Aneurysm risks grow with aging population
Story from United Press International
Copyright 2003 by United Press International (via ClariNet)
Friday, 22-Aug-2003 9:04AM PDT
NEW YORK, Aug. 21 (UPI) -- "Well, it looks like I found another place to take your pulse," Gordon Heggland's family doctor joked in 1990 as he conducted a routine annual physical exam on Heggland -- then age 60 and a chemical industry executive -- and found a potentially deadly condition.
That event marked the beginning of a tense, 10-year ordeal for Heggland of watching and waiting as an aortic aneurysm, just beginning to bulge in his abdomen, grew to a size requiring surgery.
Approximately 200,000 patients with the condition known as AAA are diagnosed each year in the United States and 50,000 are treated surgically. Of those, 35,000 surgeries are elective. The American Heart Association's 2001 heart and stroke statistical update estimates AAAs are responsible for more than 16,000 U.S. deaths annually and they contribute to 24,000 more.
An aneurysm is a balloon-like structure that forms and then inflates on the outer wall of a blood vessel. Usually, it results from an accumulation of fatty deposits, but it also might be due to heredity, trauma or disease, all of which result in a weakening of the vessel wall.
Over time, the vessel tissue loses its elasticity, allowing the force of normal blood pressure to rupture it at the site of the aneurysm, causing massive internal bleeding. If an aneurysm forms in the part of the aorta -- one of the body's main blood vessels -- that extends through the abdomen, it is called an abdominal aortic aneurysm.
The condition is dangerous because most people carrying it do not experience any symptoms. As in Heggland's case, AAAs usually are discovered by accident. A doctor conducting a routine exam might notice or feel a throbbing, tender mass in the middle or lower part of the abdomen and order a follow-up ultrasound. The condition also might be found during diagnostic imaging -- such as CT scans or MRIs -- performed for other reasons.
During the progression of Heggland's medical problem, awareness of AAA increased substantially within the medical community. Though the condition remains underdiagnosed, more aortic aneurysms are being caught and more sudden deaths are being prevented.
"It is becoming more and more evident that more people than we ever imagined have died suddenly from an aortic aneurysm, and it is the suddenness of these deaths and, often, the age of the deceased, that leads to a mis-attribution of the cause," Dr. George Todd, chief of surgery at Mount Sinai St. Luke's Roosevelt Hospital in New York City, told United Press International. "As we begin to catch more of these aneurysms and treat the condition, we believe that more people than we had guessed are carrying this physical time-bomb in their bodies, that it will develop silently, explode, kill them and be called something else."
Todd noted if an aortic aneurysm ruptures, few patients survive. Roy Rogers survived but Albert Einstein, Lucille Ball and Conway Twitty did not. He said such deaths often can be prevented with a simple annual ultrasound examination, appropriate monitoring -- as in Heggland's case -- and, when needed, surgical intervention.
"We estimate that as many people in the United States are dying each year from aneurysms as from AIDS or breast cancer," Todd said. "But we haven't instituted a simple, cheap ultrasound exam in our annual physicals, especially of patients over 70. Over 5 percent of men over 70 who receive an ultrasound will reveal an aneurysm."
An AAA usually is treated surgically if it grows larger than 5 centimeters in diameter. Smaller aneurysms are monitored for growth through annual or six-month ultrasound exams.
"Most vascular surgeons would agree that a 5-6 centimeter aneurysm should be repaired, unless other medical factors in a patient make the operation too risky," Dr. M. David Tilson, professor of surgery at Columbia University in
New York City, told UPI. "There is less unanimity of opinion about smaller abdominal aortic aneurysms, since the risk of rupture is much lower. Some surgeons are now recommending repair of aneurysms over 3 centimeters, but others would advise watchful waiting for abdominal aortic aneurysms that small."
Aneurysms larger than 5 centimeters require surgery that reaches the growth through an incision in the abdomen. The surgeon then isolates the AAA and removes it. The surgery requires general anesthesia and takes about three to four hours. Patients typically spend one night in an intensive care unit and remain in the hospital for an additional five to seven days.
An alternative procedure -- and one that came into use during the 1990s while Gordon Heggland was watching his aneurysm slowly grow -- is known as endovascular stent grafting. The surgeon places a stent graft, a woven polyester tube -- the graft -- covered by a tubular metal web -- the stent -- inside the blood vessel with the aneurysm without surgically opening the surrounding tissue.
The stent graft separates the aneurysm from the normal blood flow. The diseased vessel is not replaced, and there is a risk of aneurysmal rupture -- about 1.5 percent at four years compared to a less than 1 percent risk of surgical complications when the diseased vessel is removed.
"I chose the stent," Heggland told UPI. "I had no pain so I did not have to take any drugs for pain, which was a big plus to me. I was walking around within a day. It was unbelievable. Dr. Todd, my surgeon, came in two days after a surgery, which I had been expecting for 10 years, and he said, 'Ready to go home, Gordon?'
"I was ready and just a bit dazed to know that rather than having an eviscerating surgery I had been able to have this stent -- and this had all become a possibility since that doctor made his joke about finding another place to feel my pulse," Heggland continued.
As the U.S. population ages, Todd explained, and because aneurysms largely are the result of aging, the problem is bound to get bigger.
"Right now," he said, "ultrasound screening for aortic aneurysms is covered by insurance only after a physical exam stumbles over the problem, which, of course, won't always be the case with the standard, insurance-covered annual physical examination. So now begins the fight to get insurance to pay for screening for the highest risk patients, men over 65, men and women over 50 who are heavy smokers and men and women with a history of the condition in their moms, dads or siblings."
An ultrasound screening costs about $200.
Larry Lakey, spokesman for the Health Insurance Association of America, based in Washington, D.C., said the problem is not as simple as convincing insurance companies to cover ultrasound exams.
"The population at highest risk here is male and over 65," he told UPI. "These men generally rely on Medicare rather than private insurers to pay for their medical exams."
Lakey said if it is shown in published, peer-reviewed medical studies that routine ultrasound is effective in spotting aneurysms, without a high rate of false positives, "then this is exactly the point where insurers will want to take a close look at revising coverage policies on this procedure."
He said the challenge before the research community is to produce such published and peer-reviewed reports.
In the meantime, medicine has two highly effective surgical procedures to use and can monitor smaller aneurysms easily, Todd said.
"We just need to define this problem as a growing public health problem among an aging population and convince the insurers to see that the prevention dollars for annual ultrasound exams is cost-effective. We will," he added.