Aneurysms: A Talk With A Pioneering Leader

Aneurysm, or ballooning of an artery, is often called a silent killer because it develops without any symptoms.  Most aneurysms are discovered by accident during imaging scans that are performed for unrelated reasons.

Treatment and management of aneurysm has advanced rapidly in past decades, thanks in part to innovations pioneered by Barry T. Katzen, M.D., founder of the Miami Cardiac & Vascular Institute at Baptist Health South Florida.  Dr. Katzen joins host, Jonathan Fialkow, M.D., for a discussion about state-of-the-art care and ongoing research at the Institute.

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Dr. Fialkow:

Welcome Baptist HealthTalk podcast listeners. I'm your host, Dr. Jonathan Fialkow. I'm a preventative cardiologist and lipidologist at Miami Cardiac & Vascular Institute, where I'm also Chief of Cardiology at Baptist Hospital and the Chief Population Health Officer at Baptist Health. As our listeners know, many of our previous podcast topics have been around cardiac and vascular disease. We've had experts on to discuss arrhythmias, such as atrial fibrillation, how to avoid heart attacks and how we treat them, heart failure information, and we've had many episodes on lifestyle and medical treatments, such as lipid disorders, hypertension, venous disease, sleep, and more. But today, we have a unique opportunity to chat about another cardiovascular condition of supreme importance, aneurysms. Our guest is a true luminary in the field of vascular medicine. He's a friend, colleague, and personal mentor, a visionary who founded the Miami Cardiac & Vascular Institute at Baptist Heath South Florida, where he is also the Chief Medical Executive, Dr. Barry Katzen. Thanks for joining us, Barry.

Dr. Katzen:

Thank you so much, Jonathan. It's a pleasure to participate today.

Dr. Fialkow:

So we do have a lot to unpack, Barry, and I know you're going to be a great source of information. We want to start by talking about aneurysms in particular, but I do want to leave some time so you could really talk specifically about what you uniquely built at the Miami Cardiac & Vascular Institute the really innovative multidisciplinary collaborative work we do there. But let's start with the basics, aneurysm broad term, tell us what are aneurysms, what causes them?

Dr. Katzen:

Well, aneurysm is a medical term for a ballooning of an artery. We tend to think of the arterial tree as a branching tree, so that arteries generally get smaller as they course throughout the body. And when an artery gets bigger and even balloons out, that's called an aneurysm. Most of the time, this doesn't cause any symptoms, patients are totally unaware of it, and when they get big enough, they can rupture. So it's one of the various types of things that we can get in our bodies that's frequently called a silent killer because it sort of moves along without creating a lot of symptoms, but it's an abnormal artery.

Dr. Fialkow:

And I think that abnormality is interesting because most of the conversations we spend a lot of time preventing blockages of arteries. And you'll talk a little bit about the process, but it's maybe a similar mechanism, but it's a different consequence, balloons out and it can actually expand and rip, which is usually not what we think about, right?

Dr. Katzen:

Absolutely. I think most people who think about arteries and cardiovascular disease, they think about blockages in arteries. This is another problem, it's different than hardening of the arteries, and it's a different process and the treatments are quite different as well.

Dr. Fialkow:

So aneurysms can happen in any blood vessel, where do you see them more commonly, and maybe as a side part of that, where are they more dangerous or significant in their occurrence?

Dr. Katzen:

Well, aneurysms can occur in really any artery or vein in the body. There are aneurysms that occur in the brain, they can occur in the aorta, the main pipeline that goes through the chest and abdomen, they can occur behind the knees, women can occasionally get them in veins inside the abdomen, lots of different places. So they can occur anywhere there's an artery or a vein. In terms of what's really the most common, probably aortic aneurysms are among the most common types, and then the others are aneurysms that occur in the brain.

Dr. Fialkow:

So the aorta's inside our body, you don't see it, you don't necessarily touch it, whatever. Let's speak about those a little bit, because we're in agreement they're extremely important and dangerous. What would be symptoms or signs, or let me put it differently, how do we generally pick up someone who may be developing an aortic aneurysm? And is it different if the aneurysms in the chest part of the aorta or in the abdominal part of the aorta?

