot has stayed pretty consistent, in terms of the mortality associated with it. Now in an elective situation, certainly those numbers are far less. And there's probably about a 5% mortality associated with an elective repair versus you're looking at probably anywhere from 60 to 75% mortality with a rupture.

Host: So, let's say my primary care doctor tells me I've got a five centimeter aneurysm, should I just go to the local hospital? I mean, how important is it that I go to some place that has experienced percutaneous endovascular aneurysm repair team, and a few surgeons on staff that have been doing this for a while, or is this something really anybody can do?

Dr. Baqai: So, that's a million dollar question right there. And in fact, the Society of Vascular Surgery has, recognized this as well. And has put out guidelines in terms of the centers that should be doing these repairs, whether it's endovascular or open. And, certainly it is well-known that centers that do both the percutaneous and open repairs in significant amounts are associated with much better outcomes than places that don't do this very often.

Now, certainly if this is an emergency situation, you don't have that choice because time is of essence, right? It's like having a heart attack. The quicker you get treatment, the better the situation in terms of survival. But in an elective situation, really the centers that should be doing this are the ones that are, are doing at least 20 repairs a year, whether it's percutaneous or open, and therefore considered what we call Aortic Centers.

Host: How many repairs do you do?

Dr. Baqai: Over the time I've been at this institution, have done a number of these, both percutaneous and open, and certainly, in terms of having adequate numbers, we do more than what's considered adequate to be an Aortic Center, both in the endovascular, as well as the open.

So, we are certainly a center for treating this condition, whether it's abdominal aortic aneurysm, whether it's thoracic aneurysm, whether they're lower extremity aneurysms; as vascular surgeons, we deal with aneurysms all over the body. And so certainly any aneurysm we are capable of treating.

Host: Well, that's great to know that this resource is available. Dr. Baqai, I'd like to thank you very much for this interesting and helpful discussion.

Dr. Baqai: Thank you. It's been my pleasure. And my message to everyone is make sure you get screened. This is best thing that we can do for our patients and to making sure that they get treatment that they need and don't become a emergency situation which doesn't end well.

To connect with Ascension Illinois physicians and access support for your practice, visit Ascension.org/ILvascular. Thank you for listening to the Ascension “Vital Signs” podcast.