The Christ Hospital is recognized for exceptional treatment of aortic aneurysms, a major cause of death and disability in the U.S.
Geoff Answini, MD, discusses the latest advances in treatment options available at The Christ Hospital for Aortic Aneurysm, and when to refer to a specialist.
Selected Podcast
The Latest Advances in Treatment Options for Aortic Aneurysm
Featured Speaker:
Learn more about Geoff Answini, MD
Geoff Answini, MD
Dr. Geoff Answini is a minimally invasive cardiothoracic surgeon and one of very few cardiac surgeons in the Greater Cincinnati area who performs robotic surgery.Learn more about Geoff Answini, MD
Transcription:
The Latest Advances in Treatment Options for Aortic Aneurysm
Melanie Cole: Our topic today is aortic aneurysm and my guest is Dr. Geoff Answini. He's a cardiothoracic surgeon with the Christ Hospital Health Network. Explain a little bit about aortic aneurysm and that there are different types. Tell us about some of the main types.
Geoff Answini, MD: Thanks for having me. Aortic aneurysm disease is a big problem in the US still to this today. More aneurysms actually ruptured per year than actually get treated. In my mind, it’s an underdiagnosed problem that we need to have better screening programs out there to try to figure out who has these aneurysms and who would be at risk for having a rupture from these aneurysms. There are a few different types of aneurysms out there. There's a fusiform aneurysm which is a general dilatation of the aorta. There's a saccular type of aneurysm which is a worse kind where you have a small area of the aorta that's bulging. There are other aneurysms that can occur secondary to inflammation or infection, but by far the fusiform and saccular aneurysms are the more frequent.
Melanie: What are some common conditions and factors that lead to it? Tell us a little bit about the path of physiology of aneurysms.
Dr. Answini: I would say that most aneurysms occur secondary to what's called cystic medial degeneration, which means that the wall of the actual aorta starts to degenerate over time. Most of the time, it probably occurs secondary to people smoking and they get an increased release of what's called collagenase, which is an enzyme that can break down the wall of the artery. I would say the biggest risk factor for aneurysm disease is smoking. A close second is coronary artery disease and it's probably the same factors that cause blockages to occur in the coronaries that cause the wall of the aorta to start degenerating. The two go hand in hand. There was a study done a couple years ago called the EPIC study that looked at patients that smoked and had a history of coronary artery disease, and in those patients, they had about an 18.5% risk of having an abdominal aortic aneurysm.
Melanie: Risk factors notwithstanding and certainly other comorbidities – high blood pressure. Are there certain genetic components to this or even gender?
Dr. Answini: Yes. Typically, it’s an age-related problem, so most of the time, this occurs in people over the age of 55. As I said earlier, smokers are at a much higher risk. Males have above a four to five times increased risk than women do and it’s also associated with people that have high blood pressure, diabetes or coronary artery disease. Those are the biggest risk factors. As far as there being a genetic component to it, there are patients that are born with congenital connective tissue disorders called Marfan’s Disease or Elhers-Danlos Disease, both of which can develop aneurysms at an early age. They typically will get their aneurysms in their 20s and 30s whereas the people that get it from smoking or other related diseases like diabetes or high cholesterol will get it 55 or over. The other issue is that there's one other familial aneurysm syndrome that can occur where you'll have a patient come in and tell you that they’ve had multiple family members that have had aneurysms in the past. Typically, the patients that have connective tissue diseases and/or a familial history of aneurysm disease, we would screen them at a much earlier age, meaning they would probably start getting screen in their 20s and 30s, whereas most of these other patients that have these other factors like smoking and/or coronary disease we would start screening them when they hit 55 or above.
Melanie: Let's speak about screening then because this could be asymptomatic. It’s something that not necessarily someone might go in for their annual physical and maybe they are a smoker and hypertensive and you might notice something. Is there a screening and what are some of the valuable prognostic tools to aid in early diagnosis, which is really what you're looking for?
