Dr. Roach: Size of aneurysm determines whether surgery is necessary
Dear Dr Roach: My husband will be 83 in September and was recently diagnosed with an ascending thoracic aortic aneurysm measuring 4.8 cm. Five centimeters is when they do something. After hearing about the survival rate based on your recent column, along with your comment that “most people do not survive a rupture of the aorta,” I’m scared. Why do they wait until 5.0 or rupture? Doctor says to test again in six months and just keep his blood pressure down. Shouldn’t he be careful about strenuous activities until repair? We can only wait at this point, it seems.
Dear C.G.: The aorta, the largest blood vessel in the body, comes directly off the heart, ascends to form an arch, then descends through the chest and into the abdomen. The aorta is then considered in three divisions: the ascending thoracic aorta; the descending thoracic aorta; and the abdominal aorta. Aneurysms can occur in each of these areas, and each has slightly different criteria for when to intervene.
In my most recent column, that was an abdominal aortic aneurysm. Most adults with an ascending TAA are recommended for surgical repair at a diameter of 5.5 cm. However, if the aneurysm is rapidly expanding, surgery may be considered earlier. If a person has a medical illness, making surgery very risky, surgeons may wait until the size exceeds 6 cm. The decision on when to do surgery requires judgement from an experienced surgeon and cardiologist. This is a major surgery with potential for harm, including death, and it’s not to be undertaken unless the benefits clearly outweigh the risks. Rupture is unlikely at less than 6 cm.
Keeping the blood pressure down (below 120 systolic) is a good idea. Beta blockers are most commonly used for that, based on studies in people with genetic risk for TAA, such as Marfan syndrome. Side note: Testing for genetic syndromes should be considered in all people with thoracic aortic aneurysms. Statin drugs are often used, as there is evidence to suggest they slow down expansion of the aneurysm. Strenuous activities like heavy lifting and contact sports should be avoided, but regular exercise is probably beneficial.
Dear Dr. Roach: You recently wrote on the concerns of bisphosphonate drugs like alendronate (Fosamax) in people with osteoporosis. These drugs, especially intravenous zoledronic acid (and the antibody to RANK ligand, denosumab), have been game-changers in patients with breast and other cancers that spread to bone. They have dramatically reduced the incidence of dangerously high calcium in people with cancer and have substantially reduced bone fractures due to cancer, as well as bone pain. There is a considerable body of literature supporting their use as additional therapy to reduce recurrence and even mortality in selected patients with early stages of breast cancer.
When we first started using them [at the University of Michigan Rogel Cancer Center], we observed osteonecrosis of the jaw in about 10% of treated patients. We quickly realized we could reduce the risk by using them less frequently (every three months, rather than every month like we used to) and by having our patients see dentists to ensure hygiene before we start. With these considerations, the incidence of osteonecrosis of the jaw with bisphosphonates (or denosumab) has dropped to less than 1%.
These medicines are very important for patients with cancers that have spread to bone, and we don’t want people afraid of these very effective agents that are safe when used correctly.
Dear D.F.: I appreciate the information from Dr. Daniel F. Hayes and am happy to share with my readers.
Readers may email questions to ToYourGoodHealth@med.cornell.edu.