Background and Numbers

At least one person has asked if this surgery is in fact indicated for someone of Dad's age and condition. Beyond the assurances of the surgeon, I think so. Here's one article suggesting that it is:

Abdominal Aortic Aneurysm Repair Outcomes For Seniors Reviewed

Another thing that people tell you to do is determine the rates at which these surgerys are done at the hospital you're planning on using. I did not find these figures easy to come by. But here's what I found for New Jersey hospitals. By happenstance EVAR is one of the six or eight procedures that New Jersey has chosen to report on. Reassuring for me, but I have no idea what you would do if you were having something else done. But the data are for 2005, so while better than nothing, they're probably only marginally reflective of what's happening now.

In summary: At the hospital dad is going to, in 2005 they performed 19 of these procedures, meeting "threshold 1" for procedure frequency (10), but not threshold 2 (32). This is important because

One study that evaluated the impact of total vascular surgery volume found a significant effect for both ruptured and intact aneurysms.⁴⁰ Empirical evidence shows that AAA repair volume and mortality—after adjusting for age, sex, and APR-DRG—are independently and negatively correlated with each other (r=-.35, p<.001).⁴¹

40 Amundsen S, Skjaerven R, Trippestad A, et al. Abdominal aortic aneurysms. Is there an association between surgical volume, surgical experience, hospital type and operative mortality? Members of the Norwegian Abdominal Aortic Aneurysm Trial. Acta Chir Scand 1990;156(4):323-7; discussion 327-8

41 Nationwide Inpatient Sample.

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AHRQ Quality Indicators
Guide to Inpatient Quality Indicators:
Quality of Care in Hospitals – Volume, Mortality, and Utilization
http://www.qualityindicators.ahrq.gov/downloads/iqi/iqi_guide_v31.pdf

On the other hand, none of those 17 patients died, which is encouraging. The quality data is from "Inpatient Quality Indicators - New Jersey 2005" pages 10 and 14. http://www.state.nj.us/health/healthcarequality/documents/iqi2005.pdf

Finally, the question of whether to do the single stent and bypass to ensure blood flow to both iliac arteries, or to do a bifurcated stent and supply both arteries directly. Total absent of the particulars of the case, the following article seems to indicate that the bifurcated stent is slightly preferable:

We do not know the long-term patency of a femoral artery to a femoral artery bypass graft. By placing the AUI stent, the blood supply to both limbs are at risk if the iliac portion of the device has a mechanical complication.

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The Use of the Aorto-Uni-Iliac Device in the Treatment of Abdominal Aortic Aneurysms
VOLUME: 5 PUBLICATION DATE: Nov 01 2008
Issue Number: 6 Nov/Dec 08
http://vasculardiseasemanagement.com/content/the-use-aorto-uni-iliac-device-treatment-abdominal-aortic-aneurysms

Overall, I've found the process of getting good data to be rather frustrating, and I'm very skeptical of all the people who say that if you don't do a complete statistical run-down on your prospective hospital and surgeon you're not doing due diligence. The data either aren't out there or are very hard to find. I would have expected good data from the government, who claims to have an interest in limiting health care costs and improving outcomes. And indeed the best data I've found has been from the government, but it's pretty outdated.

All in all, this is not an issue for us because A) the hospital where Dad is getting his procedure done (and the surgeon, to the best of our knowledge) are pretty good, and B) He's decided that he doesn't want to shop around anyway.

So this is about as much due diligence as I've done.

Back on Track

Monday October 12th dad finally went in for the stress test. It sounds like his rash isn't totally gone, but it's not acute anymore.

Typically, a stress test is where they put you on a tread mill and run you till you drop. Well, I'm sure it's more scientific than that, but that's the common (and my) perception. This is not such a good idea for the aged and infirm, so when the Portsmouth NH hospital said they wanted to do a stress test on my mom when when she fainted dead away on Star Island in 2005(?), I was alarmed.

It turns out, we observed, that (in the words of Wikipedia), "patients ... who are unable to walk safely can be 'exercised' pharmacologically instead of by walking on a treadmill. The patient will typically receive a ... vasodilator or [a drug] which stimulates heart rate and pumping force while a cardiologist or physician assistant reviews the ECG tracing and checks blood pressure periodically."

This is the kind of test they gave mom back in 2005, and the kind they elected to give dad on Monday the 12th. We were a little surprised at the results. Although I wasn't on the phone with the doctor who gave dad the results, I gather the conversation went along the lines of, "So when did you have your heart attack?" To which my dad responded, "What heart attack?"

I knew that heart attacks leave chemical markers in the blood, but apparently they also leave scar tissue on the heart (which isn't to surprising upon reflection, since some heart muscle probably dies from lack of oxygen during the event). From the changes they saw in dad's heart, they concluded that he had had a heart attack.

There was some base-line data to work from, from a 1997 (or was it 1992 - details to be confirmed) stress test this same cardiologist had done on dad. Since then, dad did have a fairly major stroke the effects of which wore off almost completely after a couple of months. This led us to believe that it had been a minor event, but I recall the Dr. saying that though it had been largely asymptomatic, it had been relatively big.

Dad's characterization of his surgeon's attitude towards this was, "Well, that's all very interesting but we're going to do this anyway." As in fact we are.

