Aortic Aneurysm: Living Six Months At A Time

About 19 months ago I was diagnosed with an Abdominal Aortic Aneurysm while being checked with an IVP for kidney stones by my Urologist.

Approximately 20 months prior to this discovery I was Rushed to the nearest Hospital for a kidney stone. I had no health insurance due to being downsized at the age of 62. The Urologist who treated me and removed the stone told me I had a very large kidney stone lodged in the top part of my right kidney, and wanted me to go to Augusta Georgia to the medical school and have lithotripsy to break up the stone. Because of the lack of insurance I could not afford to have the treatment at a Hospital in Atlanta. I made the decision not to do this, but to wait until I had Medicare coverage.

The Doctor who removed the original stone was a person trained in a foreign country. He told me he was Board Certified, he was not. I later discovered that the aneurysm is a disease most common to white men of European decent. He had probably never seen or heard of the disease in his medical training in India. For some strange reason I was under the impression that foreign Doctors had to be further trained and take a license exam to be able to practice in this country. Apparently I was wrong. I don't know why the Radiologist didn't report the finding to the Urologist. There seems to be something wrong with the whole set up. I had a classic AAA, which he diagnosed as the large Kidney Stone, and if I had gone to Augusta for lithotripsy, I probably would have died in the tank, because the Aneurysm would have ruptured.

After the discovery of the Aneurysm, my Internist, who has cared for me for the past thirty years sent me to a Vascular Surgeon close to his office. When he was through with his examination of me, he informed me that I had a 3.4 cm Abdominal Aortic Aneurysm and his prognosis was that I had a twenty five percent chance of surviving surgery, but most likely the Aneurysm would rupture and I would be dead in ten minutes. To say I was in shock was an understatement. I talked with my internist and he told me the Doctor was prone to exaggeration, and not to be concerned.

I went back to see the Vascular Surgeon at his request in three months. At that time I asked him how many AAAs he had operated on, and he told me that he just saved the life of a ninety five year old woman. I again asked how much experience he had with AAAs and his response was he had just answered my question and that was all he was going to say on the matter. At that point I uttered a few well chosen words and told him if he sent a billing to Medicare for that visit I would protest the payment. I guess he got the message because he never did try to bill Medicare.

I immediately called my internist and found he was out of the country with his wife celebrating his birthday and would not be back for several weeks. I immediately got on the Internet and went to YAHOO and searched for Aneurysm. I was pointed to the Aneurysm page of Dr. David Tilson at Columbia University in New York. The page was very helpful in answering most of my questions. I E-Mailed Dr. Tilson and gave him a narrative of my experience and asked him to recommend another Doctor in Atlanta for a second opinion. He suggested I talk to Dr. Robert B. Smith, III, Professor of Surgery, Head, General Vascular Surgery, at Emory University Hospital in Atlanta, Georgia.

On my first visit he confirmed the Aneurysm and its size. I asked him what my chances were and he informed me they had about a two percent mortality rate and AAAs were the second most common surgery they performed. He also explained that the chances of rupture were not significant in AAAs under 5 cm., and to stop worrying about the AAA and come back in Three months for another Ultra sound exam. The results showed the AAA had grown to 3.9 cm. I went back six months later and it had grown to 4.3 cm. I will be going back in November, 1996 for another check up, and if it has grown to 5 cm or larger they will then consider surgery.

I have the greatest respect for Dr. Smith and his way of handling patients and I consider myself lucky to have been directed to both Dr. Smith and Emory Clinic. I have not worried about anything since he put me at ease the first time he examined me. Of course there are no guarantees regarding the surgery, but with all my many complications I still have the utmost confidence in his ability, and whatever the outcome, I feel that I have had the very best of care.

I have continued to correspond with Dr. Tilson and check his page every week or so for additional information, and, of course the Aneurysm support page at State University of West Georgia. Both of the pages give great information, and outstanding support for those having all types of Aneurysms.

I currently have the following medical problems: abdominal aortic aneurysm; high blood pressure; aortic stenosis; calcification of aortic valve; kidney stones (had surgery to remove one stone lodged in right ureter 1/14/98, released from hospital 1/16/98); gall stones; diverticulitis (active, had a colonoscopy on 11/9/95); need bowel resection; hospitalized with a severe diverticulitis infection 7/22/97 until 7/29/97; hospitalized april 20, 1998 until april 24, 1998 for diverticulosis; enlarged prostate; flexor tenosynovitis of both hands; osteoarthritis of the neck and lower back; high cholesterol; there is a possibility that I may have had a mini stroke (1995); macular hole in right eye, vision is 20/200, legally blind in right eye; mini stroke august 31,1997, hospitalized until september 3, 1997

I am under the care of physicians with specialties in: Internal Medicine; Vascular Surgery; Urology; Cardiology; Neurology; Arthritis.

