Life, Death…Or Somewhere In Between

Nov 07, 2014 at 09:51 am by Staff

Aortic aneurysms. Carotid artery disease. Peripheral vascular disease. When asymptomatic all these conditions pose little danger and in most cases cause no serious harm to a patient. But somewhere along the patient’s journey they associate those words with: life, death, or somewhere in between. So what do I do as a consumer, as someone who wants to live and be fully functional, as someone who doesn’t want to have a stroke, have a “ticking time bomb” waiting to explode, or someone who could lose their leg if they don’t have their blockage fixed. To me, the answer is simple – be informed, do your research, see the appropriate specialist. Unfortunately, there are many “specialists” out there who confidently do the wrong thing.

Primum non nocere, which in Latin means “first, do no harm” is what we are initially taught in medical school and even repeat as part of the Hippocratic Oath. Another way to state this is, given an existing problem, it may be better not to do something, or even to do nothing, than to risk causing more harm than good.” For example: a 65 year-old hypertensive, hyperlipidemic smoker who had a coronary bypass graft in the past now complains of pain when walking two blocks. He routinely sees two physicians, his primary care doctor and his cardiologist. The patient then has two endovascular procedures by his “vascular” doctor for a long superficial femoral artery occlusion. All the interventions failed, and a bypass was suggested by the same doctor. The second-opinion work-up reveals that the patient was not started on statins, nor advised to stop smoking, and was not fully treated for his hypertension. But the biggest revelation was that the patient was never told that his uncorrected femoral artery occlusion posed little risk to his life or limb. Simply stated, the patient underwent two procedures, all with their own risks, when he never needed one to begin with.

Other examples include abdominal aortic aneurysms and carotid artery disease. How many patients have family members who have had strokes or ruptured aneurysms? These same patients may get a carotid duplex for a bruit or MRI for chronic back pain, but now what. Say the ultrasound shows 50-60 percentxxxxx carotid stenosis bilaterally and the patient is asymptomatic. She asks her doctor – “Am I going to have a stroke,” “Do I need surgery,” “Who should I see for this?” Well, depending on whom she does see will impact her and maybe even change her life. The same scenario can be seen with abdominal aortic aneurysms. An ultrasound may show a 4.2cm aneurysm in a 65 year-old otherwise healthy male. All this patient really wants to know is, “when is it going to rupture?” Based on that question the patient is advised to have an EVAR (endovascular aortic repair) procedure “as soon as possible.” Wisely, he seeks a second opinion and was advised to have his aneurysm observed periodically. Eight years later the patient is well and the aneurysm has a maximum diameter of 4.5cm.

So what if these patients had had an urgent carotid revascularization or urgent EVAR for asymptomatic disease? And what if they had a complication – a stroke, bleeding, MI, or even death? Many self-appointed vascular “specialists” are not fully aware of the benign natural history of non-coronary vascular disease; others, it seems, choose to ignore it. What is clear – no matter what the specialty – is that non-coronary vascular diseases have been studied well and have a known natural history. Thus, the true vascular specialist who is trained in arterial disease, venous disease, and lymphatic disease can help medically manage and routinely survey specific disease entities. And more importantly, know when not to do surgery, ultimately helping in doing no harm to the patient. As we all know, every procedure comes with its own inherent set of risks and complications, so why would you put someone in jeopardy if they never needed to be there in the first place.

Shonak Patel, MD, of Vascular Specialists of Central Florida is board certified in general surgery and board certified in vascular surgery. He earned his MD from Ross University in 2006 with high honors. He completed his two year vascular surgery and endovascular therapy training at the University of Alabama in Birmingham, AL. He completed his fellowship in June 2013.

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