Search for tag: "aortic program"

Interviewer: You have a loved one and you've been told they have an aortic dissection. What does that mean for them in the short term, and more importantly, the long term? That's next on The Scope.

Dr. Jason Glotzbach is a cardiothoracic surgeon at University of Utah Health and if somebody's been diagnosed with an aortic dissection, let's kind of break that down a little bit and help them understand what that means. Generally, it's probably not going to be that person that had it that will be finding out this information because it's a serious thing.

Dr. Glotzbach: Absolutely. So the aorta, as we've talked about, is the largest blood vessel in the body and the aorta has several layers to the aortic wall. It's kind of like plywood where the layers should be stuck together without any space in between them and sometimes due to high blood pressure or other things, you can get a small tear in the inside of the aorta, which then allows blood to travel in between the layers of the aortic wall.

We call it dissection because it dissects into the aorta and then once that blood gets in between the layers of the wall and separates them, that can cause major problems with the aorta.

Interviewer: So when it's in between those layers is it going to break out eventually and you'll be internally bleeding or what happens at that point?

Dr. Glotzbach: It can proceed to that, although more that's rare. More commonly, the blood dissection inside the wall of the aorta will travel kind of along the length of the aorta and it can block off the branches coming off the aorta. So it can prevent blood flow from going to all the branches of the aorta which can affect any area of the body because of those arteriole branches.

Interviewer: Including the brain?

Dr. Glotzbach: Absolutely, so it can involve the carotid arteries. Obviously if the carotid artery blood flow is decreased or impaired and then it can cause a stroke. Similarly, the blood vessels going to the liver or the spleen or the kidneys or the intestines, if those are blocked off then you can have major problems in the abdomen. So it really is a critically dangerous problem once it develops.

Interviewer: And I understand that there are two different types of aortic dissections that somebody might be diagnosed with. For the understanding of, you know, a loved one that might have another loved one that's dealing with this, could you explain briefly what those two are?

Dr. Glotzbach: Absolutely, and we break it down anatomically by kind of location within the aorta and so the two types are type A and type B.

Type A aortic dissection involves the first part of the aorta coming right off the heart, so also known as the ascending aorta. And a type A dissection is a surgical emergency. Those patients need to go as quickly as possible to the operating room with a cardiovascular surgeon to repair that.

Type B aortic dissection involves the rest of the aorta, so from the aortic arch on down and including the abdomen. And so type B dissections are a little bit more complicated or nuanced in that they may require surgery or a procedure. They might not, but they definitely would need to be in the hospital.

So those two distinctions are critical for the initial treatment phase, although all aortic dissections really should be thought of as a chronic disease and so once this happens to the aorta, patients will need lifelong surveillance with imaging studies and follow up with an aortic specialist to make sure that problems don't develop down the road.

Interviewer: And what caused that to happen? Is it something that the patient did or did it just happen?

Dr. Glotzbach: It can be both. There are risk factors including smoking and high blood pressure. There are some genetic conditions or familial patterns that can predispose people to have this problem. One of the biggest risk factors for aortic dissection is developing an aortic aneurysm, which is an enlarged area of the aorta which gets thinned out and weakens, so that's more susceptible to a dissection. But a lot of times these are just bad luck and this happens to someone who's never had an aortic problem before and this just kind of happens out of the blue, so it can be a devastating problem.

Interviewer: Are there any sort of warning symptoms that would come before the actual emergency event?

Dr. Glotzbach: Unfortunately, there are not a lot of warning symptoms. A lot of, you know, an aortic aneurysm is largely asymptomatic. High blood pressure can cause a bit of a warning, and then obviously people that have known aortic problems. But most people who have a dissection have no warning sign or nothing that suggests this is about to happen until it actually does happen.

Interviewer: All right and once . . . How is it diagnosed?

Dr. Glotzbach: Typically it's severe pain and so patients who have a dissection have severe chest pain or back pain or abdominal pain or all three, and a lot of times it could mimic a heart attack or other kind of acute problems. So most people know something is going wrong and they have severe pain, which then usually people come to the emergency department with the symptoms and then it's diagnosed from there with an imaging study.

Interviewer: And how do they get fixed in the short term and then what's their long term look like?

