Conservative Medical Management

Amma’s life for five years with a recurrent aortic dissection made me think and read a bit about conservative health management.

When doctors suggested such a treatment in 2015, I was not very keen on it for two reasons. One, I did not think amma’s tattered-looking aortic dissection would stick together for more than a few hours – it was just a visceral feeling. Two, I felt I was shirking risks by not going ahead and having a surgery done.

This feeling of shirking risks increased even further two and a half years later when the doctor at CMC Vellore clearly explained how doing it with an endovascular surgery actually carried pretty low risks.

Since then, I have read quite a bit about conservative management for aortic dissections. I found that it was indeed the first recommendation worldwide for those whose descending aortic dissections were not complicated. 183 Evidently, if blood pressure is managed well, such dissections stay put and create little trouble at least in the short term.

It should be no surprise that conservative management is followed for many ailments. Problems with knees, back and spine most times are treated conservatively in the beginning until a stage is reached when surgery becomes necessary. Another example is heart itself, where effective management through medications is first attempted before more aggressive and invasive efforts involving surgeries, and in the worst case, transplants, are attempted. Even in coronary artery diseases, if the blockage is less than 70 percent and does not severely limit blood flow, medications may be the first line of treatment.

While for some of these, going for a conservative treatment might be an obvious choice because of the empirical track record of success (many of the heart ailments fall in this category), for ailments such as aortic dissection that are relatively rare, it is a difficult choice to make.

The fundamental correlation between risk and return never changes, whatever be the sphere of life – higher the risk, higher the likely return. In amma’s case, it gets translated as:

Conservative treatment = no upfront risk but likely adverse incidents in the short or medium term leading to shorter expected lifespan 184

Endovascular surgery = higher risk during and in the few months after the procedure but likely fewer adverse incidents later on, leading to longer expected lifespan.

The short equation however does little justice in conveying the many intricacies involved in decision making based on it.

For instance, consider the vexing question of how long an incident free life we can expect a conservative treatment. If it is 5 years, it might be a great bet for a person like amma, but if it is 1 year, then it is not. For amma, she had an additional 4 emergency admissions the same year that we started her conservative management (2015). While none of her admissions were directly related to her aortic dissection (which had not deteriorated at all), it is possible that some of the problems were owing to side effects of some medications. But post October 2017, she had a dream run of almost three years with almost no incident. Even her final anemia was likely related more to the use of anticoagulants given to prevent pulmonary embolisms than anything to do with the aortic dissection. For amma thus, it is very difficult to actually define the incident profile for the five years she lived under conservative management.

On the other hand, will endovascular repair really be incident free once the original operation is over? I have read cases where the grafts presented challenges post the repair, necessitating further operations within a few months of the original endovascular operation. Could there be other complications as well, given the extensive nature of the dissection for someone like amma? And given that such operations are quite expensive wherever they are performed in the world, isn’t an old patient like amma much better off investing a small portion of this expense in ensuring that her conservative management is implemented perfectly?

Fig 55: Surgery or conservative management? Undergoing a surgery involves taking an upfront risk, but provides long term benefits in terms of incident free life for many years. It is inverse for conservative management – no upfront risks, but the likelihood of adverse incidents could be significant beyond the fifth or sixth year.

Life can be complicated. Or it can be simple. Depends on how we make some decisions.

One sensible way to decide between conservative management and surgery/operation could be to look at history and empirical data for similar circumstances and similar age groups. This cannot be done by a patient or the caretaker .Only a medical expert or a team of experts who have a good grasp of this history can do it.

In this context, amma was certainly fortunate that the cardiac hospital she went to had folks who knew what they were talking about, and more importantly, knew what they did not know and were forthright about it. To a large extent, I trusted their judgement – and it worked quite well for amma.

Side effects of medications <=.Conservative medical management => Hospital experiences

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Notes

183. Complicated dissections refer to those with evidence of aortic rupture, loss of blood supply to organs, rapid expansion of any portion of the dissection, and a very large aortic diameter anywhere along the dissection.

184. Some studies done in Japan for the 2014-16 period to compare survival rates for those with conservative management and those with surgery suggest that the former (those who are conservatively managed) are twice as likely to have all-cause mortality as the former (those who had undergone surgery) – https://cardiothoracicsurgery.biomedcentral.com/articles/10.1186/s13019-018-0814-6

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