Dr. Answini: You hit the nail on the head there that these typically will grow until they rupture, so that’s why to this day still, there's more of them that rupture per year than get them fixed, and that’s a very real problem because they're usually asymptomatic until it’s too late. Screening is the key to fixing this problem and I think that it’s probably even underreported the incidence of death from this because right now they listed it at 10th or 11th on the scale of 1-20 out of things that kill people. It may be underreported because obviously a lot of these people that die at home don’t get autopsies and they blame it on some other cardiovascular thing. It is a real problem and screening is the key. Typically, what we do here at the Christ Hospital is anyone that’s over 55 or 60 that has a smoking history or has a history of coronary disease or a history of high cholesterol or diabetes, we recommend that they start screening at that point. We have a screening program here at the Christ Hospital where you can get screened for $29.99, which is basically at cost. We screen the carotids, the abdominal aorta, the lower extremities or check for blockages and then we do a rhythm strip to check for atrial fibrillation. When we do all those things for $29.99, you basically get it from head to toe vascular/afib evaluation for very little money.
Melanie: That’s amazing - $29 to get all of that type of screening. That is absolutely fantastic. As we’re talking about early diagnosis and if you do get lucky enough to find something like this early, what are some of your goals of treatments? I imagine the patient must feel like a ticking time bomb and they're not sure what their life is going to be like if this is diagnosed.
Dr. Answini: Most of the time, the term ‘aneurysm’ gets thrown away and there's a lot of fear associated with that terminology. It’s a lot like getting diagnosed with cancer. Not all aneurysms actually have to be fixed, so typically what we do is aneurysms are graded by size. Anything in the 3 to 4 centimeter range, which would be 3 to 3.9 centimeters, we typically would advise them to get screened once a year with an abdominal ultrasound to follow that, and if there's any increase in size, meaning greater than .5 centimeters in six months to greater than 1 centimeter in a year or the aneurysm grows to greater than 4 centimeters, then we recommend that they see a cardiovascular specialist at that point. We typically do not operate on any of these aneurysms unless they're greater than 5 centimeters. That being said, if a patient is symptomatic or the aneurysm has a very bad morphology, like the saccular type, and it looks like they might have had a contained rupture or there might be an increased risk for rupture, then we would recommend that they get treated sooner than 5 centimeters.
Melanie: What does treatment look like?
Dr. Answini: Treatment over the last couple decades has changed significantly. Back in 1999, then I was in my surgery training, 100% of them were treated with open surgery. In the last 1990s and early 2000s, there's stent technology that started to develop at that point and it has progressed at a very rapid rate, so over the last 18 years, we have gone from 100% of them being fixed open to 95%+ of them being fixed endovascularly with stents. The stent technology has really progressed very rapidly. We're already in about the sixth generation of stents at this point where they've identified problems or concerns for design failures on the previous stents and they've upgraded them six separate times. Now, we're at a stage where the design of the stent is excellent. We have very few complications postoperatively and they are pretty much plug-and-play where they go in there and you don't really have to worry about them a whole lot after they've been in place. The interesting thing about this stent technology is that it really replicates the open surgery. In other words, when you put these in there, the stent goes in and lands in the aorta on the inside and it basically excludes the aneurysm where the blood will only go through the stent and it doesn't go into the aneurysm anymore. When we did the open surgeries, we would do the same thing where we would open the aneurysm up and actually sew a graft on the inside of the aneurysm and then close the aneurysm over the top of the stent. It was done that way to protect it from the stent material from the bowels in the abdomen. You essentially get the same operation done, but it’s done most of the time percutaneously now where we don’t even make any incisions, and the blood loss, instead of being measured in the liters, is only measured in about 20 to 30 ccs now. There's a dramatic improvement in the OR time, the trauma to the patient, and the recovery time is dramatically improved where most of these patients are going home the next day.
Melanie: If you're not looking to doing the endovascular stent grafting, speak just a little bit about some of the medical management, the reduced risk of ruptures, and the continuity of care, how you're keeping watchful eye on these patients to see if anything changes.