Just returned from Emory Hospital for my six month check up with Dr. Robert B. Smith III, MY Vascular Surgeon. My AAA has reached 5cm and he has scheduled some tests because of other problems and a return to see him for a surgical schedule. I see him on June 25th, 1998.

It has been a long wait, ( going in every six months) for a check up. I feel funny having waited so long, and now what I've been waiting on, my AAA reaching 5cm and now surgery.

I am scared, but still feel great confidence in Dr. Smith. I will update when I see him on June 25th and have a date for my Surgery.

On June 25th, 1998, I met with Dr. Smith to set a schedule for my surgery. Dr. Smith informed me that I had a choice of Endovascular surgery or regular invasive surgery. I told Dr. Smith that I wanted the invasive surgery because, over a long period of time I had done a lot of research on the Endovascular surgery and had read many articles at the Mayo Clinic and on Dr. Tilson's page, as well as many other sources available on the Internet. I felt that with the information I had found that there was a failure rate of between 10 to 13% with the Endovascular method. I felt that with my medical problems, I was most comfortable not taking the risk of having to undergo another procedure down the road. I had not asked Dr. Smith his opinion on which surgery he would recommend for me, the next time I see Dr. Smith I will ask what he would have recommended.

On July 1st, 1998, Bill Maples e-mailed me with the following suggestion. "It would be interesting to post a journal of thoughts, and medical procedures, from your hospital check in time, through the first week thereafter. Of course you'll not be permitted to carry your pencil and paper into the OR. (g)" (meaning grin). I did Bill one better by asking a Vascular Fellow who was going to be involved in the surgery with the permission of Dr. Smith, to do a write up of the surgery in laymen's terms, so that it could be published for others awaiting a similar procedure to see what it was all about. Dr. Weiss's letter is published as part of this narrative.

We set a time schedule that allowed Dr. Smith the opportunity to talk with the other physicians treating me and get their input. We scheduled the Arteriogram for July 21st, 1998, and AAA surgery the following day. The estimated time of discharge, following successful surgery, was approximately 6 days.

I checked into the out patient clinic about 9:00 am on July 21st, to have the arteriogram performed before admission to the hospital. They knocked me out for the arteriogram and I slept the rest of the day. I had no recollection of going down to the operating room early the next morning. The following is Dr. Weiss's letter explaining the surgery.

The following is a facsimile of a letter describing the procedure used on the very successful repair of my aneurysm.

August 16, 1998

Richard Henig

As you have requested, I have detailed the steps involved in your surgery. I have attempted to explain this in as simple terms as possible. I will also be as generic as possible, since some of the features specific to each case may differ from patient to patient.

Once you are taken into the operating room from the holding area you are asked to slide from the stretcher to the OR table. The anesthesia personnel introduce themselves, and may place an IV line in your arm prior to putting you to sleep. Often they will have you breathe concentrated oxygen from a mask as they give you medicine in your vein, causing you to drift off. From this point on, you have no recollection of events, or even of time passing.

Once you are sleep, the anesthesia people (attending anesthesiologists, residence, PAs, etc.) become busy placing more lines. These include an arterial line (usually placed in the radial artery in your wrist) and a central venous (usually in the Jugular vein in your neck). We also place a catheter into your penis to drain urine from the bladder. We examine your feet for pulses or listen with the doppler machine for signals indicating blood flow. The final step in the case is to re-inspect your feet and make sure that these signals are still present, since one of the potential complications of the operation is to have plaque shoot down your leg causing the blood flow to be compromised. Your abdomen is then shaved and washed with betadine solution. The surgeons then go out to scrub. You are, or already have been, receiving antibiotics at this time.

We then start to drape the operative field with sterile towels. The incision will vary among surgeons and patients, depending upon several factors. Generally either a vertical midline incision is made on the abdomen from the bottom of the chest, around the belly button and down to the pubic area, or transverse incision is made horizontally above the level of the belly button. In either case, after the incision is made, a bovie-cautery (an electric pencil which burns through tissue, stopping bleeding as it cuts) is used to go from an area just under skin, through the muscles of the abdomen and into the peritoneal cavity in which the organs are housed.

Once we have entered this peritoneal cavity, we briefly feel around to search for unexpected findings, (i.e. tumors). This is rarely if ever found. We then place an elaborate set of retractors into the abdomen to hold the skin apart, as well as hold the large and small intestine away from the aorta.

The exposure of the aorta then begins by dividing the tissues covering the aorta above and on the sides with the cautery. We generally expose the aorta from the level of the renal (kidney) arteries to the bifurcation (the area were the aorta divides into two). Many people have enlargement of not just the aorta, but the iliac arteries as well. Depending on the findings, a graft in the shape of a tube, or in a "Y" shape may be used. On occasion, additional incisions may be necessary in the groins to sew the lower portions of the graft into the femoral arteries.