Dr. Glotzbach: Absolutely. So for a type A dissection like we talked about, that's a surgical emergency so those patients go to the operating room and we will replace the ascending aorta at least and sometimes more. Sometimes the aortic valve can be involved or the coronary arteries need to be reconstructed. Basically need to stabilize that first part of the aorta so that the blood flow to the brain and to the rest of the aorta is preserved. So that's a type A.

For a type B, which is involving the rest of the aorta, the most critical thing is to keep the patient's blood pressure under control and then to determine if there is any problem with blood flow to any of the other organs. So we look at blood flow to the liver, the gut and the legs, the kidneys, all those things. As long as there's blood flow to those organs, typically we can manage those patients medically.

Interviewer: And what does life look like after somebody has an aortic dissection? Likely I'm talking, you know . . .

Dr. Glotzbach: Long term.

Interviewer: Three to five years.

Dr. Glotzbach: Absolutely. So once we've stabilized after the initial event, then it becomes kind of a chronic disease that needs to be managed and watched closely like any chronic disease. And so the way we do that for aorta, number one, is blood pressure control so we have to . . . most patients are on one or multiple blood pressure medications and then we do long term follow up with imaging studies. And typically that's a CAT scan or a CT scan, which is a three-dimensional X-ray that gives us a very good picture of the aorta and tells us exactly what's going on.

And so we'll have the initial imaging from when it first happened and then we'll get every, between six months to a year or so and every year after that we'll get CT scans watching how that aorta is changing or not and if things start to change then sometimes we need to do procedures in the future and sometimes not, sometimes people just remain stable and we just keep watching them.

Interviewer: So what I'm getting is that it's something that could happen again to somebody who's had one.

Dr. Glotzbach: It could, and once you've had an aortic dissection your aorta's at risk for life and so this is something that is, you know, can be managed and stable and people can go on living with it but it's not something that will ever heal completely and so people just have to be aware that they need lifelong surveillance and I think that's where a true aortic program comes in where you have a dedicated team of physicians and nurses and radiologists and people that are used to watching these over long term so that we can pick up on problems as they begin to develop, before they turn into big problems, we can intervene.

Interviewer: And what about quality of life?

Dr. Glotzbach: I think that this is a very serious emergency. When these happen, they're life threatening and should be taken seriously and treated immediately at a hospital and so the quality of life after that, once you've stabilized and treated from the initial event, people can go on living normal lives and do almost anything that they want to do provided they have good follow up care and we keep an eye on things and make sure that that aorta remains stable and doesn't develop complications down the road.

updated: August 25, 2021
originally published: August 23, 2017

Interviewer: What is abdominal aortic aneurysm, how did you end up with it, and what can be done about it? We'll talk about that next on The Scope.

Dr. Claire Griffin is a vascular surgeon with the University of Utah Health and one of the things that you deal with on occasion or often—I guess we'll find out—is an abdominal aortic aneurysm, also called "AAA." So what is that?

Dr. Griffin: Well, an aneurysm is when a blood vessel becomes larger than it should be. So we define in medicine an aneurysm as any time the blood vessel is one and a half times the normal size.

Now, normal is different depending on the patient, how big they are, if they're a man or a woman. But in general, we have an idea of how big blood vessels should be, and when they're larger than that, we call them aneurysmal.

Interviewer: All right. You get a little bit concerned about it. Let's go back for one more step. What exactly is the aorta? Where is this happening in my body?

Dr. Griffin: Okay. So you can get an aneurysm in any blood vessel in the body but the most common location is in the abdominal aorta. So the aorta is the main blood vessel in our body. It actually starts in the chest where it comes directly off of the heart and it gives branches to the arms and the head before traveling through the chest and going into the abdomen.

There are actually two main branches that come off of the aorta right after it gets into the abdomen that give blood to the liver and the intestines and then another branch goes to each kidney. Once those branches have come off there's a relatively straight section of the aorta before it divides into two around the level of our belly buttons to give blood flow to our pelvis and our legs. So that's the aorta in a nutshell, the main blood vessel or the superhighway for blood to get from the heart to everywhere else in our body.

Interviewer: So then piecing together what you've just told us, an abdominal aortic aneurysm is when the aorta in the abdominal area is larger than it should be?

Dr. Griffin: Exactly.

Interviewer: All right. So can you explain that a little bit further?

