Abdominal Aortic Aneurysms Health Radio March 10, 2008 Mark Farber, M.D. Dick May. Introduction

Transcription

1 Abdominal Aortic Aneurysms Health Radio March 10, 2008 Mark Farber, M.D. Dick May Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. Introduction Hello and thanks for joining us once again. I'm Andrew Schorr broadcasting live from near Seattle. It's kind of gray here today. We're going to connect you with folks all over the country and specifically across the country in North Carolina. We're going to meet a leading medical expert and one of his inspiring patients. We're talking about something that maybe you hadn't thought about, but you should certainly if you're a man, certainly if you're a former smoker, but there may be other family members and women too where this applies, and there's a risk of being part of the tenth leading cause of death in the United States. It's abdominal aortic aneurysm. When that ruptures, imagine kind of a bulge happening in the major artery in the body supplying blood to the lower part of the body there coming from the heart. Imagine if that ruptured, and actually something like that happened to a cousin of mine. He died suddenly. People have pain; they ignore it; often there are no warning signs at all, but there are ways of being screened, and there are some people, some groups we know that may be at risk. It used to be if you were able to have surgery to repair it, it was a major surgery, and now they are much less; minimally-invasive approaches that use the best of really high-tech medical technology, and we'll talk about that along the way, but let's put the technology aside for a second and just talk about saving lives. There are 15,000 people a year who die of this. We don't want that to happen to you or someone in your family. I'd like you to meet someone. I'd like you to meet Dick May who loves to play golf in one of the golf capitals of the world, Pinehurst, North Carolina. It is just gorgeous down there so much of the year, and Dick spends many months of the year down there. He has been in the construction consulting business in the Boston area for many years, and Dick is 68 years old now. He's fortunate that he has a couple of medical people in his family. His daughter is an OB/GYN. His son-in-law turns out to be a vascular surgeon where I went to school, University of North Carolina at Chapel Hill, 1

2 one of our leading institutions for healthcare as well as so many other areas too. It was great for me for journalism. Dick's Story So, Dick, you were being followed because you had had bypass surgery in the 1990s, so you had some kind of clogging going on there, and you had intervention, and that worked. So you would go for medical exams either in Boston or then in North Carolina because that's where your family was then. What happened just a few years ago when they said, 'Well besides looking following those arteries, we ought to look at your abdominal arteries too?' Tell us about how that happened. Well, this was quite a surprise that after they had finished some scanning of my carotid arteries they did what we call a "belly scan" and found quite a large aneurysm. I think Dr. Farber can remember exactly what size it was, probably around five centimeters, and I had absolutely no indication that there was anything like that going on in my body. I was in shock really to find that I had this condition, and the rest took care of itself with the fine medical attention I got at UNC. They were able to very quickly do a little more in-depth scan of my abdomen, determined that I was a candidate for a stent, and shortly thereafter Dr. Farber and Dr. Mendez at UNC put a stent in my aortic artery, and here I am. Let's talk about that "here I am." Do you think had it not been suggested to you that you have that ultrasound of your abdomen, a very simple exam, that that test and then the intervention afterwards was lifesaving? Oh absolutely. I don't think there's any question about it. I asked about how long they thought that the aneurysm would remain as it was, not break that is, and the answer was it could happen at any time, and it could be some time. So it's just one of those things that I'm happy to be here as a result of that screening. Well, we're happy you're here too. One question before we meet your doctor, Dr. Mark Farber from UNC, about the procedure. So, I know that prior to you having bypass surgery, you were actually in for angioplasty, and sometimes that leads to bypass surgery real quickly, but in the case of angioplasty looking at the arteries that supply the heart, they go up through the groin with a catheter and nowadays they often put in a stent. Was it the same sort of thing? Was it going up through the groin and then were you able to go home the next day? 2