Once an adequate portion of aorta has been expose, the patient is given a dose of heparin (blood thinner) to prevent clot formation while the arteries are clamped. We then place clamps on the iliac arteries and the aorta. The cautery is then use to open the aortic aneurysm. At this point the blood lost increases as blood contained within the aneurysm is shed, along with bleeding that can continues from lumbar arteries. These are vessels which enter into the aorta from the bottom. We used the "cell saver" which recycles this lost blood and gives it back to the patient, thus limiting the amount of blood transfusions from the blood bank. Once the aneurysm is open, we manually scoop out handfuls of the material which lines the aneurysm. It often resembles soft cheese, and would be a great sales pitch for a low fat diet if people could see this step in the procedure! Remember that often times there is still bleeding from those lumbar arteries in the bottom of the aorta these are simply sewn shut from within the aneurysm to stop them from bleeding.

The appropriately sized and shaped graft is obtain and the proximal anastomosis is begun ( the uppermost area where the graft is sewn to the aorta). This is performed with a suture that starts at the bottom, and both sides of the suture are brought around circumferentially. Once completed, the sutures are tied, and the clamp is moved from the aorta to a positioned below the union of aorta and graft (this allows blood to flow through the anastomosis and if there are any leaks, they are repaired with suture). We then performed the distal anastomosis (the lower most connection of aorta or iliac arteries to graft) in a similar fashion.

Once the anastomosis are completed, we inform anesthesia that we are going to slowly release the clamps. They are prepared to give fluids and medicine to counteract the expected drop in blood pressure that comes at this point in the operation. Once the clamps are released, the anastomosis are again inspect. Prior to clamping the aorta, an inspection of the inferior mesenteric artery (IMA) is made. We must decide whether we will need to implant this artery into the graft at the end of the case. The IMA supplies blood to the lower part of the colon. Most often the colon can live without blood from the IMA, as it can receive blood from other surrounding blood vessels. At this point we decide whether to implant the IMA or not.

Often times we will now asked the anesthesia people to give a medicine to counteract the heparin, in order to promote clotting. This is because many of the expose sites are "oozing". When we are happy that the bleeding and oozing is controlled, we then start to close.

Closing involves several steps. The aorta is close over the graft, to minimize graft exposure. All of the layers which were divided in order to expose the aorta are then sewn closed, including the covering above the aorta, the muscles (more correctly the fascia - the thick connective tissue of the abdominal wall) and the skin. The last step involves examining the feet to ensure there is adequate blood flow.

The operation time can vary substantially, often from 2.5 to 5 hours. There are many potential problems that can arise which will add to the operative time. Additionally, some surgeons are slower than others.

I hope this help to you to understand what went on while you were asleep. It was a pleasure to take care of someone so knowledgeable in aortic aneurysms. If I can be of any further assistant, please don't hesitate to ask. You can reach me through Dr. Smith's office.

Sincerely,
Vic Weiss, M.D.
Vascular Fellow
Emory University Department of Surgery

I had no awareness of time, but I think I was out for at least another day possibly two. When I started to become aware of my surroundings I found myself in a private room and was receiving several blood transfusions and was told that I had become a free bleeder and my blood would not clot. They them gave me a shot of Vitamin K to help stop the blood seepage. I was not in pain at any time during the first days following surgery. The nursing staff and the Physicians Assistants were great. They were well trained by the vascular surgeons to do post operative care. I have never had better care from a well organized group of caretakers than I had at Emory Hospital. I became aware that I was a purple people eater from just below the incision down to and including my groin area, thus the need for blood transfusions and the shot to help my blood to clot. I was still pretty out of things and was receiving oxygen. When I asked what was going on they told me I had contracted Bronchitis and Pneumonia and was being treated for both as well as post-op care. I think I became aware of what was going on about the fourth or fifth day after surgery. My first time out of bed I was pretty wobbly and had to have someone hold my arm. The next few days I was able to start navigating fairly well. About the eighth day after surgery both Dr. Smith and Dr. Weiss came in to see me and they were both leaning against the wall at the bottom of my bed and Dr. Smith (with a very straight and serious face ) accused me of trying to mess up his statistics. I started to laugh and both of them were laughing, at that point I knew I was starting to get better. I spent a total of fifteen days in the hospital and was discharged on August the fifth. I went home to a friends house and stayed there for a couple of weeks before going home. I live alone and needed to be able to take care of myself. From that point I started to get well very quickly.

It is almost a year since my surgery and I feel great. Looking back I realize that fifty four years of smoking made me susceptible not only to the Aneurysm but to the other problems after surgery.