Not the American Automobile Association

The third week has been more or less the same as last week. I mainly shadowed Dr. Vouyouka through her clinic, which, as enjoyable as it is, becomes pretty repetitive after a while. Maybe it’s the batch of patients that have been coming in. Maybe I’ve already learned more than I expected by the third week. Or maybe I’m just really ADD and want the new and shiny things.

Many of the patients who come in with vascular diseases get them fixed noninvasively. The technology has advanced in this field to where most of the procedures rely on catheters. Only the more difficult cases require open surgery, such as fixing an abdominal aortic aneurysm, or triple-A in vascular lingo. I remember a nurse telling me that the triple-A is the most interesting and rare surgery to watch because after opening the patient up, the surgeon has to move the internal organs out of the way (read: out of the body) in order to reach the aorta. A graft is then used to replace the site of the aneurysm.

I thought that because the surgery was so rare that the triple-A itself must be very rare. On the contrary, I’ve seen at least four patients during clinical hours with enlarged abdominal aortas. It turns out that surgeons wait until the aneurysm is either symptomatic (patient feels pain because it pushes against nerves and other tissues) or has a diameter greater than 5 cm. They use this number because empirical data shows that the risks of the procedure outweigh the benefit if the surgery is performed on aneurysms under 5 cm in diameter. For reference, the diameter of a normal aorta should be less than 2 cm. Most of the patients that Dr. Vouyouka has seen have aortic diameters of 4.2 to 4.8 cm.

So if I’ve already seen 4 patients with triple-As, I should get to watch an intense surgery soon, right? Nope. Most of the time the aneurysm grows very slowly and sometimes doesn’t grow at all. All Dr. Vouyouka can do for now is to have the patient come in every 6 months to get CT scans and duplexes (ultrasound) to make sure the aneurysm isn’t growing too fast. Even if the aneurysm turns out to be greater than 5 cm and something needs to be done, there is a less invasive alternative to open repair: endovascular aneurysm/aortic repair (EVAR). With this technique, access to the aorta starts with a catheter being inserted through the groin, and the procedure ends with a stent graft being used to create an artificial lumen for blood to flow through.

I believe younger patients are able to get open repairs since they heal peri-op without as many complications as older patients. Since EVAR is relatively new (started in the 90s) and post-op results are pretty similar to that of open repair, a study is currently being done to evaluate if EVAR is as successful if performed before the aneurysm is greater than 5 cm. This way, patients can get the operation earlier and don’t have to worry about their aneurysm suddenly rupturing, which almost always ends in death.

In other, lighter news, the week ended with Independence Day. A few friends from high school flew up to visit, and we explored NYC, ate fancy French food, and barhopped around NYU. Good times (that don’t need to be blogged about here).