Dr. Griffin: Sure. So the normal size of the aorta depending, again, on if you're male or female or how big you are is normally about 1.7 centimeters to 2.5 centimeters. Which given that we don't use centimeters very often, really means about the size of a nickel.

When we see somebody who has an aorta that is bigger than three centimeters, so around the size of a half dollar, we consider that to be an aneurysm. Now, having an aneurysm doesn't mean that you need anything done about it. It really depends on where it's located and how big it is.

Interviewer: All right. And what caused this aneurysm to happen? Was it something that I did or does it just happen?

Dr. Griffin: So we know that there's definitely some sort of genetic component aneurysm disease but there's not one gene that causes them to happen. It's really multi-factorial.

We know for example that smoking is like fertilizer for aneurysms and causes them to grow really fast. So the number one thing we can do is avoid smoking to prevent them from happening. But even if you've never smoked, you can still have aneurysm. And if your parents or grandparents had one or uncles or aunts had one, that is a risk factor for you.

Interviewer: So how is it diagnosed?

Dr. Griffin: Because we know that smoking is the most common risk factor, there actually are screening programs that if you are a male over the age of 65 and you've been a smoker in your life, you can get an ultrasound to look at the size of your aorta. Although the most common way this is diagnosed is because people get a CT scan for something completely unrelated and it's found by accident on a CT scan.

Interviewer: So it doesn't really present any noticeable symptoms that . . . like shortness of breath or something like that. It just . . .

Dr. Griffin: No. If they're quite large, they can present symptoms because of their size or if they grow rapidly, sometimes patients will have pain associated with that, but they are most commonly asymptomatic.

Interviewer: All right. And kind of found by mistake.

Dr. Griffin: Exactly.

Interviewer: Because you're looking for something else. So when does it become a problem?

Dr. Griffin: So as the blood vessel, in this case the aorta, stretches it doesn't get any thicker. So the wall just becomes thinner and thinner. Sometimes that growing can cause abdominal pain but usually it's asymptomatic. Once it gets to a certain size, we worry that that thin wall can actually become so weak that the blood leaks out of it and that can be an emergency, considered a rupture. So we like to fix them before it gets to the size where it would rupture.

Interviewer: Yeah. And if it ruptures, then like you said, that's an emergency. That's your blood gushing out now at this point.

Dr. Griffin: Correct.

Interviewer: Pretty quickly, I'd imagine.

Dr. Griffin: It can be what we would call a contained rupture where you have some sort of symptom and pain, but even if it's a contained rupture it's still a surgical emergency to fix it.

Interviewer: So if a patient is diagnosed with one, what then? You mentioned not in all cases do you have to do something but . . .

Dr. Griffin: Depending on the size of it dictates what the next step is. So if we diagnose it and it looks like it has already met the threshold for repair, in other words, if we think that continuing to live with it is more risky than fixing it, we go ahead and do surgery to fix it. But if your aneurysm is small, it might be that you never need it fixed and so we continue to watch that or place it in surveillance and do serial imaging with either ultrasound or CT scan to keep an eye on it.

Interviewer: And then how and when do they get fixed? You'd mentioned you kind of keep an eye on it, right? If it gets stretched so far, that's when it gets fixed. So then what do you do, is it surgery?

Dr. Griffin: There are no medicines that fix aneurysms. The only thing that we can do is reroute the blood somehow so that the high blood pressure isn't touching this thinned out wall. There are two different ways that we can fix it:

1. We can either open up the patient in the operating room and replace that thinned out blood vessel or the enlarged area of the aorta or
2. If the anatomy is right, which is something that we can tell on a CT scan, we can actually travel inside the blood vessels through specialized IVs and re-line the blood vessel so that the thinned out wall is no longer getting the pressurized blood.

And depending on how we fix it, it has a lot to do with how fast the recovery is and when you can get back to your normal life.

Interviewer: After you've been diagnosed, is it . . . are you pretty good for the most part in your specialty at being able to know, "We need to do some about this right now or we have a couple of weeks?"

Dr. Griffin: Yeah. So the Society of Vascular Surgery actually has some really great guidelines that help us make decisions about patients and every patient is different. So I mentioned before how there are branches that come off the aorta. If the aneurysm includes those branches, that can make it a very complicated surgery to fix it. Or if the aneurysm is away from those branches, it can be a very straightforward repair.

