[HSF] A quick vascular question

Wed Dec 9 08:03:33 EST 2009

I missed the octogenarian  PFO thing .
Prasanna

On Wed, Dec 9, 2009 at 6:56 AM, Mitch Lirtzman <drmitch at cox.net> wrote:

> Ani,
>
> For the most part, I agree. If indeed a 4yo CT was recovered and there was
> a 4cm aneurysm seen, I would not consider treating it. Nonetheless, to coin
> a phrase, "it is what it is."
>
> Now as far as the pt with HCC, a heretofore undiagnosed effusion is
> important from the oncologic standpoint. I wouldn't recommend a window, but
> a diagnostic tap under local with US control, IMHO, would provide valuable
> information. And the cardiologist that did a percutaneous PFO closure in an
> octogenarian should be b*tch-slapped back to the stone age. As they say,"
> When you're the hammer, everything looks like a nail."
>
>
> Mitch At 11:15 PM 12/7/2009, you wrote:
>
>  >And if a cardiologist wants to do a LHC in a patient such as
>> > this, my response is always:  "Don't do a test that you don't want to
>> > respond to."
>> >
>> > Mitch
>>
>>
>>
>> This summarizes my first point. True you were presented with a fait
>> accompli scan showing an aneurysm but I think we as doctors have to still
>> resist treating unindicated and incidental diagnostic findings. If the
>> indication for the test remains questionable then so must the treatment. As
>> Dr Frater says, what if we stumbled accross an old CT done in 1999 that also
>> showed a 4cm aneurysm - would we then still be so convinced it is the cause
>> of the pain? And to what degree do we know this is typicaal pathology as
>> opposed to a consequence of her prior surgery. What if was a traumatic
>> aneurysm related to her splenectomy dating decades? In the autopsy suite
>> there are numerous such (incidental) pathological findings in persons of her
>> age who die of other causes, so the assumption that because we now know the
>> aneurysm is there that it has to be treated to prevent death and
>> incapacitation may not necessarily be valid. Again I do not know much about
>> the splenic artery but is *vague* abdominal pain typical presentation for
>> aneurysms of this vessel?
>>
>>
>>
>> I was also presented with a case of surgical disease found incidentallly
>> today. Patient with prior liver transplantation a decade ago and abdominal
>> recurrence of heptocellular carcinoma over a year ago presents wwith
>> abdominal pain and CT scan shows small bowel obstruction but also shows
>> large pericardial effusion confirmed on echo. He has fully active 2 weeks
>> ago with no cardiac symptoms and unlimited exercise tolerance. Do we now
>> subject him to a pericardial window because he happened to be 'fortunate to
>> have a CT scan?
>>
>>
>>
>> The other assumption in all this is that the interventions we offer are
>> relatively innocous so nothing to lose. Similar assumptions guide those who
>> push for screening for cancers and the harm done by all these 'simple'
>> interventions for incidental findings have until recently been generally
>> ignored. Very terrible things can and do happen from catheter based
>> interventions in the elderly. You may recall a famous world politician about
>> same age as your patient  few years ago who was just having a 'simple PFO
>> closure' and ended up vegetative. I do not say we should not try and treat
>> her pain but I suspect there are other approaches to managing *vague*
>> abdominal pain in the elderly which should be applied before we seek, blame
>> and treat rare pathology - hopefully these were first exhausted before she
>> was sent for a CT scan.
>>
>>
>>
>> ani
>>
>>
>> > Date: Mon, 7 Dec 2009 17:43:50 -0600
>> > To: OpenHeart-L at lists.hsforum.com
>> > From: drmitch at cox.net
>> > Subject: RE: [HSF] A quick vascular question
>> > CC:
>> >
>> > I respectfully disagree. First and foremost, we are charged with