So at this point, the EVAR stent procedure is scheduled for Monday, October 19th. Some time later this week there will be a conversation with the surgeon, at which I hope to be present by telephone so that I can ask my questions about the bypass.

Travel plans to be determined.

Nothing is Ever Simple

Thursday night (October 1st) Dad called me. He had the most horrible rash, and said that he hadn't gotten much sleep the previous night. I don't think I understood just how bad it was. He had a dermatologists appointment the following day and was wondering if he should take benadryl just to get more comfortable for the night. I thought not, because if there's nothing to see, then what can the dermatologist do?

Turns out that was not a problem (unfortunately). Dad took the benadryl and was still in extreme discomfort overnight. The dermatologist's diagnosis was allergy to the dye used in the CAT scan, for which the only cure was topical - oatmeal baths etc.

But the stress-test folks (on Monday the 5th) took one look at him and said "No way." So for most of the week we were just "on hold" waiting to see what would happen.

In the event, they re-scheduled the stress-test for Monday the 12th.

All through this, the cardiologist's advice has been to carry on as usual, leaving out the heavy lifting (not a problem), and trips to the gym (something dad still enjoys 2 or 3 times a week).

Waiting for the Shoe to Drop

Monday, September 28 dad went in for his CAT scan. I wasn't around, but by all reports it was uneventful. We waited on tenterhooks all afternoon for results because at that point we didn't really know the size of the aneurysm, nor its exact location. Anything above the renal arteries is more complicated, and anything under 5.5cm might just be a "wait and see" kind of thing.

No news.

Tuesday we're still waiting on tenterhooks. Finally, in the afternoon dad unearths a piece of paper that says "We'll call you with results 48 hours after your CAT scan. After some good natured ribbing from me and serious kvetching from mom, we attempt to relax and wait for Wednesday.

Wednesday, just as I'm walking in to the local store with Zac to buy him some clothes, my cell phone rings. I had been at pains to make sure that I could participate in the conversation my parents had with the surgeon and he called while he was talking to them.

That is when we learned all the particulars about the aneurysm (6cm infra-renal), and when the surgeon let us know his preference for a procedure: a stent. The Wikipedia article is brief, but gives you the idea: you thread a hose liner up into the widened part of the artery to relieve the pressure on the (presumably) weakened arterial walls. Relieved of pressure, they then settle back around the "liner" (stent) and all is well.

The slight complication, which I'm still trying to understand, involves the fact that, due to an insufficient "landing zone" at the bottom end of the stent, the surgeon expects that he will be unable to supply blood to both iliac arteries. He needs an 18mm margin at the top and bottom, and has only 17mm at the bottom. I have no idea what the tolerances are here, but he clearly doesn't believe that he'll get what he needs.

So the plan is to do a bypass from below the end of the stent to the other (right, I think) iliac artery. I don't understand why that's preferable to one of the bifurcated stents illustrated in the wikimedia commons picture.

So at that point, the major piece of work-up remaining before the surgery was a cardiac stress test, scheduled for Monday, Oct 5th. Surgery was scheduled for Monday, Oct 12.

Jordan Sr's Aneurysm Drama Begins

This section of blog entries will be about Jordan Sr., who's having one of those health episodes that happen when you're 89 years old. Actually, our story starts when he was just about to turn 89, on September 24th, 2009. I was planning to surprise him for his birthday and just show up on the eve - September 24th, for what I expected would be a quiet but celebratory day on the the 25th.

While my train was pulling in to Penn Station in New York (from Albany), I got a text message from Margy saying that my dad had an aortic aneurysm. That's the brave new world: bad news by text message.

As you might imagine, much telephone calling ensued while waiting to change trains in New York, culminating in a taxi ride from Princeton Junction to my folks' house.

The story: Dad had what turned out to be a urinary condition that led him to his doctor that day. The doctor (the urologist, I think) was sufficiently concerned that he walked dad over to the hospital for the ultrasound. That's when they discovered the aneurysm.

These come in several sizes: the "don't worry about it but watch it" size, the "holy smokes, this could go at any time" size, and the "we'd better do something about this" size. Dad has the medium sized one - close to 6cm in diameter, where the limit of "don't worry about it" is 5.5cm.

Aneurysms also come in several locations, the most common being below the renal arteries and above the iliac ones. The renal location is why they found this in the course of looking at what was wrong with his kidneys. And that's exactly where his is. The wikimedia commons picture is quite good; follow the link if you're interested; the Wikipedia article is quite good as well. All of this was, of course, unknown to us on that Thursday night, so we were fairly stressed out.

In fact, at that point he had had the ultrasound, and was to be scheduled for a CAT scan some time Friday, with the admonition from the nurse at the practice that if radiology didn't call, we were to call her to make sure the appointment was scheduled for sooner rather than later. In the event, they called and scheduled the CAT scan for Monday, which the cardiologists were satisfied with.

So I stayed the weekend and went home on Sunday night.

Zac at Blenheim Palace, England

Did we mention how tall Zac is getting?

Meg and Tonia in Cambridge, England

Here are Meg and Tonia when we visited Tonia and John and Sarah while they were living in Cambridge, England.