Dr. Katzen:

Yeah, that's a great question, John. Probably 20 or 25 years ago, the most common way we knew we had an aneurysm was when it ruptured and it was a catastrophic event. There have been so many great advances in imaging, people have ultrasound exams and CT scans and x-rays that have occurred in the last 20 years, and so now most aneurysms are discovered by accident, through advances in medical imaging, when we're looking for something else or looking to work up a problem that a patient has. So as a result, they rarely cause symptoms. When they do, they can cause pain, you can get pain in your abdomen, pain in your chest, in terms of warning symptoms. But the more common way is they present with a catastrophic kind of pain that generally takes you to the emergency room, pain in the abdomen, acute chest pain, that sort of thing.

Dr. Fialkow:

So in your experience, as international leader in aneurysm management and treatment and detection, do more people come to you and us because the aneurysm is found somewhere and they're stable and then we evaluate them and treat them, or is it more common that they present with the catastrophic situation?

Dr. Katzen:

It's much more common that they come because something's been discovered. Everybody's surprised about it. What are they going to do? What does it mean for me? What does it mean for my life, my family? All those kind of questions. But they're generally incidental findings.

Dr. Fialkow:

So it's important, we want people to pay attention to them, but we shouldn't live in fear that at any given moment, I may have an aneurysm that ruptures. It's not the more common way- [crosstalk 00:05:53].

Dr. Katzen:

Right, and in fact, once we discover an aneurysm, a good part of what I have to do with many of our patients is tell them, "Listen, most aneurysms don't rupture." We may need to treat it at some point, but just knowing it's there is a real advantage for the patient, but actually, most aneurysms do not rupture.

Dr. Fialkow:

So if a patient has an aneurysm discovered based on getting a test for something else, or even, in some degree of somehow, it's being screened and looked for, and they identify, you have an aneurysm, again, in your leg or in your belly or whatnot, as we said, if they're asymptomatic, it's not, they have to rush the emergency room. It's not that kind of thing. What do you educate, both doctors and patients, about what to do about that? What'd be the first steps that you would recommend an individual does if they're told they have an aneurysm?

Dr. Katzen:

Once a patient discovers that they really need to see someone who's knowledgeable in aneurysm therapy. There's a lot of variation in care and knowledge about aneurysms, and there are a lot of advances that have occurred in the past decade or so in treatment. But the first thing we have to do is learn as much about the aneurysm as possible. How big is it? Where is it? What branches might be involved? And this is all a process of trying to assess what the rupture risk is. So when we see somebody who's had an aneurysm discovered, we have to really wind up for that particular patient, identifying what their rupture risk is and that determines what therapy or no therapy might be involved.

Dr. Fialkow:

So I think you said a very cogent comment at the beginning, which is if you're told you had an aneurysm, wherever it is, you want to seek help by someone who has expertise in aneurysm assessment and management, which is, I think, from my standpoint, the real purpose of this. So let's talk a little bit about MCVI, your vision, what you've developed, what's brought around MCVI, and how it supports the community and our patients. So again, person recognized they have an aneurysm, they go to the doctor, they said, "I'm going to take care of you, but I want you to be evaluated by Dr. Katzen and his team." What drives that referral? What did you develop that deserves that reputation? Let's put it that way.

Dr. Katzen:

Well, in the earliest years of treatment of aneurysms and the change and the formation of the Institute, we built on foundation of teamwork that whenever a patient presents with a problem, in this particular case, aneurysms, we bring a team together to look at that patient. Could be a vascular medicine physician along with an interventionalist, someone who works with catheters along with a vascular surgeon. And we generally try and make the decisions about whether something needs to be done or not, and what the best therapy is, by teamwork. So I think one of the things that came about as a result of the development of advanced aneurysm therapy was the development of teamwork. I'm proud to say that this all evolved in a long time ago, and it was quite unusual, and became the foundation for a model of teamwork that really has passed through culture of all aspects of cardiovascular disease at MCVI. But that's the key thing.

Dr. Katzen:

The key thing about treating a patient who has a problem that's not bothering them at all, basically, because most patients are not symptomatic, is making the right judgment about protecting the patient from rupture, making sure that it's not producing an extraordinary risk, and making sure they don't get treatment that they don't need or get treatment when they do need it.