>> abating/
>> > eliminating a patient's pain. The first point in your #1..."what do we
>> hope
>> > to gain..." is a valid point, but that's what I was presented with from
>> the
>> > PMD. And now I am charged with doing something to eliminate this
>> person's
>> > pain (or try to). And there IS something wrong with vague pain. It hurts
>> > this old lady.
>> > I would treat this aneurysm as the most likely cause of her pain. It
>> will
>> > likely not affect her survival, but should improve her quality of life.
>> Why
>> > should I leave this
>> > woman in pain for the rest of her days?
>> > With regards to Michael's conundrum, we can decide when not to treat.
>> What
>> > is the likelihood of the patient recovering? Can he/ she participate in
>> > their own care?Does the patient understand the consequences of treatment
>> or
>> > non-treatment? And if a cardiologist wants to do a LHC in a patient such
>> as
>> > this, my response is always: "Don't do a test that you don't want to
>> > respond to."
>> >
>> > Mitch At 09:57 PM 12/6/2009, you wrote:
>> >
>> > >I dont either do or know vascular surgery, but in light of Michael's
>> > >recent discussion on futility, what is the object of care here.
>> > >
>> > >1) What do we hope to gain doing CT scan on an 81y old alzheimer
>> patient
>> > >with vague abdominal pain? What perfection are we seeking - what is
>> wrong
>> > >with vague pain?
>> > >
>> > >2) Why are we treating this 'aneurysm'? Or are we seriously convincing
>> > >ourselves that he pain will go away after?
>> > >
>> > >Are we hoping to improve her survival, improve her quality of life or
>> just
>> > >treating 'pathology'?
>> > >
>> > >
>> > >
>> > >I try to apply 'Hal's rule' here - I do not know much about the splenic
>> > >artery, and dont want to, but find it hard to accept that I would allow
>> > >any doctor to touch my mother or any family at age 81 who has
>> alzheimer's
>> > >and complains about vague pain. Maybe I will get some senna or
>> lactulose
>> > >but it stops there. What next - maybe after the embolization she still
>> has
>> > >the vague pain and then earns herself a cath which shows 3-VD. I forgot
>> > >she is a 'good 81' in decent shape....maybe we then pluck 3
>> > >grafts.....then comes one of Michaels four scenarios - alzheimer's,
>> trach,
>> > >PEG etc etc where do we stop? I am sure she would have rathered endured
>> > >her vague pain. When you are not ill, doctor's are dangerous.
>> > >
>> > >
>> > >
>> > >ani
>> > >
>> > > > To: OpenHeart-L at lists.hsforum.com
>> > > > Subject: Re: [HSF] A quick vascular question
>> > > > From: rowlesjohn at aol.com
>> > > > Date: Mon, 7 Dec 2009 03:37:16 +0000
>> > > > CC:
>> > > >
>> > > > I don't do vascular surgery anymore, but I believe embolization of
>> > > splenic artery aneurysms is the standard of care.
>> > > >
>> > > > John Rowles
>> > > > ------Original Message------
>> > > > From: Mitch Lirtzman
>> > > > Sender: openheart-l-bounces at lists.hsforum.com
>> > > > To: OpenHeart-L at hsforum.com
>> > > > ReplyTo: OpenHeart-L at lists.hsforum.com
>> > > > Subject: [HSF] A quick vascular question
>> > > > Sent: Dec 6, 2009 7:00 PM
>> > > >
>> > > > For those of you that also do vascular work.
>> > > >
>> > > > I was referred an 81yo woman with several weeks of vague abdominal
>> pain.
>> > > > She has mild-moderate Alzheimer's. Physiologically in decent shape.
>> > > > Non-smoker, non-diabetic, not obese. The PMD did a CT and found a
>> 4cm
>> > > > splenic artery aneurysm. The hooker is that she had a splenectomy
>> after an
>> > > > MVA several years ago.
>> > > > The only thing I would think of doing for her is a trans-catheter
>> coiling
>> > > > of the thing. Any takers?
>> > > >
>> > > > Mitch
>> > > >
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-- 
Prasanna Simha M