"A danger foreseen is half avoided": My father's abdominal aortic aneurysm is a fine example

Many patients are just not great candidates for an open abdominal-aortic-aneurysm (AAA) repair, and my dad is one of them. Stanley Walton's catlike ability to defy death is legendary, with an impressive tickertape of life-threatening events, starting with a pneumothorax at the tender age of 20. By age 78, he would have undergone a sigmoid colectomy, a melanoma excision (Clarks level III-IV), a five-vessel CABG with a three-month ventilator stay, suffered a small cerebrovascular accident postop, and then, devastating for a lover of "all things musical," the traumatic amputation of his left hand in a corn-picker accident. That one required a marathon 9-hour surgery, leaving him with only a thumb. At the end of last February, he was hospitalized for five weeks with pneumonia that almost chased him back onto his arch nemesis, "the ventilator," accompanied by a three-unit bleed, forcing the discontinuance of Coumadin (CHADS₂ score=5). Never mind the Schatzki's ring dilatation ad nauseam (literally) and the food impactions, the pneumonitis, the recurrent urinary-tract infections, and the sleep apnea he refuses to treat. Despite all of this, he still farms, attends church regularly, and eats breakfast every single Saturday morning at the local, often smoke-laden Cracker Barrel restaurant in Cave City, KY. He doesn't tolerate statins due to the development of overwhelming weakness that he attributes to them. It is no wonder that his AAA has grown by leaps and bounds. It has been nourished by renegade LDL cholesterol and sabotaged by a genetic tendency toward vascular disease. It was seeded and fertilized early on by a heavy smoking habit, long forsaken but still very much a part of his present illnesses. His glucose intolerance (never say diabetes) has been an excellent catalyst, so in three short years his infrarenal gremlin grew from an unimpressive 3.7 cm to a concerning 5.4 cm.

Ten days ago, we traveled with dad to Baptist East Hospital in Louisville, KY for an arteriogram. Dr Tom Bergamini is his surgeon because he's performed so many of these procedures on my patients with great results. Getting dad to this point wasn't easy though. We had to complete a two-stage plastics procedure on a superficial melanoma on the tip of his nose (started before we got into the aneurysm process), followed by the extraction of a "bad tooth," so as not to chance infecting the graft postop. He underwent a cardiac cath in April of this year confirming graft patency, normal LV function, and mild aortic stenosis. We had him packaged and as ready as he ever would be for the arteriogram at around 4:30 pm on September 16. Tom performed an intravascular ultrasound utilizing around 40 cc of contrast to complete the hour-long study. He was relieved there was a "4-cm neck" above the aneurysm, easily clearing his renal arteries, and a nice straight interstatelike left iliac for easy access, unlike his right iliac, which is markedly tortuous. His procedure was scheduled for September 23.

The two-hour procedure went off without a hitch. Dr Bergamini chose an Endologix device for the repair. He utilized bilateral horizontally situated groin incisions to assist in the implant of the 18-French gadget, (a garden hose compared with our 4-6-French coronary diagnostic and interventional catheters). My father awoke immediately from anesthesia with an O₂ sat of 96% on nasal cannula O₂. He drank clear liquids that evening without difficulty but did not sleep well. He ran a temp to 100.8º the following evening, attributed to atelectasis. His WBC was normal, and there were no bands. His urine and chest X-ray were clear. He had a small right groin hematoma, moderately tender but with good distal extremity perfusion. He had significant back discomfort for three nights that was treated with Ultracet (tramadol/acetaminophen), but he has chronic pain from spinal stenosis and peripheral neuropathy. He insisted that the pain was actually from just being away from his own bed. The physician in me could not resist taking a stethoscope up to his room to make certain there was no sign of those telltale rales that always herald a long and trying respiratory complication for him. Thankfully, his lungs were clear, and we came home almost exactly 48 hours from the date of endovascular graft implant. He continued to run a low-grade temp, so on postprocedure day 4, I cultured him up and placed him on Levaquin (levofloxacin), following the plan outlined by a covering physician. He's doing well now, and thankfully the main goal has been achieved: His aneurysm has been effectively excluded from his circulation.

