Aortic Aneurysms

Understanding Aortic Aneurysms with Dr. Raghuveer Vallabhaneni

Host: Debra Schindler
Guest: Dr. Raghuveer Vallabhaneni, Director of Vascular Surgery, MedStar Health Baltimore Region

The aorta, your body’s largest blood vessel, acts like a fire hose — forcefully pumping blood from your heart to every part of your body. Over time, parts of the aortic wall can weaken and stretch, forming a bulge known as an aneurysm — a silent and potentially deadly condition. In this episode, Dr. Vallabhaneni explains the difference between aneurysms and aortic dissections, discusses risk factors such as high blood pressure, smoking, and genetic predisposition, and emphasizes the critical importance of screening and early detection, especially for men over 65 who have smoked.

In this episode of DocTalk, Debra and Dr. Vallabhaneni discuss:

·       Types of aneurysms (abdominal and thoracic)

·       Who should be screened

·       Warning signs and when to act

·       How aneurysms are monitored

·       Treatment options, from lifestyle changes to minimally invasive stent procedures (EVAR)

·       Why lifelong follow-up care is vital after a repair

Dr. Vallabhaneni also shares remarkable cases, including treating a 13 cm aneurysm and how imaging advancements have revolutionized care.

Key Message: Most aneurysms grow slowly and can be safely monitored, but they become dangerous when undetected. If you or someone you love is at risk, screening can be lifesaving.

Baltimore-area listeners: To schedule an appointment with Dr. Vallabhaneni, call 410-554-2950.

For more episodes of MedStar Health DocTalk, go to medstarhealth.org/doctalk.

