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Scott Webb: Though aneurysms can be fatal, they don't have to be. Knowing our risk factors and getting screened are the keys to finding and treating aneurysms before they become life threatening. And joining me today to discuss the various types of aneurysms and screening and treatment options is Dr. Andreas Sakopoulus. He's a Cardiothoracic Surgeon at SVMH. This is Ask the Experts, a podcast from Salinas Valley Memorial Healthcare System. I'm Scott Webb. So doctor, thanks so much for being on today. We have a lot to cover primarily about aneurysms. So let's start with really the obvious one here. What exactly is an aneurysm?

Dr. Sakopoulus: An aneurysm is a localized dilatation of an artery. So if you have an artery anywhere in the body, and there is a spot on it, a portion of it that is grown like a swelling more than the other parts of the artery, the areas adjacent to it. Well, that's called an aneurysm, so a localized swelling of an artery, and it can affect any artery of the body. The most common aneurysms actually occur in the abdominal aorta. The aorta is a big tube of blood, kind of the size of the garden hose that comes out of the heart heads up towards the neck and gives off branches that go to the arms into the brain arteries then takes a big U-turn around the neck area and then goes down the spine adjacent to the spine. And then when it hits around the belly button area, it splits into two. One goes to the left leg. One goes to the right leg. Anyway, that big tube called the air that goes from the heart all the way down to basically the around the area of the belly button. In the portion of it that lies beneath the diaphragm, so that is in the tummy area, that area has a higher propensity than other areas to swell up and form an aneurysm.

But it can also happen in, so that's an aortic aneurysm that can happen in different parts of the aorta. In fact, sometimes it happens with a tube comes out of the heart immediately as it heads up towards the neck, that area, it can get dilated as well, can get swollen as well. So that's an aortic aneurysm. However, a lot of people have heard of aneurysms in people's brains. Well, there are arteries in our brains and those arteries can swell up, can get dilated. It can also happen in the arteries that go down the legs. It can also happen in the arteries that give blood supply to the intestines. So any artery of the body is potentially prone to develop this aneurysmal dilatation or this swelling. And what's the danger of aneurysms. Well, Aneurysms intuitively one can understand, one can maybe envision that if an artery continues to get bigger and bigger and bigger, it could potentially at one point burst gets so big that it bursts. And so the, that should be flowing in this tube will actually instead emanate out of the artery and bleed that is potentially a life threatening situation.

Host: And so, what are some of the complications?

Dr. Sakopoulus: The complications of aneurysms can be indeed a rupture, but there are other things that can happen to aneurysms. If an aneurysm gets big enough, depending on what part of the body that aneurysm is located within the intuitive complication would be a rupture. But other things that can happen is the body can develop clots within the aneurysm. And then these little clots can break off and float downstream and plug up arteries downstream. And that's actually one of the major complications of aneurysms in the what's called a popliteal artery. That's the artery that goes down the legs and specifically it's located around the knee area. So just so happens that very few people, but some do get popliteal artery aneurysms. And one of the sort of more famous people in recent years was Dick Cheney. He had popliteal artery aneurysms, and the way these popliteal artery aneurysms manifest, how they show up is that these clots form inside the aneurysm, they break off, they float down to the smaller arteries downstream, plug up those arteries.

And now you have poor circulation down your feet, and it can be an emergency because there's no circulation going down the feet. So what's called in medical terms, embolization. That means breaking down of clots, that travel downstream, that is also one of the potential complications of aneurysms. Another potential complication of aneurysms, which happens to occur more often in aneurysms that are located in the chest right outside the heart is the aneurysm can develop a tear, but it's not a tear that goes all the way through that causes a complete rupture, but it just tears the inner layers of this tube. And so now blood will go within the wall creating what's called a dissection. And that is actually a very dangerous situation also, and can lead to many complications, which can be life-threatening. So aortic dissection, which is this partial tear of the aorta, can be a very life threatening situation as a complication of an aneurysm.

Host: Doctor, what causes abdominal or thoracic aneurysms?

Dr. Sakopoulus: Arteries throughout the body are made of a few different layers. And if there's some factor that weakens these arteries, they will have a propensity to grow. The situations or the factors that tend to lead to aneurysms are number one, smoking number two, high blood pressure, number three, family history, and number four, male gender. We think that the direct toxic effects of smoking hurt the inner lining of the arteries. And what will end up happening is they get weakened. And because of that, they don't have the strength to maintain their size. And because they get weakened, they progressively get bigger. They dilate what actually works on that additionally is having high blood pressure. So if you have the combination of being a smoker and having high blood pressure, the smoking will weaken the wall and the high blood pressure will exert its force with every heartbeat and progressively that artery gets bigger and bigger and bigger. The other thing is we have seen that it definitely runs in families. It doesn't mean that if a family member has an aneurysm, that you will develop aneurysm.