So the CT scan that we usually get to diagnose it and to surveille it is critical in helping us decide how to treat it.

Interviewer: Okay. I guess what I was trying to figure out is if I was told I have an aneurysm, to me, that's an emergency, like right now. But you have a pretty good body of evidence that kind of helps dictate how dangerous you are at any given time.

Dr. Griffin: Exactly. And since this is something that I treat all the time, as a vascular surgeon, when I hear that somebody has an aneurysm, that is part of what I take care of every day. So I don't think that patients should be scared or think that it's an emergency to fix it right away. On the other hand, it is important to get plugged into a vascular surgeon so that they can tell you when and how and what the next step was going to be.

updated: August 13, 2021
originally published: August 22, 2017

Interviewer: Coming up next on The Scope, learn more about a specialized clinic that treats just diseases of the aorta. That's next on The Scope.

Announcer: Health tips, medical news, research and more for a happier, healthier life. From University of Utah Health Sciences, this is The Scope.

Interviewer: Dr. Jason Glotzbach is a cardiothoracic surgeon, and Dr. Claire Griffin is a vascular surgeon, both at University of Utah Health, and they're both part of the Aortic Disease Program at University of Utah Health. And today I want to get a better understanding about that specialized clinic, why somebody might be referred there, and the advantage for the patient versus other options.

So, first of all, why is it necessary to have a clinic dedicated to the treatment of aortic disease?

Dr. Griffin: So the aorta is one of the major blood vessels in the body, and any pathology associated with it can be very complex, and it's often not something that regular doctors have a lot of familiarity with. So our training gives us the opportunity to understand not just focused pathology in one particular area, but the whole aorta. And working together means that patients can come to one place and have a variety of opinions that really helps get the full scope of treatment options, natural history of the diseases associated with their aorta, and the full gamut of specialists to help take care of everything in one place.

Interviewer: So what I'm getting is it's a pretty complicated part of your anatomy and you need some pretty specialized people to take care of it?

Dr. Griffin: Yes.

Interviewer: Let's go back to anatomy class, Dr. Glotzbach. Where is the aorta? I know it's somewhere near the heart and it carries blood, but beyond that I don't remember much.

Dr. Glotzbach: Absolutely. That's a good place to start. The aorta is the largest artery in the body. It starts at the heart. So the aorta is the first stop of blood. As it leaves the heart, it goes into the aorta, and then from there it goes up and around the aorta and, through all of its branches, goes to every part of the body.

So the aorta is literally the kind of main superhighway for blood as it travels through our body. And so given that, obviously diseases of the aorta are very critical to the entire body, and so we have arteries in the chest, the abdomen, the legs, all that feeds off of the aorta.

Interviewer: Dr. Griffin, you'd mentioned that it takes, you know, a specialist to kind of understand this. In your general four years of med school, how much of this part of the body is really covered?

Dr. Griffin: So the understanding of most medical students coming out of medical school is probably exactly what Dr. Glotzbach just highlighted. It's the superhighway for blood, it's what takes blood everywhere else, but the understanding of the diseases that are in the aorta and how to treat them, and the thought process behind the approach to them is all something that is specialty training.

Interviewer: And what's the advantage for the patient to come all the way to University of Utah Health, I mean, other than the experience part which, I guess, is a pretty big advantage, right?

Dr. Glotzbach: Oh, we like to think so. I think we like to look at the patient as a kind of individual and tailor the treatment to each individual patient's needs, and I think that that's one of the things that we can do well here, is that we have specialists from multiple different disciplines so that we can think about the disease process in many different angles or from many different perspectives.

Interviewer: When you say "from the patient's needs," what does that mean exactly?

Dr. Glotzbach: Because the aorta is such a complex organ and aortic diseases are very complex in that they are very unique to each person, so one person's disease may not be the same as another person's disease, which is a little bit different than other problems that we focus on. So it's really important to take each patient as an individual and look at exactly what kind of treatment they need, and then hopefully we can provide that in a very targeted, individualized way.

Dr. Griffin: We just have very different thoughts when we approach the aorta. The training that I received, I spend a lot of time thinking about complex endovascular or minimally invasive ways to treat the aorta and its branches. And the approach that Dr. Glotzbach might have from a CT surgery perspective comes more from a major open perspective, and having the two of us working together means that we really constantly open each other's eyes about different ways to approach the same problem.