Transcript

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Comprehensive, relevant and insightful conversations about health and medicine happen here on MedStar Health DocTalk. These are real conversations with physician experts from around the largest healthcare system in the Maryland DC region. The aorta is your body's largest blood vessel To understand how vital and vulnerable the aorta is, picture a fire hose. Imagine that the fire hose is connected to your heart and with every beat, every single second blood is rushing through it from the heart to every organ, every limb, every inch of you traveling roughly at three feet per second. A blood cell in the average person travels through the entire body in about one minute, which incredibly equates to 83 gallons of blood an hour. Over time, like a fire hose section of the aorta can weaken under the pressure the wall stretches and thins out, and that's when an aneurysm can form a bulge that may go unnoticed until it ruptures. Today on doc talk, I'm joined by Dr. Raghuveer Vallabhaneni, the Director of Vascular Surgery in the Baltimore region of MedStar Health, to discuss the hidden dangers of aortic aneurysms, the importance of finding them and how they're treated. I'm your host, Deborah Schindler. Dr. Val Benini. Thanks for being with me today. Thank you, Debra. I appreciate the opportunity to discuss a topic close to my heart. Literally. Right. I think the first time I heard of an aortic aneurysm was when John Ritter from the old TV show, three's company died because of an aneurysm, rupturing known as a dissection, something that also claimed the lives of Albert Einstein and Lucille Ball. Are they common? That's a great question. Deborah aneurysm and aortic pathologies are one of the leap in men, especially over the age of 60. They are quite common, and as we all speak about today, I do refer them as the silent killer because aneurysms can develop and you don't really know that they're a problem until they're about to burst, which could be too late in some situations. Typically, in most aneurysms are what we call asymptomatic or they don't produce any symptoms until they get to a point where there's a lot of tension on the wall of the aorta. Like you mentioned, it's sort of like a fire hose. So if that section of the fire hose begins to bulge, you don't really feel that it's about to burst or cause a real problem until it's stretched to the point where it's actually tearing. So the symptoms of that late stage would be things such as severe back pain, abdominal pain pressure in your abdomen. It also could, depending on where in the aorta the aneurysm is located, caused chest pain as well. A lot of patients when they come in, they feel like they're dying and that's what they say. They don't know what's going on. So it's not something subtle. It's not like an ache in your back, like if you have lower back pain, don't be concern that that's an aneurysm because it is unlikely that that's what it is. However, screening is a very important way of detecting these aneurysms prior to them becoming a problem. We actually had a colleague here at MedStar Union at his desk, just collapsed, fell over, and luckily he was in the hospital when this dissection happened and they were able to save him for him to share his story and tell us about it. But sitting at his desk and I mean that's pretty quick. When. This rupture happened. It can happen. And I just want to clarify a few things and different types of aortic problems. So the first one is an aneurysm, which is the bulge in the aorta, which is caused by the weakening in the wall, which grows slowly over time and then can rupture if it gets too large and is untreated. The other problem that could happen in the aorta is something like you mentioned called a dissection. That's what John Ritter had as well as Lucille Ball. And what that is is a high blood pressure or a weakening of the aorta from either a small aneurysm or a problem with the tissue of the aorta causes a tear in the wall, which makes blood go in the wall of the aorta as opposed to where it's supposed to go in the tube of the aorta down to the vital organs. This causes a tearing sensation and further weakening of the aorta, which could cause bleeding and rupture. So this is definitely something that has certain risk factors that can be treated and prevented before they become a problem. The risk factors for aortic dissection are the most common one is very high blood pressure. The high blood pressure causes such a force in the aorta that it can cause a tear or a hole in the wall of the aorta. The second most common reason for this is a problem with the patient's, what we call connective tissue or the strength of the tissue that holds everything together. That can be from either a genetic variation where either someone in your family passed on something onto you that makes your aorta weaker, or it could also be from you having a small aneurysm, which is weaker tissue by nature. Those are the most common causes of an aortic dissection. So along with the aortic dissection, there's also two different kinds of maybe more, but let's talk about the two different kinds of aortic aneurysms. You have abdominal aortic aneurysm, the aaa. Yeah. So let me talk about the aortic dissections first, then we'll talk more about the aneurysms. And I want to make sure everyone understands there are two separate things. Dissections are the tear and the aneurysms are the bulge. So with dissections, they could start in your chest or they could start in the back of your aorta and your upper chest, and sometimes they