Dr. Answini: Most of these patients, when the aneurysm shows up in the four-centimeter range or higher, typically means that unfortunately, their disease process will progress and at some point, they're going to need something to be fixed. The abdominal aorta is a little bit different than the thoracic aorta in that some patients may be born with an aorta that’s slightly enlarged, so some of those aneurysms in the chest that are in the four-centimeter range may never progress to needing a surgeon done. The vast majority of the ones in the abdominal aorta that are in the four-centimeter range typically will continue to grow and eventually will need something done. Obviously, we try to treat anyone that’s less than five centimeters medically and to try to maximize their medical therapy to see if we can stop the progression and avoid a procedure. Most of that consists of smoking cessation, putting them up tight blood pressure control where you try to keep their systolic blood pressure in the 140s or below at all time, and then avoiding any high risk type of activities, which would be overexerting themselves in the gym, lifting heavy weights, avoid doing any exercise that would cause them to profusely sweat – all of those things can reduce the rates of progression of the disease. If they're already in the four-centimeter range, typically those will continue to progress and we need to keep a close eye on them. That’s why we usually recommend that when they do get diagnosed above four centimeters, they should be referred to one of the cardiovascular surgeons so that we can keep a close eye on things and watch it. Some of these patients will be in their 80s or they're debilitated, and obviously, in those cases, we would recommend just watching them and treating them medically. Sometimes we'll even watch them into the 5+ centimeter range, but the vast majority of them, it usually means they'll end up getting fixed endovascularly at some point.
Melanie: Looking forward to the next 10 years in the field, what do you feel will be some of the most important areas of research? Give us a little blueprint for future research.
Dr. Answini: The Linder Research Center here at the Christ is very active in the aneurysm research component. We are currently involved in two research trials that are looking at new generations of the stents. We were the leading rollers in a stent trial that just finished about a year ago and the current stent trials that we’re looking at are one stent that’s being developed that’s going to actually have side branches that can go into the aortic arch and they can fix aneurysms that involved the aortic arch where the branch vessels go to the brain. This is unchartered territory right now because you can't afford to have any problems with side branches that go to the brain because it could result in a stroke, but fixing those types of aneurysms or aortic dissections with a stent is obviously a lot easier on the patient and it improves their recovery time, so there's no doubt in my mind that this is the wave of the future for treating those areas. We're in the fledgling stages of looking at that right now.
The other area is aneurysms that span from the chest down into the abdomen. They're called thoracoabdominal aneurysms. For years, the only way to treat this up until about two years ago was through open surgery. You want to talk about a morbid operation. If you had to list all the different operations that are out there, this might be at the top of the list for morbidity for patients. The incisions would go from their armpit all the way down to their pubic bone. It was incredibly difficult for these people to recover from these operations. A lot of times, they would actually not be the same person afterward, even if they survive the operation; they wouldn't have the same quality of life and they wouldn't be the same person afterward. There's a friend of mine who's a bioengineer who happens to also be a vascular surgeon, we worked together in St. Louis University about 15-16 years ago, and he developed a stent along with Medtronic – Medtronic actually produces the stent – and we're doing a physician-sponsored investigational device trial through the FDA. Christ Hospital is only one of four other sites that is involved in this trial and we're utilizing a new stent that stands from the thoracic aorta all the way down to the iliac arteries in the pelvis. We've already fixed four of them here at the Christ Hospital and we have four more of them on the docket to be treated here in March and April.
Melanie: Wrap it up for us what you would like other physicians to know about aortic aneurysm and when to refer.
Dr. Answini: I think the biggest thing that I would like people to know is that if you have anyone with a family history of aneurysms or risk factors, they're over 60 years old, they smoke, they have a history of coronary disease, all of those patients should be considered for our screening program. That would include an ultrasound of the abdomen, of the neck and of the lower extremities. This disease continues to be a problem that’s underdiagnosed and you'll literally be saving lives if you check for aneurysms in these patients. Anyone that’s diagnosed with an aneurysm above four centimeters, we would recommend that they get a surgical consultation at that point, and anyone that’s less than four centimeters, we would recommend that they continue medical management with tight blood pressure control and smoking cessation. Anyone that’s diagnosed with any aneurysm above three centimeters needs to be followed with a yearly ultrasound to make sure that it doesn't progress.
