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  Vol. 25, No. 2  Previous Table of Contents Home  Next February 1, 2003 

The ABCs of AAAs


By KATHY WATSON
Texas Heart Institute

As Diane and Stephen Brezner were planning for a long-awaited cruise to the Greek Isles, Diane put her foot down – her husband absolutely must get a check-up before leaving the country.

“It had been a while since my last physical – sometime in the late 1980s,” admits Stephen Brezner, D.D.S., with a laugh. “Diane refused to go on the trip if I didn’t go to the doctor.”

Now Stephen credits his wife’s tenacity and his internist’s skills with saving his life. Just two minutes into the physical exam, the internist, while palpating Brezner’s abdomen, identified a critical pulsation – a classic sign of an abdominal aortic aneurysm. Brezner was referred to a cardiologist to confirm the diagnosis.

“The cardiologist’s staff asked me, ‘Why are you here? You look perfectly healthy.’ And of course I was totally asymptomatic,” says Brezner.

“Abdominal aortic aneurysms are called silent killers because there usually are no warning signs. A family history of this condition is a strong indication to be monitored for development of an AAA,” says Zvonimir Krajcer, M.D., a cardiologist on the staff of the Texas Heart Institute at St. Luke’s Episcopal Hospital, and co-director of THI’s Peripheral Vascular Disease Service.

Up to 2 million Americans have a diagnosis of AAA, which occurs when the pressure of blood passing through part of a weakened blood vessel forces the vessel to bulge outward, forming what may be compared to a thin-skinned blister. The aorta is the large vessel that carries blood from the heart to other parts of the body. If the bulging stretches the aorta too far, it may burst, causing a person to bleed to death very quickly. Only about 20 percent of patients with AAA make it to an emergency room after a rupture, and then they have only a 50 percent chance of survival.

“It’s amazing to me that about 200,000 Americans are diagnosed with AAA each year, but only about 40,000 seek treatment,” says Krajcer. “I think a lot of people are afraid of the risks of the traditional surgery, and they’re unaware we have a minimally invasive alternative now.”

Krajcer explains that traditional surgical repair of abdominal aortic aneurysm requires making a long incision in the abdominal wall and getting behind the internal organs in the abdomen, because the aorta is located close to the spine. The surgery takes at least four hours. About half the patients have surgical complications, and there is about a 6 percent risk of dying. Recovery takes months.

“My father had an abdominal aortic aneurysm, so I was aware of the risks of rupture,” says Brezner. “I knew it would have to be corrected sooner or later, and I knew I was running a risk if I put it off.”

After Brezner’s cardiologist performed a few tests, he was able to see that the dentist was an excellent candidate for nonsurgical aneurysm repair. He referred Brezner to Krajcer, who is a leading authority on the minimally invasive procedure. Kracjer began performing the procedure about six years ago in clinical trials, and it was approved by the Food and Drug Administration about three years ago. He has performed the procedure in more than 500 patients with a technical success rate of 98 percent.

Physicians who perform the majority of stent graft repairs still use general anesthesia and small incisions in the groin to gain access to the groin arteries. Several years ago, Krajcer pioneered the percutaneous (without incision) repair of AAA with the use of local anesthesia in the groin area.

“With percutaneous repair under local anesthesia, we can significantly reduce the discomfort and complications that are seen with general anesthesia and surgical incision in the groin,” he says.

Krajcer threads a catheter into the femoral artery through a tiny puncture hole near the groin. When the catheter reaches the AAA, he can then deploy a Dacron-covered stent graft through the catheter. When exposed to body temperature, the stent graft expands to a custom fit for the patient, excluding the aneurysm and providing additional support for the blood vessel. Patients are usually discharged after overnight observation.

“I was surprised it went so easily. I was a little tender around the groin punctures but I never even took an aspirin,” says Brezner. “I had the procedure on a Thursday, was driving by Saturday, and was back at work on Monday.”

About 80 percent of patients with AAA are candidates for the nonsurgical procedure. The AAA must be located below the kidney arteries and above the small arteries in the groin. The procedure is ideal for candidates who are at high risk of surgical repair.

“The majority of my patients are either over 70 or have serious health problems such as heart disease, diabetes or very high blood pressure. This is a wonderful alternative for patients that are at high risk for surgery or those that do not have any other options available,” says Krajcer.

Patients with aneurysms more than 3 centimeters in diameter should be monitored once a year. If an abdominal aortic aneurysm expands more than a centimeter in six months, the patient should be monitored every six months. An AAA larger than 5 centimeters is dangerous, and at high risk for rupture.

Krajcer says it’s common to see an AAA develop in people over the age of 60, especially in those with a family history of the condition. Males have a seven times greater risk than women. Patients who smoke or have high blood pressure or emphysema have a ten times higher incidence of developing an AAA.

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