could be a life-threatening heart attack. If there is a tear there. With the aortic aneurysms, they could also be located anywhere along the whole length of the aorta. So it could be located right next to your heart all the way down to in your pelvis. It could also be in the blood vessels that go to different organs as well as even in your leg arteries. How long is that aorta? Well, the aorta goes right from the heart and the chest, and then it forms in the shape of a candy cane and it goes down to around the area of your belly button, and that's where it splits and it goes down into the leg artery. So an aortic aneurysm can form anywhere along the aorta, but you could also have aneurysms in any part of any artery in your body. The most common aneurysms that people normally identify, or you could hear a brain aneurysms where people have bulging of an artery in their brain that could rupture, could But the aorta is actually one of the more common places that aneurysms occur in the entire body. So it's very important that people get screened, especially if they're at risk for development of aortic aneurysms to try to prevent them from occurring and growing and rupturing. What is a thoracic aortic aneurysm? So thoracic aortic aneurysm, it refers to an aneurysm that would be in your chest cavity. So anywhere from around your diaphragm right around where the bottom of your rib cage is to your heart along the aorta, they're a little bit more complicated to take care of because they're in your chest and not necessarily in your belly. So especially with open surgical repair, it could be a much more complicated repair. Thankfully, over the past several decades, we've made huge advances in the treatment of aortic aneurysms. To give an example, Albert Einstein, you mentioned earlier, he had an aortic aneurysm and you would never guess how they treated it. He choose not to have treatment or surgery anyway. Well, they originally, one of the things they did, and they thought that this was going to cure it, is they wrapped it with saran wrap cellophane. Oh my goodness. And they did that to induce inflammation sort of and scar tissue around the aorta to hold it in place. Needless to say, it didn't work. So that was in the fifties. We made a lot of advances since that time in the treatment of aortic surgery, Michael DeBakey, one of the forefathers of cardiovascular surgery, was one of the first people to use an aortic graft, which he actually, this is an interesting story too. He was trying to find a good material to use for the graft, and back then he thought that polyester might be a great material to use, but there weren't as many rules and regulations in the fifties. So he went to Sears Roebuck. For those of you old enough to remember what that store is? I sure do. And he bought a roll of fabric called Dacron, and he took the bolt of fabric to his wife who sewed an aortic graft for him. He took it to the hospital the next day, sterilized it, and then implanted it in a patient. And that was the first aortic graft that was done in Texas in the fifties. Was it at all successful even? Yes, it was a success. Wow. And it was the birth of real aortic, open aortic surgery in the United States and the world. That's amazing. That's amazing. The innovation of medicine. Yeah, thankfully, since that time, open aortic surgery requires large incisions. So for an abdominal aortic surgery in the belly region, typically it would either involve a long incision from your rib cage down to your pelvis and staying in the hospital for about a week. We still do those surgeries in certain situations, but a lot of times we try to do less invasive procedures. The early nineties, there was something called the endovascular revolution that occurred with aneurysms. And what endovascular means is instead of taking a bulge in that fire hose we were talking about before, there are two ways to fix it. You could either cut out a piece of hose and sort of sew in a new piece of hose that's open aortic surgery. The other option would be to slide in a slightly smaller hose through the hose and redirect the water through it without putting any pressure on that weakened area that's minimally invasive surgery. So basically what we do is we put a tube or a stent in the aorta to redirect the flow away from the weakened walls of the normal blood vessel and with a tube covered with graft material, the blood will travel through the weakened area to areas of normal artery to the legs and every other organ. So you're bypassing. It's sort of an internal bypass with the stent and it doesn't require opening up the belly. It requires just typically key holes in the groin arteries right under in the groin area. So it doesn't even require an incision most times these days. When you said one option was to remove the bulge from the fire hose and then sew in another piece of fire hose, I thought you were just going to say to remove the bulge and then reconnect them and sew them together, that not possible? Or would that make the aorta too short? The aorta is connected to lots of different organs. Sometimes in areas in the leg artery or in the carotid artery in the neck. That is possibility, but there's usually not enough extra length of the aorta to bring them back together. That is a good question, but just technically it's not possible. So we need to have something to fill that space up, so we have to sew a new piece of hose in there. Okay. I want to come back to options for treatment, but to get to that, I want to know if there are no symptoms where the symptoms are absent, how do patients usually get