Melanie: Thank you so much for being with us today. Really great information. You're listening to Expert Insights, Physician Views and News with the Christ Hospital Health Network. More information on Dr. Answini and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.
The Latest Advances in Treatment Options for Aortic Aneurysm
Melanie Cole: Our topic today is aortic aneurysm and my guest is Dr. Geoff Answini. He's a cardiothoracic surgeon with the Christ Hospital Health Network. Explain a little bit about aortic aneurysm and that there are different types. Tell us about some of the main types.
Geoff Answini, MD: Thanks for having me. Aortic aneurysm disease is a big problem in the US still to this today. More aneurysms actually ruptured per year than actually get treated. In my mind, it’s an underdiagnosed problem that we need to have better screening programs out there to try to figure out who has these aneurysms and who would be at risk for having a rupture from these aneurysms. There are a few different types of aneurysms out there. There's a fusiform aneurysm which is a general dilatation of the aorta. There's a saccular type of aneurysm which is a worse kind where you have a small area of the aorta that's bulging. There are other aneurysms that can occur secondary to inflammation or infection, but by far the fusiform and saccular aneurysms are the more frequent.
Melanie: What are some common conditions and factors that lead to it? Tell us a little bit about the path of physiology of aneurysms.
Dr. Answini: I would say that most aneurysms occur secondary to what's called cystic medial degeneration, which means that the wall of the actual aorta starts to degenerate over time. Most of the time, it probably occurs secondary to people smoking and they get an increased release of what's called collagenase, which is an enzyme that can break down the wall of the artery. I would say the biggest risk factor for aneurysm disease is smoking. A close second is coronary artery disease and it's probably the same factors that cause blockages to occur in the coronaries that cause the wall of the aorta to start degenerating. The two go hand in hand. There was a study done a couple years ago called the EPIC study that looked at patients that smoked and had a history of coronary artery disease, and in those patients, they had about an 18.5% risk of having an abdominal aortic aneurysm.
Melanie: Risk factors notwithstanding and certainly other comorbidities – high blood pressure. Are there certain genetic components to this or even gender?
Dr. Answini: Yes. Typically, it’s an age-related problem, so most of the time, this occurs in people over the age of 55. As I said earlier, smokers are at a much higher risk. Males have above a four to five times increased risk than women do and it’s also associated with people that have high blood pressure, diabetes or coronary artery disease. Those are the biggest risk factors. As far as there being a genetic component to it, there are patients that are born with congenital connective tissue disorders called Marfan’s Disease or Elhers-Danlos Disease, both of which can develop aneurysms at an early age. They typically will get their aneurysms in their 20s and 30s whereas the people that get it from smoking or other related diseases like diabetes or high cholesterol will get it 55 or over. The other issue is that there's one other familial aneurysm syndrome that can occur where you'll have a patient come in and tell you that they’ve had multiple family members that have had aneurysms in the past. Typically, the patients that have connective tissue diseases and/or a familial history of aneurysm disease, we would screen them at a much earlier age, meaning they would probably start getting screen in their 20s and 30s, whereas most of these other patients that have these other factors like smoking and/or coronary disease we would start screening them when they hit 55 or above.
Melanie: Let's speak about screening then because this could be asymptomatic. It’s something that not necessarily someone might go in for their annual physical and maybe they are a smoker and hypertensive and you might notice something. Is there a screening and what are some of the valuable prognostic tools to aid in early diagnosis, which is really what you're looking for?
Dr. Answini: You hit the nail on the head there that these typically will grow until they rupture, so that’s why to this day still, there's more of them that rupture per year than get them fixed, and that’s a very real problem because they're usually asymptomatic until it’s too late. Screening is the key to fixing this problem and I think that it’s probably even underreported the incidence of death from this because right now they listed it at 10th or 11th on the scale of 1-20 out of things that kill people. It may be underreported because obviously a lot of these people that die at home don’t get autopsies and they blame it on some other cardiovascular thing. It is a real problem and screening is the key. Typically, what we do here at the Christ Hospital is anyone that’s over 55 or 60 that has a smoking history or has a history of coronary disease or a history of high cholesterol or diabetes, we recommend that they start screening at that point. We have a screening program here at the Christ Hospital where you can get screened for $29.99, which is basically at cost. We screen the carotids, the abdominal aorta, the lower extremities or check for blockages and then we do a rhythm strip to check for atrial fibrillation. When we do all those things for $29.99, you basically get it from head to toe vascular/afib evaluation for very little money.