3 Absolutely. They went through the groin the same as the cardiac catheterization, and it was done with a local so that when it was done I recovered quite quickly from that, and the next morning I walked out of the hospital. Wow. Well let's meet Dr. Mark Farber. Dr. Farber is a true expert in this procedure and also in abdominal aortic aneurysm. He's Director of the UNC or University of North Carolina, Endovascular Institute, and he's also an Associate Professor of Surgery and Radiology, and he was one of the doctors who placed this stent we're going to hear about in Dick May that saved his life, and hopefully Dr. Farber you get to do that, save lives, all the time. I know it's frustrating because there are many people like Dick who don't know they have his aneurysm that could burst or rupture at any time, and that must sort of grieve you that there are people walking around with it, and you could help them if only they knew. That's true Andrew. In one sense it is fortunate that Mr. May has family members in the medical profession, and they were astute enough to realize that he was at higher risk for having this problem, and they asked when he had his neck arteries looked at to have his abdomen looked at, and his aneurysm was about 6.4 centimeters, which means at that size that's nearly three times the normal size of his artery, and the chances of that artery basically rupturing or bursting like you mentioned at the onset of the program is about 15% to 20% per year, which means one in five people would rupture their aneurysm in a year. The problem is we can't figure out how that is because 75% of the people, three out of four of those people, do not have any symptoms whatsoever. Fortunately, like Mr. May, we have new technology since 1999 in our hands, and before 1999 what really was another problem for us was we had a lot of patients who couldn't withstand the open surgery because it was too invasive and too stressful on them, and now I will tell you that it is rare that a patient cannot withstand a minimally-invasive repair and get their aneurysm fixed, so it really has helped us take care of patients better with this new technology. Let's understand who's at risk. So, Dick, you shared with me the other day when we spoke on the phone that you used to be a smoker. Right. 3

4 And you stopped, and that's great, and smoking is not good related to a lot of health things. Where does someone having smoked, and tell us how much Dr. Farber, have some risk factors related to abdominal aortic aneurysm? Well, from the risk of smoking, anyone who's ever smoked is at increased risk. When you smoke there is an eightfold increase of having an aneurysm if you smoke versus if you don't smoke. So there's a big difference. The government reimburses for screening if you've ever smoked more than 100 cigarettes, but rarely is there an individual who doesn't smoke who hasn't already smoked 100 cigarettes, and it's any time in your lifetime, not that you are currently smoking. Wow, okay. Now, are we talking about men more than women? Yes. Aneurysms are predominantly in the belly for men. The ratio or the distribution is about 80% are men and 20% are women; however, that distribution can change because you can have an aneurysm in your abdomen, but there are also other places that you can develop an aneurysm such as in the chest or down in your legs. In the chest, for instance, the distribution is 60% men, 40% women, so it changes upon location, but all of them for the most part inside the chest and belly have the same potential for rupture and bleeding and death for those patients unless the problem is corrected. What is an Abdominal Aortic Aneurysm? Let me, let's just have a visual picture. I think we're almost there. So, how big is the aorta, this major artery, and what happens when you have an aneurysm? What is an abdominal aortic aneurysm? For most people the size of the artery that carries blood below your kidneys to the legs and the lower half of your body should be about an inch in diameter, 2.5 centimeters, and that's about the equivalence. It may vary a little bit if you're a small person versus a big person, but that's about the average size. Once it gets two times that size or 2 inches, around 5 centimeters, the risk goes up, and what happens is the wall has thinned out as it's gotten bigger, and basically the artery that was a 2 is now more like an apple on a string type of concept. It's gotten bigger in the center, thinned out, and the actual blood pressure is strong enough to rupture the artery; so the pressure 4

5 pushing on the wall is stronger than the wall itself, and then once that wall cracks or tears then you start to bleed. Most people never even get a chance to call an ambulance once the bleeding starts because it's a major vessel that has ruptured, and you start to bleed internally very quickly, and so they never get a chance to even get to the hospital when that occurs. Screening and Intervention Are there, for the lucky people I guess, are there any signs? Like if you felt this, you felt that, boy get to the hospital. Maybe there's something we can do. What would be the symptoms if there were any? So, in the group that is fortunate enough to have the rupture contained, so in some people they may have some scar tissue that's formed over time around the aneurysm, and so the bleeding isn't as rapid as in others. Then they usually develop severe back pain or belly pain, and when that happens then its, they feel this is the worst pain they've ever felt, and they go to the emergency room, and fortunately either they have an astute emergency room physician or they happen to get a CT scan that comes about that they were able to pick up the aneurysm and detect it, and then they are rushed off to surgery. I will say that most patients' aneurysms are picked up serendipitously. The come in. They think they may have a kidney stone. They've got some minor problems. They have some chronic low back pain that's probably not related to the aneurysm, and someone gets an imaging study, and we pick up the aneurysm, and then it progresses from there as to their medical care. Wow, well, they're actually lucky. I had previously done a program on aortic aneurysms. The same thing, that patient was an emergency room doctor who had a CT scan for something else, and as soon as they saw something they said, 'Hey you know, it's an aortic aneurysm,' and of course he understood completely because he, as an emergency room doctor, had had patients who just didn't survive; they came in at such a late stage. Let me ask you about his situation, which was a little different than Dick's. His was very large, as you said, over 6 centimeters. Might you notice an aneurysm that is much smaller and you decide to watch it, or is it if you see any aneurysm at all, do not pass go, we need to intervene? 5