But in my experience, I would say about 30% of patients who have aneurysms also have family members with aneurysms, but that means that 70% of the time there is no family history. There are also certain conditions where there is actually weakening, a congenital familial weakening of the structures of the arteries. There's something called Marwan syndrome or Ehlers Danlos syndrome. And these are genetic situations where a lot of the families would have an aneurysm. Another factor is gender. There's no doubt that the majority of patients with aneurysms are male and not female. However, very important point to make about this, even though the incidence of aneurysms is higher in men than in women, probably the outcomes for women with aneurysms is worse. And that's because a lot of times doctors don't think about women having aneurysms. So sometimes we discover aneurysm in a woman, later on in a man.

Host: That's really interesting. So I'm taking all this in. So we've got the risk factors, blood pressure, smoking, family history, and also gender. Do we know why it is that more men than women seem to suffer from aneurysms?

Dr. Sakopoulus: There's a lot of disease processes where we see differences in gender, in race, ethnicity, and it just has to do with the genetic makeup.

Host: Are there any signs and symptoms of an aneurysm?

Dr. Sakopoulus: Aneurysm does not give you any symptoms until it is getting complicated until it's developing one of those complications that we talked about previously, which is either it's rupturing or it's carrying, which is called the dissection, or it's embolizing, which means little clots within it, you know, flow downstream. So generally speaking, we don't really have signs of aneurysms becoming complicated. So that is the importance of screening. If a person has the risk factors, I talked about recently, male, greater than 65 years of age smoker, high blood pressure. That person is more likely to have an aneurysm than the general population. So what we should do on those patients is screen them. Generally speaking, if you start developing pain, it means that the aneurysm is either rupturing or dissecting or embolizing there is a complication occurring. So the key would be to try to discover who has an aneurysm before it develops a complication, how you detect the presence of an uncomplicated aneurysm really depends on what part of the body that aneurysm is located in.

So, if it is an aneurysm in your abdominal aorta, it's actually a very simple thing to do. You can get an ultrasound and the ultrasound that normally is used to look at gallbladders and to see if you have gallstones or other situations, that same probe can be utilized to look inside and see what the size of the aorta is. And if it shows that the aorta is big, well, that's an aneurysm. The difficulty with diagnosing aneurysms in different parts of the body is that sometimes it's hard to see them. So for instance, if it is an aneurysm inside your brain, there, isn't an easy ultrasound that you can use to diagnose it. In the chest, also, there's no ultrasound that can be utilized to detect an aneurysm. Generally speaking, we need a CT scan, but there are tests that can be utilized. Some are easier than others, again, depending on the location of the aneurysm.

Host: Okay. So now you've talked about the importance of screening and what you can do if you catch it before it becomes complicated. What do we do for people after they've had an aneurysm? What are the surgical procedures? What's that like for people?

Dr. Sakopoulus: In the last several years, there has been tremendous progress in the treatment of aneurysms. What is done generally speaking, not a hundred percent of the time, but the vast majority of the times is rather than cutting out the aneurysm and sewing a graft in its place. Nowadays, what we generally do is we place a stent graft within the artery. So imagine we place a sleeve inside the aneurysm and fix it above the aneurysm and then downstream from the aneurysm. So imagine you have a normal looking vessel, then you have a dilated portion of the vessel, and then it gets normal again. Well, as long as you can put a sleeve, a tube that will fit inside and attach it snugly, upstream, and downstream from the aneurysm, then the aneurysm will still be there, but the blood will be flowing in. This tube, made out of Gortex material, made of cloth, and the blood will go inside the tube, essentially creating an internal bypass. So the aneurysm will still be there, but it will not be pressurized. It will not be seeing the patient's blood pressure because there's a tube inside it.

I've been doing this for a few years, but I haven't been doing it for 50 years, but I've been doing it for about 20 years. And it's really interesting how in the early part of my career, especially with regards to abdominal aneurysms, I mean, we would make an incision that would basically go from the xiphoid process. That is, you know, like where the top of your tummy and go down, you know, an incision about a foot long. And what we'd end up doing is we'd move all the intestines to one side during this operation. And then, cause the aorta's way in the back by the spine. And we put a clamp above the aneurysm, the clamp below the aneurysm that we open up the aorta and you know, it's a great operation is lovely for, you know, for a surgeon and, you know, essentially cut up the aneurysm. And you'd end up putting essentially this tube, which is again the size of a, you know, like a big sausage, the size of, you know, two centimeters and you'd sew it up stream.