Dr. Fialkow:

Again, I appreciate that, and again, it's been a privilege to be part of what you've built. The individual approach to the patient, I think is, again, something to parse out, we don't just treat the aneurysm, we treat the individual, and you make that appropriate multidisciplinary approach towards the assessment of what the patient need. What are some of the lifestyle components of what someone can do to, I'll say both avoid an aneurysm, but we would also want someone who has aneurysm, to emphasize? And then we can get to some other kind of treatment and modalities. So what are those dimensions?

Dr. Katzen:

Just to take a step back, I think it's important that everybody understand that many types of aneurysms are familial and there's a genetic link, and when we see a patient with an aneurysm, the first thing I do is talk to them about their parents, their brothers, their sisters, because most type of aortic aneurysms and certain types of peripheral aneurysms that do run in families, more in males than females. That's not true, by the way, for aneurysm in the brain, but we'll leave that one aside. So the first thing is to-

Dr. Fialkow:

Actually, can we unpack that? So if someone has a first-degree family member that had a cerebral artery brain aneurysm, that does not necessarily place an individual at an increased risk?

Dr. Katzen:

Right. There are other risk factors that are more important than family risk.

Dr. Fialkow:

It does come up quite often, that's why I think that's an important point to say. So I appreciate it.

Dr. Katzen:

Cranial aneurysms occur in men and women. They're very difficult to predict. They tend not to be discovered by accident because we tend not to do as much sophisticated imaging of the brain of people as we do in the rest of the body. We see many patients at MCVI with that problem, it happens to be a center of excellence for us, but there are certain vascular problems that are associated for instance, fibromuscular dysplasia, which occurs in younger women. We tend to think of aneurysms as occurring in older people, but brain aneurysms tend to be in younger people and frequently associated with these types of problems with the blood vessels.

Dr. Fialkow:

OK. Now, continuing, I'm sorry to interrupt. I just wanted to [inaudible 00:11:51]. So going back to the aortic aneurysms, as you were saying, go ahead. Risk factors and things one can do-

Dr. Katzen:

Yeah, so in terms of things that patients can do once they have an aneurysm, probably the most significant thing is to stop smoking. Despite the genetic link, smoking has been linked to the presence of an aneurysm, it's been linked to the risk of rupture, and it's been linked to how patients do after they're treated. So smoking is a causative factor and patients can do themselves a very big favor, in a lot of different ways, but related to the aneurysm, particularly, by stopping smoking.

Dr. Fialkow:

Of the patients that you see, what percent would you say are smoking or was smoking related?

Dr. Katzen:

Probably 80 or 90%.

Dr. Fialkow:

Okay. That high. Okay. Thanks.

Dr. Katzen:

It was high enough that the Center for Medicare Services, CMS, actually a few years ago approved a one time screening program for men over the age of 55, who had a history of smoking, to get an aortic screening, that being the highest risk of yields from a screening program.

Dr. Fialkow:

And that remains a recommendation?

Dr. Katzen:

Still today, yeah.

Dr. Fialkow:

Okay. All right.

Dr. Katzen:

The other thing that's very important with aneurysm management is blood pressure control, and keeping your blood pressure under control because, obviously, because this bubble is present in the aneurysm, the artery wall is weakened, and with continual high blood pressure, this weakening can continue to expand a little bit like a balloon and ultimately if it expands too much, then a rupture can occur. So blood pressure control, don't ignore it, you really need to keep an eye on it if you have an aneurysm. Then the other thing that's really had an unintended effect was the use of statins. Many patients with cardiovascular and the cardiovascular age group are on statins for a variety of reasons. But statins, in addition to an effect on cholesterol, have an anti-inflammatory effect, they reduce inflammation, and inflammation is an important part of aneurysm activity, what's going on in the wall of the vessel.

Dr. Fialkow:

So now we decrease the risk of aneurysm development and growth, we improve the lifestyle, improve the risk factors, now it's to the point where your assessment, your team's assessment, is that this is an aneurysm in this individual that runs the risk of rupture. What will we then do? What are the technologies and improvements, if you will, in managing those aneurysms from a mechanical standpoint?