6 That is true. So for very small aneurysms, if your artery normally we said is 2.5 centimeters or about an inch, if your aneurysm is a little bit bigger, 3, 3.5, or 4, somewhere in that range, the risk of it rupturing is about maybe 1% to 1.5% per year, so the risks of having major surgery to fix it are probably greater than the risk of it rupturing. So in those patients they start to get serial scanning of their abdomen looking to see when the aneurysm is starting to get bigger because most aneurysms when they're small have been there awhile, several years, and we need to find out how it's growing, and the rate of growth impacts things. Obviously if you have an aneurysm that's growing very quickly then we generally tend to fix you a little sooner than someone who's got a very slow-growing small aneurysm, especially if you're a very elderly patient because there are some risks to fixing it. So those do come into play in terms of things. We also look at other issues, patients with a family history. So if Mr. May's son came in to see me with an aneurysm, I would fix his aneurysm at a smaller size because genetically-speaking patients with a family history rupture their aneurysms at a smaller size than patients without a family history. Let's go back then to who should have like an abdominal ultrasound. So if I understand it right, when somebody is new to Medicare; I'm not there yet, but age 65; and if I've been a smoker, more than 100 cigarettes in your whole life, which is easy if you've smoked at all, and then if you have a family history, then Medicare is willing to pay for an abdominal screening to see if there are the signs of an aneurysm, right? So that's the Medicare. Correct. They're willing to pay for it during the first six months of your entrance into Medicare. They don't currently pay for someone maybe who is age 75 who the doctor stumbles across the fact that maybe he had a family history that something came up now. They generally don't do that, although most physicians at that point would really direct the patient to go get a screening because of the higher risk. Whether Medicare would pay for that patient or not just depends upon if he's having symptoms or other things, and so most of the time I think that can get reimbursed by Medicare, but that's not what we're after because that's a very relatively inexpensive test at thirty to fifty dollars. We're actually looking to take care of the patient and make sure he gets the appropriate medical care. Right, and we're trying to save someone's life, and you're right. This is very inexpensive. 6

7 So let's say someone's listening today, and they're 60 years old, and they have been a smoker some time in their life, and they are male. It sounds like maybe this should be part of a physical they have, or it's something if they're going in for a physical that they should maybe bring up with their doctor. Correct. At age 60, if we did an ultrasound screening at age 60 and waited five years, we're still going to miss a few people. So they may not have it at age 60, but they may develop it five to seven years later. By waiting until you're age 65, we may miss a very few small aneurysms because rarely is your aneurysm going to be big enough by age 65 because it is a disease of the elderly population, and I think the government with the data didn't want to give people the false sense of 'Well, at age 60 I'm negative; I don't have to get another screening study.' At age 65, if you're negative, it's very rare you're ever going to develop an aneurysm in your abdomen after that. And these don't develop that fast. Right. All right. Now, let's talk a little bit about the intervention. So you said you used to have to do major abdominal surgery, and some people, elderly people, just couldn't withstand that, so you couldn't do the repair on the outside of the artery, and I know you also, the open surgery if I've got this right, and of course I'm not a surgery; you would actually have to cut open the artery and stop the blood flow for some time to make the repair. So, it's a big deal, right? It's a major surgery. Correct. The differences between the two techniques are there, but we're trying to accomplish the same thing. So for the traditional open surgery, which we still do but fortunately we only have to do that one out of ten times, we have to shut the blood flow off to the lower half of the belly and legs with a clamp and then we replace the diseased section with an artificial piece of polyester, and we attach it by sewing it with stitches. With the new technology you don't have to go to sleep. We do it with you awake and give you some medicine to calm you down. We make two small hernia incisions, and we go up on the inside of the artery and we put a new lining on the inside, and we use special hooks and barbs to attach the fabric to the artery. So it's the same polyester fabric, the only difference is that instead of using stitches, we use hooks and barbs and a stent to hold it in place, and we provide a new lining, and by doing so the blood is channeled inside the new lining, and the pressure on the wall is 7