Melanie: That’s amazing - $29 to get all of that type of screening. That is absolutely fantastic. As we’re talking about early diagnosis and if you do get lucky enough to find something like this early, what are some of your goals of treatments? I imagine the patient must feel like a ticking time bomb and they're not sure what their life is going to be like if this is diagnosed.
Dr. Answini: Most of the time, the term ‘aneurysm’ gets thrown away and there's a lot of fear associated with that terminology. It’s a lot like getting diagnosed with cancer. Not all aneurysms actually have to be fixed, so typically what we do is aneurysms are graded by size. Anything in the 3 to 4 centimeter range, which would be 3 to 3.9 centimeters, we typically would advise them to get screened once a year with an abdominal ultrasound to follow that, and if there's any increase in size, meaning greater than .5 centimeters in six months to greater than 1 centimeter in a year or the aneurysm grows to greater than 4 centimeters, then we recommend that they see a cardiovascular specialist at that point. We typically do not operate on any of these aneurysms unless they're greater than 5 centimeters. That being said, if a patient is symptomatic or the aneurysm has a very bad morphology, like the saccular type, and it looks like they might have had a contained rupture or there might be an increased risk for rupture, then we would recommend that they get treated sooner than 5 centimeters.
Melanie: What does treatment look like?
Dr. Answini: Treatment over the last couple decades has changed significantly. Back in 1999, then I was in my surgery training, 100% of them were treated with open surgery. In the last 1990s and early 2000s, there's stent technology that started to develop at that point and it has progressed at a very rapid rate, so over the last 18 years, we have gone from 100% of them being fixed open to 95%+ of them being fixed endovascularly with stents. The stent technology has really progressed very rapidly. We're already in about the sixth generation of stents at this point where they've identified problems or concerns for design failures on the previous stents and they've upgraded them six separate times. Now, we're at a stage where the design of the stent is excellent. We have very few complications postoperatively and they are pretty much plug-and-play where they go in there and you don't really have to worry about them a whole lot after they've been in place. The interesting thing about this stent technology is that it really replicates the open surgery. In other words, when you put these in there, the stent goes in and lands in the aorta on the inside and it basically excludes the aneurysm where the blood will only go through the stent and it doesn't go into the aneurysm anymore. When we did the open surgeries, we would do the same thing where we would open the aneurysm up and actually sew a graft on the inside of the aneurysm and then close the aneurysm over the top of the stent. It was done that way to protect it from the stent material from the bowels in the abdomen. You essentially get the same operation done, but it’s done most of the time percutaneously now where we don’t even make any incisions, and the blood loss, instead of being measured in the liters, is only measured in about 20 to 30 ccs now. There's a dramatic improvement in the OR time, the trauma to the patient, and the recovery time is dramatically improved where most of these patients are going home the next day.
Melanie: If you're not looking to doing the endovascular stent grafting, speak just a little bit about some of the medical management, the reduced risk of ruptures, and the continuity of care, how you're keeping watchful eye on these patients to see if anything changes.