diagnosed? How do they come to see you? So most times these days it's when someone gets a CAT scan for any number of reasons, abdominal pain, looking at their spine, they're trying to figure out some other problem. And this is found what we call incidentally by accident Because of the seriousness of this. When the Welcome to Medicare package, there was a law passed that actually allowed screening for abdominal aortic aneurysms in anyone who meets a select criteria, which is a large amount of people. What this criteria is is in anyone who is 65 years old male and has smoked more than five packs of cigarettes in their lifetime, males traditionally have higher risk factor for developing abdominal aortic aneurysms than women do. That being said, in my practice, any woman or male who has ever smoked and is over the age of 65, they should be screened for an abdominal aortic aneurysm. And usually that's done with an ultrasound, which is a Noninvasive takes about 20 minutes to perform and you'd be good to go just putting an ultrasound probe on your abdomen and looking. Is there a family history for this? Should John Ritter's kids be screened? Should they go and get an ultrasound? It sounds like a pretty easy. Step. To take. So if anyone has a family history of aneurysms or aortic disease, they should also be screened pretty much 10 years prior to the diagnosis of the other person. So we're at the very least by the age of 50 years old, if they've had a history of someone who has died or had a significant aortic problem. Do all aneurysms need to be treated? What's the threshold for treatment and not treatment? No, that's a good question. So whenever I see patients in the clinic, everyone thinks that an aneurysm is a ticking time bomb, and generally when they come to me, the aneurysms have been slowly growing for years and years and years. So they grow slowly and we normally stud. Large studies have shown that you don't need to have a repair of an aneurysm until of meet certain size criteria in men in an abdominal aneurysm, in most instances it's about 5.5 centimeters. In women, it's about five centimeters just in general because general. So the relative risk of a five centimeter aneurysm is higher than that of a male. So once it's five centimeters, you're saying that's when. That's when it should be repaired. And thankfully, aneurysms for the most part, grow quite slowly, only a few millimeters a year. So if someone has a three and a half centimeter aneurysm, it can be several years before a repair is needed. And sometimes a repair is not needed because if someone has other illnesses, we want to make sure that we're actually going to extend someone's life by fixing this aneurysm. So if they have severe lung disease or heart disease or they have a cancer, it may not make sense to fix an aneurysm, especially if it's probably not going to be the thing that harms them. However, anyone with an aneurysm should be followed very closely by a vascular surgeon. It seems though, every time we talk about disease, that early detection means better outcomes, survival. If I had an aneurysm, I think I just want to get it fixed. That's a good point. You could just wrap that Dacron around it and send me home. With any surgery there is risks, and even though surgery is very safe these days, even open or minimally invasive aortic stem surgery, the risk of a rupture in most patients if it doesn't reach a certain threshold is still very low. What is the process of monitoring an aneurysm? How often do you have to check it, and how fast does the bulge typically grow or worsen? So typically they tend to grow about two to three millimeters a year, which is not that big. If you look at a ruler and look what three millimeters is, it's really not that much larger a year. And that's determined purely by ultrasound. Purely by ultrasound, or if it's closer to needing a repair. If it's in the four and a half centimeter, four centimeter range, it could then be followed with a CAT scan to get more precise measurements and see also help with planning of repair. Have you ever seen it where it went from a non concerning size to suddenly becoming very perilous? I have, and that's why we follow patients pretty closely. So generally, especially if it's above four centimeters, you want to see that patient every six months to a year, depending on the size. Generally, if a patient grows more than half a centimeter in one year, that's another indication to repair it regardless of the size, because then in that patient it's growing too fast. Is that a decision that you make for the patient? It's always a discussion. We give patients our opinions on when these aneurysms should be repaired to help prevent it. It's one of the few prophylactic surgeries that we do as vascular ss. I mean, I'm trying to Is it elective? Is. It still elective at that point? Yeah, generally it's elective until it's causing pain or a problem, then it's an emergency. So I always tell my patients I'm not God. If I was, I would call them the day before they were about to rupture, then I would tell them that it's time to get it fixed. Get in. Here, because without that knowledge, you have no idea. And patient's aneurysm sizes vary. I've had patients with six centimeter aneurysms rupture, and I've had patients show up in my clinic with 10 centimeter aneurysms who have not ruptured and someone just found it. So it's very difficult to predict. There's a lot of research trying to figure out different prognostic indicators of what makes an aneurysm more likely to rupture, and we're making some progress with it, but it's still imperfect