8 reduced. Therefore, the risk of it rupturing since we've reduced the pressure because it's inside the tube is subsequently reduced. It sounds elegantly simple. I know it's now, and it sounds like kind of a really great example of medical technology today. It is. This is one of those major advances, and not only has this advance occurred for aneurysms in the belly like we're talking about today, but it's also occurred for aneurysms in the chest, and even there it's even a greater advantage. So Mr. May will tell you it probably took him roughly about a week to get back to full activity, and he was in the hospital over night. That's right. The traditional surgery was you're in the hospital for seven to ten days, and it's three to six months of recovery, so you can imagine the impact to the patients, their family members, and their lifestyle if it takes them three to six months, and some of them never even made it back to the same baseline versus a week like it was in Mr. May. So for you as an endovascular surgeon, you must be delighted you have a tool like this and approach; it's not for everybody; but nine out of ten as you said can make a huge difference, and again, these are people who maybe didn't know that they had a freight train about to hit them, potentially very much life threatening, and were looking forward to kind of their later years in retirement. There's Dick playing golf all the time. That's what they're looking forward too that that can be preserved. That's the best of medicine, isn't it? It is, I mean you know, in a sense when a patient comes to you with an aneurysm, as you mentioned before, most of them don't have any symptoms, and for me to tell them they've got a ticking time bomb inside them that may kill them, and then they have to have a major surgery or procedure to have it fixed, they're not going to feel better right after the surgery than what they were before because nothing was really bothering them, so it is very difficult for patients to understand that they have this problem that's life-threatening, if they need a major procedure to get it repaired. Now, I don't think it helped Mr. May's handicap any, but at least I didn't hurt it by him having the procedure. 8

9 No, no. There you go. Do no harm. There you go. Now, Dick. So when you listen to this, I'm sure you would urge people to take advantage of screening if they have these risk factors. Oh absolutely, and the fact that this can be done non-invasively in many cases, one out of ten I think Dr. Farber said, he's also very amazing because I had absolutely no feeling going in or coming out. I walked out the next day, and it's just quite amazing. Right. It's a great story. We're going to take a quick break, Dick. We'll hear more from you and from your doctor, Dr. Mark Farber, who is the Director of the Endovascular Institute at the University of North Carolina. We'll hear about really lifesaving approaches for abdominal aortic aneurysm, and we'll talk about it in the chest as well as we go ahead. Much more of Patient Power live on right after this. Welcome back to our live webcast on Andrew Schorr here with Patient Power. We do these programs from the patient's perspective basically every day. You can get all the information on our website and then there's a vast array of replays including one previous hour we did just a week or so ago on abdominal aortic aneurysm with another specialist, someone Dr. Farber knows well, Dr. Ben Starnes, three thousand miles away at the University of Washington, and they're all echoing the same thing and that is if you are at risk, a former smoker, midsixties, predominately male, or with a family history of aneurismal disease, these bulges in the arteries, then you want to get a simple ultrasound because it could be lifesaving, and it was for my new friend Dick May from Pinehurst, North Carolina. He's lucky enough to have a daughter who's a doctor and a son-in-law who's not just a doctor but an endovascular surgeon and a partner of Dr. Farber's, and they said, 'You know, we've looked following your arteries because you've had coronary artery disease, but let's take a look in your abdomen too because you're at risk for that, and lo and behold there's this big bulge. Then the other part of it of course is in recent years now there's this very elegant, if you will, stent procedure that can be put in through the groin as you heard just like many men and women have had angioplasty for their heart arteries where they can go in and now get to the aorta and go into the inside of the artery and put this device that shores up, if you will, the strength of the artery and gets around that bulge. It's really remarkable and lifesaving. We want that to happen for you to have the screening or have a family member look around. Is Uncle Charlie 65-years old and is or was a smoker or has this happened in your family? It's a very simple test, and Medicare will 9