Dr. Answini: Most of these patients, when the aneurysm shows up in the four-centimeter range or higher, typically means that unfortunately, their disease process will progress and at some point, they're going to need something to be fixed. The abdominal aorta is a little bit different than the thoracic aorta in that some patients may be born with an aorta that’s slightly enlarged, so some of those aneurysms in the chest that are in the four-centimeter range may never progress to needing a surgeon done. The vast majority of the ones in the abdominal aorta that are in the four-centimeter range typically will continue to grow and eventually will need something done. Obviously, we try to treat anyone that’s less than five centimeters medically and to try to maximize their medical therapy to see if we can stop the progression and avoid a procedure. Most of that consists of smoking cessation, putting them up tight blood pressure control where you try to keep their systolic blood pressure in the 140s or below at all time, and then avoiding any high risk type of activities, which would be overexerting themselves in the gym, lifting heavy weights, avoid doing any exercise that would cause them to profusely sweat – all of those things can reduce the rates of progression of the disease. If they're already in the four-centimeter range, typically those will continue to progress and we need to keep a close eye on them. That’s why we usually recommend that when they do get diagnosed above four centimeters, they should be referred to one of the cardiovascular surgeons so that we can keep a close eye on things and watch it. Some of these patients will be in their 80s or they're debilitated, and obviously, in those cases, we would recommend just watching them and treating them medically. Sometimes we'll even watch them into the 5+ centimeter range, but the vast majority of them, it usually means they'll end up getting fixed endovascularly at some point.
Melanie: Looking forward to the next 10 years in the field, what do you feel will be some of the most important areas of research? Give us a little blueprint for future research.
Dr. Answini: The Linder Research Center here at the Christ is very active in the aneurysm research component. We are currently involved in two research trials that are looking at new generations of the stents. We were the leading rollers in a stent trial that just finished about a year ago and the current stent trials that we’re looking at are one stent that’s being developed that’s going to actually have side branches that can go into the aortic arch and they can fix aneurysms that involved the aortic arch where the branch vessels go to the brain. This is unchartered territory right now because you can't afford to have any problems with side branches that go to the brain because it could result in a stroke, but fixing those types of aneurysms or aortic dissections with a stent is obviously a lot easier on the patient and it improves their recovery time, so there's no doubt in my mind that this is the wave of the future for treating those areas. We're in the fledgling stages of looking at that right now.
The other area is aneurysms that span from the chest down into the abdomen. They're called thoracoabdominal aneurysms. For years, the only way to treat this up until about two years ago was through open surgery. You want to talk about a morbid operation. If you had to list all the different operations that are out there, this might be at the top of the list for morbidity for patients. The incisions would go from their armpit all the way down to their pubic bone. It was incredibly difficult for these people to recover from these operations. A lot of times, they would actually not be the same person afterward, even if they survive the operation; they wouldn't have the same quality of life and they wouldn't be the same person afterward. There's a friend of mine who's a bioengineer who happens to also be a vascular surgeon, we worked together in St. Louis University about 15-16 years ago, and he developed a stent along with Medtronic – Medtronic actually produces the stent – and we're doing a physician-sponsored investigational device trial through the FDA. Christ Hospital is only one of four other sites that is involved in this trial and we're utilizing a new stent that stands from the thoracic aorta all the way down to the iliac arteries in the pelvis. We've already fixed four of them here at the Christ Hospital and we have four more of them on the docket to be treated here in March and April.
Melanie: Wrap it up for us what you would like other physicians to know about aortic aneurysm and when to refer.
Dr. Answini: I think the biggest thing that I would like people to know is that if you have anyone with a family history of aneurysms or risk factors, they're over 60 years old, they smoke, they have a history of coronary disease, all of those patients should be considered for our screening program. That would include an ultrasound of the abdomen, of the neck and of the lower extremities. This disease continues to be a problem that’s underdiagnosed and you'll literally be saving lives if you check for aneurysms in these patients. Anyone that’s diagnosed with an aneurysm above four centimeters, we would recommend that they get a surgical consultation at that point, and anyone that’s less than four centimeters, we would recommend that they continue medical management with tight blood pressure control and smoking cessation. Anyone that’s diagnosed with any aneurysm above three centimeters needs to be followed with a yearly ultrasound to make sure that it doesn't progress.
Melanie: Thank you so much for being with us today. Really great information. You're listening to Expert Insights, Physician Views and News with the Christ Hospital Health Network. More information on Dr. Answini and all of the Christ Hospital physicians is available at tchpconnect.org. That’s tchpconnect.org. This is Melanie Cole. Thanks so much for listening.