science, so it's pretty safe. We don't put patients' lives at risk. When we wait till five and a half centimeters, we know that it's the likelihood versus the risk of the procedure. It really meets that minimum around that size. So a patient comes to you, you do the ultrasound, you determine they have a aneurysm, maybe it's not ready, it's not severe enough for surgery. What would be the first step then? Walk me through the stages of treatment. So the first thing is I had to get a full history. I ask them about their family, ask them if anyone's ever died of sudden death where they didn't really know what was happening. Because a lot of times, especially if people didn't really get an autopsy or know why they died, it could have been an aortic problem. They just didn't know about it. And after the history, we get imaging, so whether it be an ultrasound or if they show up already having a CT scan, we could look at it together. And then we talk about a plan where we talk about a follow-up plan and also signs and symptoms that we mentioned about that would make you seek a comeback earlier than our regular scheduled intervals. And that would be things like increasing pain, just not feeling well. Again, it's very unlikely in someone who's followed regularly for them to rupture, but we have to just educate the patient just for that off chance that something could happen. How would you describe the aorta? I mean, how big is it? So normal aorta is anywhere from about two to two and a half centimeters in diameter. It. Seems very small then. Yeah. And an aneurysm that needs to be repaired is about five and a half centimeters, so it's about double that size. The definition of an aneurysm is any blood vessel. That's one and a half times its normal. Size is an aneurysm. It's not necessarily an aneurysm that needs to be repaired. It's just one that needs to be followed because it's weakened from the bulging. So it sounds like it would be very easy for you to see that on an ultrasound. You wouldn't likely miss it. It's. No. Pretty pronounced. If you get a screening, most people, you're able to see a pretty clearly, but if not, there are other alternatives such as CT scans or MRIs or different things you could do to follow it. What's the worst one you ever saw? The worst. The worst one. Aneurysm? Yeah. The biggest aneurysm I've ever seen was 13 centimeters. And it didn't rupture. Well, that one was causing pain and I had to fix it. Oh, wow. It was in a mail? It was in a mail, yes. See, we did a story some years ago, many years ago, and the patient was a very young man and he was getting a physical and they heard something, can you hear something? The cardiologist didn't think it sounded right. Sent this young man for imaging, and that's when he found out that he had an aneurysm that required surgery. Yeah, you could hear what we call a brewery sometimes, which is an abnormal flow with a stethoscope, which could tell you that something is off with the blood vessel. Generally on physical exam, it's feeling the mass, a pulsitile mass is the giveaway that someone has an aneurysm. You can feel it through the skin. You can feel it through the skin, and the people who are thin enough and it's large enough aneurysm, you could actually, if they're laying flat, it's pretty common, especially when I'm fixing large aneurysms that they're lying flat in the operating room and you could just see their belly rising with every pulse from the aneurysm pulsating through their skin. I think it sounds like a hernia. Could it be mistaken for a hernia. Except with the pulse is what gives it away. So a pulsitile mass anywhere in your body, you got to be concerned of an aneurysm. Are there medications? Oh yeah. So medical management is very important for a treatment of aortic aneurysms to try to prevent rapid growth rates, and those include blood pressure control being on a statin, which is a very common medication that a lot of our listeners may be on that helps prevent growth of aneurysms. Also, just decreasing everyone's stress level. Quit smoking. Quit smoking. Smoking is definitely a big risk factor for aneurysm growth, and it definitely increases the rate of growth. So even quitting smoking, even though you have an aneurysm potentially from smoking, quitting smoking could reduce your risk of that aneurysm growing at a rapid rate. Okay. Medical treatment monitoring, lifestyle changes, endovascular repair, EVAR. Tell me about that. So the minimally invasive approach with the stent for the abdominal aortic aneurysm, we use the acronym EVAR for endovascular aortic aneurysm repair. That's normally where we slide a tube or stent into the abdominal aorta and right below the kidney arteries, we land our stent and we go into the iliac arteries, which are the arteries underneath the belly button, which split and go to the legs. So this is thrown incision in the belly? No, this goes just through a small pinhole needle hole. Needle stick in the groin arteries, the femoral. Artery, the femoral. Oh, okay. Can. You do it through the radial. That we cannot do through the radial at this time? No. The stents are too large to travel through there. When they go in, when they're not deployed, they're about the size of a thin marker is about the size of a stent that is non-deployed, and then when you deploy the stent, it opens up to be about two and a half to three and a half centimeters in diameter. It's on the inside of the artery. It's on the inside of the artery, so relining the inside of the artery, redirecting the blood flow. So that technology started around the early nineties, but even since