Our experience with the percutaneous approach to AAA therapy has been extremely positive. The hospital staff was friendly, accommodating, and competent. The facility was immaculate and the discharge smooth as silk. On our OR day, the waits were minimal, although the arteriogram a week earlier got off to a late start due to the patient's procedure ahead of us requiring an extra few hours. We never uttered a word of complaint, because we were often informed of how close we were getting to our procedure time, and I completely understood, being in the profession. We took lemons and made lemonade, enjoying the opportunity to just visit and talk, a rarity for a busy family. Dr Bergamini was great throughout the entire scenario, just as he was when he was my resident in surgery almost 24 years ago. I still shudder to think of how complicated this AAA repair would have been if we had gone the "old route" with an open procedure.

The discovery of my father's aneurysm, like those of so many others, was a complete and total accident. According to Medicare.gov, any male with a family history of aneurysm age 60 to 80 who has smoked at least 100 cigarettes in his lifetime is eligible for screening, but we discovered my father's aneurysm before this cost-effective program was approved. Every eligible patient should take advantage of that one-time screening opportunity. In our cardiology practice, we screen everyone's aorta during cardiac echo and thus this accidental discovery around eight years ago led to a CT that gave my father an opportunity to avoid the 90% mortality rate that accompanies acute rupture. Serial follow-ups ensued, though there was a "too-long" three-year gap in testing due to his reluctance to deal with doctors, medical testing, and procedures. Nonetheless, he has survived the several-year-long "triple-A" journey. "A danger foreseen is half avoided," but due to the option of a percutaneous approach for abdominal aortic aneurysm repair, this particular danger for my father has hopefully been avoided altogether.

Your comments

	"A danger foreseen is half avoided": My father's abdominal aortic aneurysm is a fine example
	# 1 of 5	October 1, 2010 12:23 (EDT)
	BH Nguyen	Great story on your experience with EVAR. I would add that low grade fever and leukocytosis occurs commonly, immediately after endograft implantation and has been termed "post implantation" syndrome. It is usually not caused by infection and can be treated with aspirin and other anti pyretics. The suspicion for infection is well justified, though.
	# 2 of 5	October 1, 2010 02:20 (EDT)
	Bill H	" According to Medicare.gov, any male with a family history of aneurysm age 60 to 80 who has smoked at least 100 cigarettes in his lifetime is eligible for screening"   Just to be clear Medicare covers the screening if you have a family history OR have smoked at least 100 cigarettes.
	# 3 of 5	October 1, 2010 10:37 (EDT)
	Melissa	BH, Thanks for your post.  I had actually wondered aloud if he could be having some sort of a "rejection" or "reaction" to the device.  I've referred many patients for implants, but I've not had any occasion to care for them in the immediate post implant period so I was very concerned.  I appreciate the information and thanks for your insight!   Bill H, Thanks for your clarification.  Makes a lot more sense.   I've found so many dilated aortas throughout the years by just panning down to the iliacs post LV gram during cath that I think that should be standard practice as well. Thank you for your post and have a lovely weekend! Weather has been BEAUTIFUL here in Kentucky! (and much better appreciated now that my dad is doing better!) Melissa
	# 4 of 5	October 3, 2010 10:48 (EDT)
	Dan H.	What a beautiful piece - thank you for posting it! I try to screen for AAA in all elderly with a history of smoking (however remote) or family history of AAA. The latter is very insensitive but pretty specific.  On a personal note it is hard to attend medical procedures on loved ones when one is a physician. I've seen my father through an RP and wife through a cardiac ablation. We do our best for them and don't want to step on the health care professionals toes - they are anxious enough just knowing that our loved ones are under the knife and we are colleague-physicians. I've learned to advocate and advise but only up to a point - I try to empower rather than direct care.
	# 5 of 5	October 3, 2010 06:25 (EDT)
	Melissa	Thanks Dan!!! I'm so glad you enjoyed the piece. Dad was at church again today I'm told (I was absent for morning service because I rounded today). I hope to see him tonight at the evening service!  Hope you are having a wonderful weekend. It's been beautiful here in Kentucky but a bit cool, high of 62 degrees today with fluffy billowiy clouds everywhere against a dark gray blue sky. Mesmerizing!  Melissa

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