10 pay for it often at the beginning of your entry into Medicare, so that's something to think about. Now, I want to understand Dr. Farber, we do this screening for breast cancer, and we do it for prostate, yet I said at the outset from what my dear producer, Tamara, gave me here is that this ruptured abdominal aortic aneurysm is the tenth leading cause of death, so we haven't heard that much about it, but it sounds like it's up there, and we should be having people screened who are in the right, or wrong, if you will, groups. You're absolutely correct, Andrew. The data says that people who die of ruptured aneurysms approximately the same number die of breast cancer and prostate cancer both of which have screening programs currently in the United States. Fortunately as we've gotten better and the screening tools are very cheap now that we can actually pick up aneurysms as of January 2007, the government re-looked at everything and now agrees that it can be done, it's cost effective and worthwhile for patients. So we have a tool to do it, and the government agrees that we should be doing it and fixing these problems. Risk Factors Now, we mentioned along the way that there can be bulges in the aorta up in the chest, and I think that's what my 35-year-old cousin died of. He just didn't feel well. He was eating a sandwich with his brothers and right at the office, they shared a company, and he just put his head down and died and bled to death internally. It was a tremendous tragedy. In talking with the doctors, it sounds like that may have been in his chest, and he also may have had a fairly rare condition called, I think you call it Marfan's Syndrome where his chest was somewhat sunken rather than a big broad chest. So help us understand just about risk factors for that because that could be catastrophic too, and can the same sort of procedure help if that's identified? Correct. So you're right. He may have had an aneurysm in the chest or he could have had another problem with the arteries of the chest called a dissection where the layers kind of separate and tear, and patients who have Marfan's have a problem with some of the connective tissue or the junctions that hold things together in your body, and it may be that that's what he had. So patients with connective tissue disorders or Marfan's, and there are some other disease processes like that, generally get either dissections or aneurysms. Once you get a dissection where the wall is split, then that 10

11 artery is relatively weakened and you can go on to develop an aneurysm, so he may very well have had that problem. We use the same devices in the chest that we use in the belly. They're obviously bigger, and instead of it being a device that divides to go down to each leg, the one for the chest is a straight tube, so we can fix those problems. The one issue that comes up, however, is it's harder to screen people in the chest. Ultrasound works by sound waves obviously, but they're blocked by air, so the lung tissue around the artery in your chest makes it very difficult for us to screen with an ultrasound. So the way that those patients are picked up generally is they get it on a routine chest x-ray because they had a cold and they came in for a cough or a CAT scan because they're having some type of back pain or something else go on. That's why we find them in the chest, but the same disease process happens, and we have the same type of technology to fix it. Dick, it was 1991 when you went in for angioplasty to look at the blockages of your coronary arteries, right, and that was back in Boston? Right. That's correct. And then real quickly you found you were in operating room and you had what was it, a quadruple bypass surgery? Yes. I remember watching the angiogram taking place on the screen, and the blockages were too close to the heart to be able to go any further. And they said, 'Here we go to the OR.' Yes. Now, Dick, here's my question. Did they say along the way, or your cardiologist did, 'Well, Dick, part of this happened because you were a smoker or,' I know, I think you've told me that you had family members with coronary artery disease, so maybe that was going on too. What seemed to be the bad actors that led to you needing the bypass surgery? 11