then, we've even become more advanced. So the problem is just putting a stent across an artery. That's fine. If there are not that many important branches coming off that artery and in the abdominal aorta below your kidney arteries, there's not that many important blood vessels coming off of it, so you could block those vessels off and not really having too many problems. The problem occurs when you have significant important blood vessels coming off the aorta. So blood vessels like the kidney arteries, intestinal artery, the artery going into your liver and stomach, those are very important. If you block any of those arteries off, you could have a significant problem with your health and even your life for those reasons. There's been more advanced development of minimally invasive techniques. Previously you'd have to do big open surgeries where we make a really long incision from your shoulder, shoulder blade to below your belly button. Oh my. Open you up, go through your ribs, go through your diaphragm. It sounds medieval. And we still do it sometimes in certain patients, but it does have an increased risk of complications the bigger the surgery is. Infection. Sure. Yeah. Infection wound complications. Just being able to do it, especially as patients get older and as generally older patients who have these aneurysms, it definitely becomes more of a problem doing these bigger operations on them. For that reason, these stents have been a lifesaver. We've really been able to extend this operation to patients who we never would've thought of previously. When I was in training 20, 30 years ago, I remember calling up patients in their eighties who've had an aneurysm, which was involving some of these major blood vessels and telling them, we can't really tolerate an open surgery, so there's really nothing we could do for you. That was a very common thing that occurred unfortunately for patients because aneurysms grew as they grew older. That had to be a horrible part of the job. Yeah, it was unfortunate, but we were doing what was in the best interest of the patient because the open surgery in patients in their eighties is very hard for them to tolerate in some instances. So with minimally invasive techniques, we're able to treat aneurysms that we weren't able to before, including aneurysms that include the major arteries of the body, like the kidney arteries, the intestinal arteries, and the liver artery, including the arteries that go near, go to your brain, even into your arms in the chest with these minimally invasive techniques. So some of the advances have been what we call fenestrated technology where there are holes that are custom made for the patient's individual anatomy to cover them and put stents in them so they're getting blood flow even though the aneurysm is covered with a stent. And there's also a branch technology branched endovascular repair where we actually have a tube with branches that come off of it where we're able to put stents in to all the different blood vessels. Both of those operations. We do quite a few of at MedStar hospitals throughout the region. The case that you said was the biggest aneurysm that you did that you said it was what, 15. 13 Or 15 centimeters? Yeah. 13 Centimeters. Yeah. How did you treat that? One. That was minimally invasively with a stent. And the patient recovered well. Patient did well. If a patient has an aneurysm like that, is it likely that they're going to develop another one? They can. That's why if someone is repaired, especially with a minimally invasive aneurysm, is very, very, very important. And I always really drive this home with point home with our patients that they need to be followed for the rest of their life because with the stent, although it's very secure, we're not curing aneurysm disease, we're treating a specific aneurysm. Whatever factors led them to develop this aneurysm could develop weakening in another portion of their aorta, and if that happens, the seal, which is basically just the force of the stent against the artery could become compromised and then they are not a fully repaired aneurysm if they develop a leak potentially. I was going to ask how does it not move inside the vessel? It is basically there's some hooks, internal hooks, and also radial force are the main ways that these stents stay in the blood vessel, which is different than when we do open surgical repair. We're actually using suture to sew the graft to the patient's aorta. How do you discern who should get the endovascular repair versus surgery? Like I mentioned before, it's always a joint decision. A lot of times younger patients may be better served by an open surgery because although there are higher risks associated with it when compared to the minimally invasive surgery, it's also better tolerated because they're relatively younger and also it could be more durable in the long-term. So long-term being potentially decades if they're in their fifties now with minimally invasive approaches, typically they have a higher rate of reintervention, meaning that you might need another procedure to keep your aneurysm repaired in the future, but that could be several years down the road and most likely in the future, that will also be another minimally invasive procedure, not a big open procedure. So it depends on the patient's anatomy, where exactly their aneurysm is and also their other health problems when deciding. So it's always a very individualized approach. That being said, the vast majority of patients generally desire the minimally invasive procedure when they're given all options and when