Thursday, November 06, 2003

In yesterday's WSJ a story about aortic aneurysm, and why they are often misdiagnosed. Multiple examples are given, mostly young people who presented to their ED with chest or back pain and once "ruled out" for an MI they were either sent home or languished in the hospital until they died.
Some interesting statistics: (from yesterday's story as well as from January 13, 2003)

A common misconception among physicians is that aortic disease is rare, when in fact it kills an estimated 25,000 Americans a year. That is a larger toll than that of AIDS and most kinds of cancer

The National Institutes of Health will spend $2.77 billion for research on AIDS this year, along with $732 million on breast cancer and $408.3 million on prostate cancer. The amount for abdominal aneurysms is just over $6 million.

About eighty percent of aortic aneurysm deaths are from abdominal aorta, the remainder are those in the chest. The young people mentioned in the story almost certainly had a genetic cause for their aneurysms, such as Marfan or Ehlers-Danlos syndrome. These usually present in the chest. The most common aneurysms occur in the abdominal aorta, and these occur most often in older individuals with atherosclerosis.

There are many advocates for ultrasound screening especially for men over the age of sixty with vascular disease or tobacco abuse.

A huge British study provided some last fall. After following 61,000 men aged 65 to 74 for an average of four years, it found a 42% drop in risk of death from abdominal aortic aneurysm among those who had been screened. Their aneurysm death risk was 1.9 per 1,000, vs. 3.3 in the others. "Screening can significantly reduce mortality rates associated with abdominal aortic aneurysms," concluded the study, published Nov. 17 in The Lancet, the British medical journal.

There is some debate over whether this is cost-effective. I think it is because (and I know this is anecdotal) every patient with a ruptured aneurysm that I have operated on had no idea they had any problem.

Ruptured aneurysms carry a mortality rate of 80-90 percent. An attending where I trained wouldn't even repair a free rupture because they had no chance of leaving the hospital alive. Elective aneurysm surgery carries risks as well. Renal failure, MI and limb loss may occur. Colonic ischemia can be especially problematic. Even years later the patient may have an aorto-enteric fistula, a diagnosis that should be high in the differential in any patient with a history of aortic surgery and a GI bleed (the fistula may be primary, or form the aneurysm itself)

Newer endovascular techniques are helping to eliminate the physiologic complications from open aneurysm repair. Some of the earlier devices had problems which the company covered up and now they are getting to meet the lawyers. The company will (justifiably) get punished, but I feel that this is a bit much.
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