12 Well, first of all, the genes. My dad actually was a country doctor who died at 46 of a coronary, and in 1991 I was 51-years old. I had been not taking very good care of myself even though I had been watching this condition. I had stopped smoking around that time, but I should have known better, and I think it was the combination of that plus the genes that created this condition. Well here's my question for Dr. Farber then. So given Dick's history where he had coronary artery disease and a family history of that and he was a smoker, is there sort of a crossover risk to say, 'Hmm, this guy is at risk for as you say aneurysmal disease?' There is. There is a crossover in all the disease processes. So patients who develop blockages in their neck arteries, in their heart arteries, in the leg arteries, and their kidney arteries; somewhere around ten percent of those patients also can develop aneurysms. We really don't know currently what the cause of aneurysms is in the sense that we know there is some degradation of the wall that occurs. What the pathway is that makes that happen is what's really being looked at from a scientific research standpoint right now. How do we arrest the process, and can we reverse it? Right now no one has figured out any way to reverse the process. Once the artery is damaged it's damaged, but there are many people looking about how we're going to prevent it from happening by blocking the pathway in certain patients, like Mr. May, who do have a higher chance at having a problem like that. Okay, now, so smoking. This whole idea of the blockages in the arteries, there's been this talk in the last few years about well is there an inflammatory process. So is smoking leading to inflammation? What's the thought there? It can. Is the inflammatory process from a bacterium that gets in your body? Is the inflammatory process from a virus? Is the inflammatory process because people who smoke have these byproducts that come out that basically are kind of like little enzymes that break down some of the tissues in your body? The same thing that happens when you smoke you do damage to your lung tissue. Well, is the same type of process going on in other parts of your body? We don't have a direct link. We know that smokers are eight times more likely to have an aneurysm than nonsmokers, but we can't say that smoking leads to "A" which goes to "B" which goes to "C" and "D" and that causes aneurysm. We haven't been able to plot that out yet and prove that, but that's what we're looking at because we know there's a direct relationship. We just haven't been able to get it all down scientifically. 12

13 Yes. Well, I know you're working on that. I'm going to spring an question on you. Dr. Farber, here's a question from Peter in Salinas, California. He writes, 'I had an abdominal aortic aneurysm three weeks ago and had to under emergency surgery.' He doesn t say which approach. 'I am walking and exercising to a sensible extent. It seems that my entire body is sore. Is this usual after this type of surgery?' So postoperative, and maybe you have a sense of whether he had the open procedure or not. I have a sense that if his whole body is sore three weeks after he may have had the open surgery because usually, like I said, you're in the hospital around seven to ten days, so it sounds like he's at home now and starting to recover. Most patients, you know, to have your artery to the lower half of your body clamped and blood flow shut off, that's not a normal thing to do to someone, so it's not unusual to have these other issues. If he happened to have a minimally-invasive repair, there are some just reactions to the blood clotting outside the device that can give you some general malaise, but he should have that checked into either way if he's having those problems. He should just talk to his doctor about that. Connecting with the Experts Let's talk about finding the right doctor. So obviously if I'm around North Carolina I'm coming to see you, but how does someone find a qualified endovascular surgeon, and is this minimally-invasive approach that you've described, is everybody familiar with it? Is it pretty straightforward as long as you have how do you find the right doctor? So you get the screening, and now it says, 'Well what are we going to do about it?' And of course I'd like to avoid the open surgery if I at all could. That's a great look at things, Andrew, because the technology is relatively new in the sense that it got approved in the United States in 1999, and there were very few specialists in 1999 that were doing the procedure. So major institutions like UNC were performing it and helped drive the data that got it approved, and so if you go to a place like that where we've done over a thousand repairs, you know you're getting someone who's an expert. Like all procedures, you should ask your doctor how many of these he's performed because generally if he performs less than ten or twenty a year, he's not doing enough to keep his skills up on a regular basis. 13

14 Every couple of years we have a new device or improvement. So what I used in 1999 is not the same thing that I use in 2008 in terms of devices and how I perform the procedure. Things are getting better and better. In 1999 I could only treat 60% of my patients. Well now I'm at 90%, and I will tell you in the next five years I'm probably going to be at 99% because new devices or new techniques are coming out that allow us to treat more and more patients. So you need to make sure that whoever you go to does a fair number of them and is comfortable doing it because there is a difference. If it's a straightforward simple one where the anatomy or how things are shaped and formed are very standard and straight and not curved and angled, then the less experience you have the easier it is to get done. If it's a very complicated one, then you need more experience to make sure that you get the device put in the right way. Well, here's my question then is obviously if there's a vascular surgeon who has had a lot more experience with the open procedure they're going to lean towards that, that may be. If you could qualify for the minimally-invasive procedure that would certainly be better from the patient's perspective. So given that this can be sort of a ticking time bomb, does somebody have time to get a second opinion? Normally when we talk about surgery we say get a second opinion. So I'm not talking about, you know, you haven't been brought to the ER but maybe somethings been noted, or maybe it's even being followed. So what would you say about getting a second opinion? I think it's very good to get a second opinion. Short of the patient having severe back pain, which means they have symptoms related to aneurysm, you have time to get a second opinion. The aneurysm didn't just start overnight. It's usually been there for a couple of years by the time it gets to be five centimeters, so you have time to get that. At UNC our approach is a little different. We don't have people who just do open surgery and people who do minimally-invasive surgery. So I'm an aortic specialist, so when you come to see me I will look at you, and you'll get my medical opinion about how to manage your aneurysm medically with lowering your blood pressure and reducing your risk factors if it's not time to fix it. You'll get my opinion about whether it should be treated open with a traditional repair or if it should be treated with a minimally-invasive repair like we've been talking about, or a combination of the two. So you get all the options because rarely is it always only one answer for all the patients. The difficult cases and the spectrum of disease that get sent to us here need someone who's a specialist in aortic disease, not someone who's a specialist in minimally-invasive surgery or someone who's a specialist in open traditional surgery, and that way the patient gets the best tailored care to his or her problem. 14