they ask my opinion of what would be best for them, especially because it's in most commonly in patients in their seventies and eighties. So once you come to the decision with your patient that surgery is needed, what happens next? Based on the size of the aneurysm patient's symptoms? If it is elective, meaning that they aren't having any symptoms, we want to make sure that they're able to tolerate the surgery well. So I will contact their primary care doctor and their cardiologist. They have one to make sure their heart could tolerate the procedure. They may need some diagnostic testing to verify that they don't need anything to optimize them for the surgery. Are there surgical options. Following their medical clearance once they're scheduled for surgery? Typically, a hospital stay for a straightforward abdominal aortic aneurysm using a stent is only overnight, so they go home the next day. A lot of times the patients have no pain. They don't even need pain medications just because it's a very small needle hole incision that maybe has one stitch, and that's about it. So the more complicated operations that usually incorporate blood vessels in the kidney arteries, the intestinal arteries, and the liver artery, they typically may stay a few more days just to make sure that everything is okay. As I mentioned before, if someone requires open surgery, they likely will be in the hospital for about a week. It'll still take time to heal after they get home, and they probably won't be feeling back to their full normal self for about three to six months. What do you call the surgery to repair an aortic aneurysm or a dissection? Are they different surgeries? So for aortic dissection, if someone comes in with tearing chest pain, tearing back pain, have very high blood pressure, typically the way we repair that is we seal the tear. So depending on where the tear is, if it's by right by the heart, for the most part these days, cardiac surgeons would have to open up the chest and replace that portion of the aorta. If it is not in that area, if there's an area further along the pathway of the aorta, we are able to fix it with a stent where we're able to tack the tear along the wall and prevent blood flow from going in the wall of the aorta. The acronym we use for, that's called tbar, which is thoracic endovascular aortic repair. That's just a larger stent in the aorta in the chest, which is called the thoracic aorta. There is, again, lots of advances in this field, and we are treating more and more aortic problems closer to the heart with stents. So my guess in the next 10 or 15 years, a lot of these therapies that were previously required open heart surgery potentially could be repaired with a stent. It looked like there was a lot of excitement online about this approach called tbi. Yes. So the gore. Tell me about that. So. The GORE TBI is a new commercially available device, which was recently became FDA approved this last year, and we are one of the few institutions in the region that are performing that repair. That repair requires patients with more complicated aneurysms that extend from chest into the abdomen and cross that delicate area where the kidney arteries and the intestinal arteries come off of. We're able to use branch stents to maintain blood flow to those vital organs while repairing the aneurysm. Typically, we use an approach where we still don't make any incisions, but just may go through needle holes in the upper arm on the left side and both groins. So it's a remarkable new technology that enabled us to treat a lot more patients, including patients in their eighties. And I assume they're under general sedation for that? Yeah, typically it's under general anesthesia for those just because we of the careful imaging required to make sure we're in those vital organs. How long are you usually in the lab with a case like a Tam ABI case? Yeah, so with those TAM ABI cases, we're pretty expert at those, but it's a very complicated case. So it still takes about three hours, three to four hours, I'd say, which is very good for that type of complicated repair. And the patient can go home maybe a day later. Generally, for those patients, they're in the hospital for two nights just to make sure that everything's working okay. Do your patients feel differently after they've had an aneurysm repaired? That's one of the hard things about an aneurysm, especially if it's elective and they found it by accident. I'm repairing something that doesn't make them feel. Badly that they didn't know they had. So no matter how minor the repair is, they're likely going to feel a little bit worse than they did just because they had surgery. Understood. That being said, that's why it's very important to follow up with your primary care doctor, get the abdominal aortic surveillance, especially if you're having risk factors such as smoking, family history, and make sure that you keep on following with your vascular surgeon even after you have it repaired, because it is very, very important just to make sure that this stays not causing symptoms. We want having an aneurysm to be as boring as possible. Right? Absolutely. The aortic aneurysm isn't usually a headline condition, but it should be. Awareness and screening can change that. If you or a loved one is at risk, talk to your doctor. That conversation could save a life. If you're in the Baltimore area and would like to make an appointment with Dr. Vallabhaneni, call 4 1 0 5 5 4 2 9 5 0. If you would like to provide feedback on this podcast or get more information on aortic aneurysms, send me an email schindler@medstar.net.