There's a reason abdominal aortic aneurysms are called silent killers. Commonly referred to as AAA, or triple-A, this swelling of the body's main blood vessel in the abdomen can develop and worsen without causing symptoms. If it bursts, 70 percent of patients die from massive blood loss, even if a hospital is nearby.
Rex Norris of Mulberry thought he was in pretty good health until about three weeks ago when he saw blood in his urine. An abdominal CT scan revealed Norris, 82, had a tumor in his bladder, which was probably responsible for the blood. But doctors also found a large bubble on the wall of his aorta. "It was huge," according to Dr. Bruce Zwiebel, director of vascular and interventional radiology at Tampa General Hospital. "It was about 8 centimeters. It needed to be fixed right away."
Small aneurysms, less than 5.5 centimeters, or about 2 inches, are less likely to rupture but warrant careful monitoring. Larger aneurysms like Norris', which was the size of a small apple, are more likely to rupture. But like most patients, Norris had no idea it was there.
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The Society for Vascular Surgery estimates that more than 1 million Americans have an AAA and don't know it. According to the National Institutes of Health, 14,000 Americans die each year from the condition, a fraction of the more than 600,000 who die of all forms of heart disease.
The defect can be found with a painless abdominal ultrasound. Medicare recipients with certain risk factors can get a one-time screening ultrasound if they get a referral as a result of their "Welcome to Medicare'' physical exam. But although this test is being offered more often these days, medical authorities including the U.S. Preventive Services Task Force say it's for people with risk factors, and it shouldn't be considered a routine heart health screening such as cholesterol and blood pressure checks.
Most AAAs are discovered during tests for unrelated problems, such as a CT scan or MRI for gallbladder disease or back pain, said Dr. Thomas Maldonado, a New York University vascular surgeon. He is part of the Find the AAAnswers Coalition, a national alliance of physicians working to increase AAA awareness and screening for people at risk.
"When they are picked up this way, it is really a blessing because they can be treated before they become symptomatic or rupture,'' he said. "But why take a chance on having it detected coincidentally? Knowing whether you are high risk and requesting a screening makes more sense. Awareness is the most important thing. If you're at risk, get screened."
Tobacco use is the biggest risk factor, but age and gender also matter (see box at right).
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Doctors usually take a "watch and wait" approach with small aneurysms, but they must be treated if they seem to be growing. There are two major treatment options: Either the abdomen is opened and the diseased part of the aorta replaced with a synthetic graft or tube, or a less-invasive procedure is employed in which the aorta is reached with a catheter and a stent graft is used for the repair.
Eighty percent of patients qualify for the catheter approach, in which the stent, shaped like a tiny pair of pants, is expanded so it presses against the healthy walls of the aorta, closing off the aneurysm and making a new pathway for blood flow. Zwiebel and vascular surgeon Dennis Bandyk performed that procedure on Norris on Monday at Tampa General.
This less-invasive procedure, introduced in the 1990s, has meant many more people can survive a triple-A. "Patients previously considered too elderly or too sick to have the repair now have another option," Zwiebel said. The open surgical repair means an incision from the breastbone to the pelvic bone, a week to 10 days in the hospital, plus a long recovery at home. But the catheter procedure usually requires just one or two nights in the hospital and allows the patient to return to normal activity within two weeks.
Norris has other health issues that are expected to keep him in the hospital until Friday. His 60 years of cigarette smoking, his family history and age all put him at high risk for AAA.
But he's optimistic. He says his father was diagnosed with an AAA at the age of 92, had a surgical repair and lived another 10 years.
Irene Maher can be reached at firstname.lastname@example.org.
This story has been updated to reflect the following correction:
Vascular surgeon Dennis Bandyk participated in Rex Norris' AAA repair.