Dr. Katzen:

I think it's a great question because there are a lot of options for patients today. It wasn't that long ago where the only treatment was open abdominal surgery. That was the kind of traditional surgery where a patient wound up in the ICU for three or four days, in the hospital for another four days, and then had about a 30 day recovery. In the early 1990s, places around the world, including Miami Cardiac & Vascular Institute, began pioneering new techniques to work and treat the patient from the inside, putting, they're not really stents like we use in the heart, but stent grafts and basically less invasive approaches. We happen to have done the fifth patient, I think, in the United States in 1994, 93, in Miami at MCVI.

Dr. Fialkow:

I was in kindergarten at the time, I don't really [crosstalk 00:15:25]. I'm kidding, of course.

Dr. Katzen:

Since then, we have a huge experience and a large database that we try to learn from. Now, from a personal research and futuristic kind of thing, we're trying to execute on the vision one day that if a patient has an aneurysm, they can come into MCVI or other sophisticated cardiovascular centers and be able to have that aneurysm treated and go home as an outpatient. [inaudible 00:15:53] been pretty close. So nowadays, working from the inside of the artery, we have techniques and technologies where we can treat the patient, exclude the aneurysm, and they can go home in about two days, but without necessarily having incisions at all. We have a lot of technologies, it's somewhat complicated to explain, but the simple idea is that if you have a problem with your plight, but you have a balloon or a bubble in a garden hose type of thing and it's expanding out, the way we repair it in the body is to go in from the inside of the hose and kind of reline it with an entire new pipeline inside that aneurysm.

Dr. Fialkow:

So remembering my medical school days when we would be on the surgical service and seeing those big, long, complex aneurysm repairs from the outside, if you will, and the long recuperations, it's really remarkable how far we've come. And again, you as a pioneer in things that are considered relatively routine these days. So couple of sum up points: people should not get up in the morning and be worried that they have an aneurysm; the proper lifestyle improvements for all cardiovascular conditions also improve the risk of avoiding aneurysms, not smoking, monitoring your cholesterol, using statins where appropriate, blood pressure control, et cetera; and then if you're diagnosed with an aneurysm, it's found, we definitely would advocate seeking high end multidisciplinary approaches with people who specialize in aneurysm management and if it gets to the point where it's something that you, as an individual, would benefit from an intervention, you lead a team and we have the resources to do such, right?

Dr. Katzen:

Absolutely. Absolutely. And the one thing I would add to that to people is if you or a member in your family had an aneurysm of any sort and you're aware that there might have been an aneurysm, then you should talk to your doctor about it.

Dr. Fialkow:

Thanks. This is great stuff, Barry. Last plug, if you will, talk a little bit about the National Center for Aneurysm Therapy you've been developing for some time.

Dr. Katzen:

We're very excited about that, thank you for asking. So we had a very grateful patient who happened to suffer from aneurysms, and there's aneurysms ... Even though we have made a lot of improvements over the last 20, 30 years, to execute on a vision like, as I spoke to you, where you can have aneurysm treated as an outpatient, really still requires a considerable amount more of research and study and further understanding.

Dr. Katzen:

And so through philanthropy, we're establishing the National Center for Aneurysm Therapy, and one of the reasons is because Miami Cardiac & Vascular Institute has become expert at treating aneurysms anywhere in the body, whether in the brain, the rare type that they might be in the heart even, or in the blood vessels, in the arteries or the veins. And because we have experts in all these areas, what we're trying to do is unify it so that a patient who has any questions about aneurysms, regardless of where they can be, will get the best possible care and answers to their questions, but also, where we can conduct the kind of research where we really change the way aneurysms are treated in the future.

Dr. Fialkow:

Again, Barry, thank you for, again, your vision, your persistence, which is something we've discussed together, and certainly your leadership. We're very fortunate to have you in the Miami Cardiac & Vascular Institute as a great resource for our community and our patients.

Dr. Fialkow:

To our listeners, remember that you can send us your comments and suggestions for future topics at [BaptistHealthTalk@BaptistHealth.net 00:19:30]. That's BaptistHealthTalk@BaptistHealth.net. On behalf of everyone at Baptist Health, thanks for listening and stay safe.

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