15 Yes, I agree. Thank you. That's a great mission and philosophy there. Now you mentioned something just now that I thought we should just take a couple of minutes on. You said there could be a combination procedure. I've also heard of it referred to as a hybrid procedure. What's that, and where does that come into play where it's part open procedure and part up through the groin? How does that work, and who would that be for? So when the FDA approves devices like Mr. May had put into him, you need an area for the device to attach to, so basically the top end of the gasket, and the gasket has got to sit against the wall so that all the blood flow gets channeled inside the device. If there's not enough room for the gasket to get a good seal, then blood is going to go outside the device and still put pressure on the wall of the aneurysm. In some patients, in order to get a better attachment site, we have to move an artery out of the way because if I put the device across the artery, for instance to your left kidney, you wouldn't have blood flow to your left kidney, and that wouldn't be good. You would lose that kidney. So what we would do in those cases is reroute the blood flow to the left kidney, get us a better area of the gasket to sit against and seal, and then we'd do the minimally-invasive repair because a left kidney bypass is much easier tolerated than an open abdominal aneurysm repair procedure. So we look at the patient, and we say, 'Well, here are your risks and benefits for each of these different types of ways to fix your aneurysm, and this as more risk here, this has less risk here, and you then decide where we want to take the risk for each individual patient. All right, well let's back up because as you said you're often telling this to people who may not have even been aware they had a problem, so they have to kind of pick themselves up off the floor and say, 'I have a life-threatening condition, and I'm going to need to have some sort of intervention because I'm too much at risk of really sudden death.' So then you kind of catch your breath, and then you have this discussion. So related to the hybrid procedure, you mentioned with the traditional open surgery there are people who just can't withstand it. Are there more people, some of that group, who couldn't withstand the traditional open, stop the blood flow to the lower part of your body, type surgery who can have this hybrid procedure? Yes. There's a spectrum of patients. For certain patients with bad hearts that don't pump very well, clamping the artery and shutting off a quarter of your blood flow puts a lot more stress on the heart. If I can just take a little bypass and reroute it to the one kidney, it's not the incision that makes this surgery hard, it's stopping the blood 15

