Aortic aneurysms, abnormal bulges in the body’s largest artery, are an underappreciated health threat for which reimbursement by Medicare is available to selected patients. The two available treatment options -surgery and “minimally-invasive” repair -were the subject of a recent article and editorial in the prestigious New England Journal of Medicine.
Roughly the diameter of a garden hose, the aorta runs from the heart, through the chest, and down to the lower abdomen where it divides into two main branches, each one then supplying a leg. Aneurysms can occur anywhere along the course of the vessel, but more commonly in the abdomen (hence the term abdominal aortic aneurysm, or the medical “slang” of “triple-A”). The danger of these bulges lies in the risk of rupture, which is directly related to the size of the abnormality. Each year 15,000 Americans die of triple-A rupture---heightening the importance of screening.
Most aneurysms are caused by atherosclerosis, or hardening of the arteries.
Aneurysms are thought to be caused by a complicated combination of genetic factors, atherosclerosis, and smoking. Other causes include congenital weakness of the arterial wall, smoking, high blood pressure and trauma. The vast majority of aneurysms are asymptomatic and, without screening, are often discovered accidentally during x-ray procedures performed for other reasons. Unfortunately, many are discovered at the time of rupture and acute medical risk.
In 2007, Medicare adopted the policy of reimbursement for abdominal ultrasonic screening of men between the ages of 65 and 75 if they have smoked more than 100 cigarettes in their lives. This recommendation is based on the much higher incidence of aneurysms in male smokers.
If an aneurysm is detected and of a small size, the recommendations will likely include aggressive blood pressure control, tobacco cessation and serial ultrasound examinations to make sure the size is stable. If aneurysms continue to expand, or reach a large size, intervention is indicated. Historically, the standard treatment has been replacement of the aorta with an artificial graft. Expert surgeons have achieved impressive results, but the surgery is major. In recent years, endovascular aortic repair (EVAR)-the placement of a graft through a catheter inserted through an artery in the groin-has gained popularity because of its minimally invasive nature, and lower short term risk.
The November 22, 2012 issue of the New England Journal of Medicine compared the outcomes of patients who had elective repair of their abdominal aneurysms by traditional surgery to EVAR. Despite the short term advantages of EVAR, over 5 years there was no difference in survival. Since the two approaches appear equivalent, patients must discuss options with their surgeon. There are often patient specific conditions or preferences which would favor one approach over the other.
Most importantly, if you are a 65 year old man with a history of cigarette smoking or not, you should talk with your primary care physician about the potential benefits of screening. For a review on the topic please see www.sts.org/patient-information/aneurysm-surgery/aortic-aneurysms. To make an appointment to see a NuHealth vascular surgeon-a specialist in aneurysm management- please call 5 16 572 4848.