A second ticking time bomb

Post her discharge in Sep 2015 after being treated for pulmonary embolism, her situation stabilized significantly and 2016 was fairly uneventful with just one brief hospitalization. The period of calm continued into 2017 and everything held together very well for most of that year.

But I knew intuitively that such peace could not last a long time for amma.

One day in October 2017, amma suddenly had severe chest pain and breathing difficulties.

She was rushed to the same cardiology hospital again. After going through her case history, a young doctor in the Emergency Room politely called me aside and said in a low voice, “Sir, I thought you should know that your mom’s condition is like a ticking time bomb. Anything can happen to her anytime. Please be prepared.”

I nodded my head, told him I was aware of that and requested him to look at the date of the last discharge in the case history – it was about 20 months earlier.

The young doctor looked at me with a mix of surprise and a hint of respect. I guessed he was new to aortic dissection, and also to the fact that some caretakers actually understood a bit about the patient’s disease.

A new CT scan showed that fortunately, amma’s recurrent dissection had not extended since the one taken almost two years earlier. Her chest pains and discomfort were owing to some problems in her lungs. 63 Wow! Conservative management was working very well for amma’s aortic dissection.

But while reviewing the details of her latest CT scan, the chief cardiologist suddenly looked up and said, “There is something else you should see here in the report”.

He quickly explained why he was concerned. While the aortic dissection had not extended or deteriorated in the previous two years, the table showed that the diameter of the arch of the aorta had dilated and grown to almost 6 cm, while in the normal case this would be only a maximum of 3 cm. 64

At such a large arch dilation, the aorta could burst. If it did, that would be it – pretty much.

This was scary. If the descending aorta had been threatening to leak for a while, now the arch was threatening to rupture.

Fig 20: Since when did amma have the aortic arch dilation? Aortic dilations are different from aneurysms. As can be seen from the image above, amma’s dilation was owing to a dilation of the outer lumen (false lumen) because of the dissection, but it is not the same as localized bulges that aneurysms usually are in which the inner wall (true lumen) also expand significantly. In the context of rupture, it is not clear from my research whether dilations have a different prognosis compared to that for dissections. For amma’s dilation, the key question was: since when had the dilation been present? If it was present for a few years (since the recurrent dissection in 2015) and had not expanded/grown in size, it will perhaps remain so for much longer. But if it was new (as of October 2017) and was growing, it could rupture soon.

Fig 21: A copy of the print from the aortogram CT scan results for amma, done in Oct 2017

I was really at my wit’s end. Couldn’t this too be managed through medications?

They were not entirely sure. While history was on our side when it came to managing the descending aorta dissection through medications, a dilated aortic arch may not be so obliging to medications alone. A surgery might be needed. 65

Could the hospital undertake the surgery?

Unfortunately no, as nobody from their expert team had worked on doing a surgery to correct the arch dilation. Instead, the chief doctor suggested I meet a leading surgeon and one of the few in India to have done such surgeries. This expert practised at the Christian Medical College 66, located at Vellore, South India.

A couple of weeks later, I met the expert at CMC 67 and discussed amma’s case. After reviewing amma’s case history and CT scans in detail, he said he could do the surgery and reinforce the arch and the entire descending aorta with stent grafts. I was a bit surprised with his confidence as I thought that an open heart surgery at amma’s age could pose serious risks. And then I understood the reason for his confidence – it would not be an open heart surgery, but he would follow a relatively new concept, an endovascular repair that would be much less invasive and consequently much less risky. 68

But any type of invasive repair for amma was bound to have some risks. I asked him what would happen if we didn’t do the surgery and left it to be conservatively managed as we had done for the descending aorta.

He said it was difficult to predict as he did not know for how long the dilation at the proximal arch had existed. If the dilation was recent and was hence likely progressing, he felt that it could rupture within a year.

Flirting with danger <= A second ticking time bomb => Dilation dilemma



63.  She had what is called bibasilar atelectasis, in which there’s a partial collapse of the lungs.

64. Amma’s dilation had happened in the proximal part of the aortic arch, the part closer to the heart. Normal values for the diameter for these are 2.6+/- 0.3 cm, so a maximum of about 3 cm. The diameter of amma’s proximal aorta was twice the normal size, a pretty dangerous level.

65. Typically, surgery is suggested when the diameter reaches close to 6 cm or when the diameter is growing at more than 0.5 cm/year.

66. https://www.cmch-vellore.edu/

67. Dr George Joseph, senior cardiologist, CMC Vellore

68. In the minimally-invasive endovascular aneurysm repair, a stent graft , which is a tube supported by metal wire stents, is inserted into the aneurysm through small incisions in the groin. This procedure does not require a large incision and has a substantially shorter recovery than the conventional open surgical approach.


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