16 flow and all the fluid changes that occur. So I can reroute the blood flow very easily without a problem. There are other people who have had several procedures in their belly that makes it very difficult for me to get into certain areas where the aneurysm is that needs to get fixed, but I can get to maybe some side branches and reroute the blood flow where I don't have to go into the areas that have previously been operated on, which can make a difference for a patient. So, we look at all of them, and then we look; it's a risk-benefit ratio. What is the risk of doing something versus what is the risk of not doing something, and when the risks are equal or lower for doing something than not doing something, then we generally recommend a repair. So every patient gets looked at. We look at all the options available to them because everyone has different anatomy and different configurations and things that we need to do, and we see what their best options are. Okay, now I've got a question for Dick. So, Dick, you've got a son-in-law who works up there at UNC in vascular surgery, Dr. Bill Marston, who maybe you owe your life to too. He's got to be your favorite son-in-law because he suggested that test, but we're listening to Dr. Farber, and obviously this is pretty sophisticated, and he eats, drinks, and sleeps this and has done many, many procedures. For the people listening, what would you say to them as far as connecting with a leading center like UNC's wherever they may be seeking out people who are really on top of this and then hopefully like in your case can bring in state-of-the-art medicine and a minimally-invasive approach? I just totally endorse that. There's no way not to do something like that, and fortunately in this country I think certainly east coast and west coast you have a better chance of doing that maybe than some other parts of the country, but you've got to find people like Mark Farber and my son-in-law and their partners that you can go and do your research and find out what kind of record that have and how well they do this, and that's where you've got to go. Traveling in the United States is not that difficult. If you're obviously an emergency case you can't do that, but if there is some, I think it's worth the travel if you can't find it in your back yard so to speak. If I could add one thing, there is one aspect of the procedure that we haven t talked about is that you do need follow-up. You do need to get an imaging study, a CAT scan, at six months, one year, and yearly thereafter. The only thing I would caution patients about is if you're going to travel from South Dakota to Florida and get your procedure down there and never get followed up, that could potentially be a problem. Traveling an hour or two, there is in most places a specialist within a couple of hours of most places by car or by plane, but you do need to make sure that they go and get their follow-up because we've got to make sure what we put inside continues to work. If it doesn t work, and about one in ten don't work at five years, we need to modify it and 16

17 add a little piece to it to make sure it stays working to continue to protect the patient against rupture. One last question related to that just quickly is, if someone has had an aneurysm in one part of the aorta and you fixed it, are they are risk of another bulge somewhere else? Yes. This is not a focal problem. It is a problem with all of the arteries. So generally speaking when I have a patient like that I'm looking behind their knees for aneurysms, I'm looking in the groins, I'm looking up in their chest because there is an association with other problems. Okay, well I think it's still a very positive story. Dick, I'm sure you've told these guys thank you along the way, right? Oh I absolutely have. They won't give me any more strokes on the golf course, but it's just an amazing process, and we do talk about it frequently. The follow-ups, I'm glad Mark brought that up because that's been very gratifying for me to have those followups and to then have not only a discussion with the physician who did the procedure but an explanation of what's happening and why what they're seeing is positive, and you leave on a very high note. Okay. All the best to you, Dick. If I get down there; my kid has applied to UNC where I went; if I get to come down there and haul all his stuff down there, I'm going to bring my golf clubs, okay? You'd better. That would be fun. Dr. Mark Farber, I want to thank you so much too and the work you do at UNC Health Care and the Endovascular Institute and really paving new ground and it's really exciting. There are a lot of things that are talked about as breakthroughs in medicine, but some of them really aren't. But this approach being able to really help save lives in a minimally-invasive way to me sounds like a big deal. I know Dick says that too, and hopefully we've saved some lives today in urging people to have the screening that would make a huge difference, would you agree? 17

18 I hope so. It is enjoyable to take care of patients, and it is fun to bring them something that ten years ago we wouldn't have had anything to offer them in the clinic. So now we have a lot of options that we never could have helped patients with before. Okay, well thank you so much. So we've been listening to Dr. Mark Farber who's an Associate Professor of Surgery and Radiology at UNC Chapel Hill School of Medicine and UNC hospitals there. He's also Director of the UNC Endovascular Institute in Chapel Hill, and my new best friend Dick May who I'll play golf with, and hopefully he'll give me lots of strokes down in Pinehurst, North Carolina. All the best to both of you. As I mentioned, we did do an earlier program just a couple of weeks ago on this as well, so if your family is affected by this, listen to them both. It will be very helpful. It could be lifesaving, and as always we have a vast library of programs with leading medical experts similar to Dr. Farber in a variety of areas of medicine that are all waiting for you at Thank you for listening in today. Coming up this week we've got lots going on. We're going to a program tomorrow on the management of chronic pain. We're going to look on Wednesday at childhood obesity. We're going to look at the risk of sudden death for people who have cardiac arrhythmias on Thursday. That's what we do on Patient Power. As always, knowledge can be the best medicine of all. I'm Andrew Schorr wishing you a great day. Thanks for listening. Please remember the opinions expressed on Patient Power are not necessarily the views of Health Radio, our sponsors, partners or Patient Power. Our discussions are not a substitute for seeking medical advice or care from your own doctor. Please have this discussion you re your own doctor, that s how you ll get care that s most appropriate for you. 18