And then you sew it downstream, and take the clamps and you know, there was, but my point is then you have to close the tummy and patients who have been in the ICU for one or two days in the hospital for about a week, they would need blood transfusion. I mean, it was a massacre. They all went to the ICU is a big deal. And now it's amazing because nowadays some of the young nurses that I work with, they're like, Oh yeah, they did aneurysm. And I'm thinking, well, you don't know what this was just in my lifetime. I've had a complete change and now we do this and they go home the next day and they're in no pain. They have just a little. And yet the other thing is a few years ago and I do these procedures with a little, not a big incision, but it was like about a two inch incision in both groins. And now we're able to do it percutaneously. I mean, it really, truly is one of the most fascinating parts of my job because I am actually not getting my hands dirty. Now, when I'm doing that, it's like if I'm using x-ray and it's all done inside, and yet we still are fixing a huge aneurysm in the body, but we're actually not cutting it out. We're just putting the sleeve inside it awes me.

Host: And Doctor, how long do the modern surgeries take and how soon can patients go home?

Dr. Sakopoulus: Usually abdominal aneurysms that are treated with these stent grafts are a procedure that takes about two hours and folks usually go home. The next day, recovery is minimal. The thoracic stent grafts are perhaps a little bit more complicated, but patients even there will usually go home after one or two days. The success rate of stent grafts in the thoracic aorta and the abdominal aorta are superlative. The mortality rate is exceedingly low and the success rate is exceedingly high. The operations are fairly straightforward quick and the recovery is a few days.

Host: That's really amazing because in my mind I'm thinking this is something fairly traumatic and something that may not have a high success rate. But as you're saying, not only is it a fairly, I'm using air quotes, a fairly simple or routine procedure for an expert like yourself and your team, but then some people are going home the next day or maybe at most two days. That is really amazing. And one of the things I learned from hosting these podcasts is just how fascinating the human body is and how important it is that we have experts like you to not only explain to us what our bodies do and why they do it, but also fix us when things are broken. It's really amazing as we wrap up here today, anything else you'd like to add about aneurysms in general and making sure that people don't delay care and definitely don't let COVID stand in the way of going to the hospital. Anything else you'd like to say today?

Dr. Sakopoulus: Medicare passed an act a few years ago, whereby if a patient is greater than 65 years of age, male gender, and are a smoker and have a high blood pressure, they should get routinely screened at 65 years of age to see if they have an aneurysm. So I encourage all patients to get the screening. It is exceedingly simple. It is an ultrasound. There's no needles, there's no radiation. It's just a simple ultrasound placed on somebody's tummy to see if there's an abdominal aortic aneurysm. The incidence of abdominal aneurysms is probably four times higher than that of thoracic aneurysms, abdominal aortic aneurysms are very easy to diagnose, but once the person develops an aneurysm, it doesn't mean that they need an operation done right away. So it has to be more than twice the normal dimensions. Then we start seeing complications do the size of the normal abdominal area is about, say two centimeters. As long as it stays less than four centimeters, it can probably just be watched.

We don't need to do an intervention on that. Now, once it gets bigger than four and a half, five, five, and a half centimeters, then we do need to do operations. So the point that I'm trying to make is that once aneurysms have reached a certain dimension, they will continue to grow until something's done. It will continue to grow and have a complication unless we do something about it. But early on, if they are in the abdominal area, they're 4.5 centimeters. We can watch them. And if a patient stops smoking, if a patient's blood pressure gets under good control, they might not need to have an operation ever, but we do need to monitor them. I just wanted to let everybody know that things are very safe at our hospital. Please do not hesitate to come and visit, and please do not delay medical care. All precautions are taken in the hospital for prevention of COVID. We have an excellent emergency room department and please don't hesitate to come.

Host: Really fascinating stuff today. Great conversation. You have a great way of explaining things that I think everyone will understand, and I really appreciated this. So thank you so much for your time and you stay well. For more information, visit svmh.com. And we hope you found this podcast to be helpful and informative. This is Ask the Experts, from Salinas Valley Memorial Healthcare System. I'm Scott Webb, stay well. And we'll talk again. Next time.