Interviewer: Yeah, you might be able to do something a little less invasively, perhaps?

Dr. Griffin: Exactly.

Interviewer: Or you might be able to talk to each other and go, "Well, actually we do have to be a little bit more invasive in order for it to be successful?"

Dr. Griffin: And talking about those cases together and making sure that there's open collaboration means that there's never a time that Dr. Glotzbach doesn't weigh in on something or I don't weigh in on something, and so we really get the benefit of both training backgrounds for every patient.

Interviewer: Two heads are better than one.

Dr. Glotzbach: Absolutely.

Interviewer: And you have even more than just the two of you on the interdisciplinary team. Who are some of the other members, and how do they contribute?

Dr. Glotzbach: We have basically the entire division of cardiothoracic surgery and vascular surgery are both committed to making this collaborative effort work. So my division chief, Dr. Craig Selzman is very committed to this, and so he's involved in all these collaborative discussions, and all of my partners on the cardiac surgery side have weighed in on all of these cases and, you know, individual cases and also as programmatically as a whole.

Dr. Griffin: Similarly, from the vascular division we have Dr. Larry Kraiss who's our division chief, and then the remaining members of the vascular division all are involved in the collaborative discussion of patient care. And because of other collaborations between our two divisions, as well as the Cardiovascular Center as a whole with cardiology and intervention radiology, there really is a lot of expertise at the University of Utah for this kind of disease pathology.

Interviewer: That's pretty cool. How old is this clinic? It's fairly new, isn't it?

Dr. Glotzbach: You know, we've had this expertise in kind of individualized divisions and aspects of care for years, but the collective pursuit of this as a multidisciplinary thing is really within the last year, we've been trying to build this up. And we've had a lot of buy-in from the leadership of the hospital in the cardiovascular service line, and so we're starting to really get some momentum with this.

Interviewer: One call, and you don't have to look around for all the experts, you're still in one spot.

Dr. Glotzbach: That's the goal. We're really trying to streamline things for the patient and for referring physicians who want to send people here for us to help out with. I think that it can be very complex to navigate a system like University of Utah, these large academic medical centers, and so our goal is to make it kind of a one-stop shop for the patient to come in, and we bring whatever expertise we need for the individual patient. We bring that to the table.

Interviewer: How do patients generally end up in the clinic? I don't imagine that's their first stop.

Dr. Griffin: That's a great question. There are a couple of different ways to find our program, and it really has to do with the kind of problem the patient has. So some of the aortic diseases are picked up by primary care doctors with routine screening evaluations or as incidental findings on CT scans that patients have for other purposes, and those patients really come through the referral process. There's a whole other section of diseases that affect the aorta that are really emergencies or acute findings that take patients to the emergency department, and they would come to us through emergency transport.

Interviewer: Let's talk about the referrals. If there is a patient that has been diagnosed with some sort of aortic issue and the physician doesn't know about the clinic or doesn't make a referral, is there a way a patient could find their way to you in that instance?

Dr. Glotzbach: Absolutely. We have a kind of dedicated administrative pathway where we have one phone number that we can . . . you know, both patients, or physicians, or doctors' offices could call and get an appointment with us. And it doesn't matter whether they end up needing a cardiovascular or cardiac surgeon, vascular surgeon, or both of us, you know. We can streamline that process, and our goal is to have it. So as soon as we hear about a patient, we will get them into our system and get them plugged in with the appropriate providers that can help them with their specific problem.

Dr. Griffin: One of the things that is helpful about our system, and having as much expertise as we do, is that a lot of times people can have really rare disorders of the aorta or its branches, and their primary care doctor or maybe the physician taking care of them doesn't see it enough to feel comfortable managing it, and that's one of the benefits of having such a collaborative effort that it's not rare to us. We're familiar with it, we're comfortable with it, and we're happy to help take care of it.

And in addition, I think that one of the things that's unique about our effort right now is that it's very collaborative, and so we're not competing with each other to take care of these patients. We're working together, and I think that creates an environment not just for the physicians and the patients, but also for all the support staff that really can be focused on patient care and patient outcomes instead of trying to be competing with each other.

Interviewer: And make sure that the patient gets exactly what the patient needs to get back to their life, however it may have been before they ran into the problem?

Dr. Griffin: Exactly.

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