I received a telephone call here in Kuala Lumpur a few days ago
from my eldest brother in Singapore who together with my own relatives here in
Malaysia and in Singapore who would normally consult me on their health
problems. I shall not reveal my brother’s name for personal and ethical reasons,
but I shall just address him here as ‘brother’.
I may also consider sharing out some medical cases for general
discussions and updates I normally
encounter from many other patients, but they shall only for educational purposes. All patients’ names shall not be revealed as
this is strictly for general medical information only.
………………………………………………………………….
Dearest brother
I reviewed the results of your CT
scan again a short while ago, and found you actually have what is called an
“aortic dissection”.
What I explain here is just my
personal opinion. You should also discuss what I mention here with your own
vascular surgeon in Singapore.
Furthermore, your own son Lin
Ming Shyue is a paediatrician and neonatologist, and your
granddaughter is also a doctor, both in Singapore, with Anne Ann Ling
Hsu our niece as a Senior Consultant Respiratory and Critical Care
Physician in Singapore General Hospital. We also have so many of our relatives
and their children who are also medical experts, medical and surgical
consultants in Singapore, plus our youngest brother Lim Yew Cheng here in
Gleneagles Hospital Kuala Lumpur who was a Professor of Surgery at the
University Hospital, University of Malaya, and now a Senior Consultant
Cardiothoracic Surgeon at Gleneagles, all of whom you should also seek their
opinion. The more collective professional opinions the better.
However, since you have asked me,
here’s my take on this is about your condition.
An aortic dissection can
be serious as it may bust causing massive internal bleeding especially the
blood will be flowing out from the aorta, the main artery in the body.
Let me explain a bit further.
There are three layers to the aortic wall. The inner wall or layer is
called the tunica intima, the middle layer is called the tunica media, and
the outer layer or wall is called the tunica adventitia.
Aortic dissection is the result
from some tear in the aortic intima causing extravasation of blood into the
aortic wall. This may result in aortic regurgitation and acute myocardial
infarction, arrhythmias, haemopericardium, CVA, paraparesis, BP fluctuations in
the extremities, bowel infarction and renal failure.
The presentations are severe
acute chest pains during onset, radiating to other areas.
Aortic dissection may be
categorized according to DeBakey classification into
1. Proximal to distal, from
ascending aorta, arch down to the ascending aorta
2. Proximal, affects only
the ascending aorta
3. Distal, affects only the
descending aorta, distal to left subclavian artery.
The urgent aim of treatment is to
reduce systolic blood pressure to 100 to 120 mm Hg.
The therapy of choice
consists of giving IV nitroprusside combined with IV propranolol at 1 mg
diluted in 5 ml of water every 5 minutes up to a maximum of 10 mg.
Once BP is under control,
surgery is considered for type 1 and type 2
Conservative treatment may
be considered for type 3 aortic dissection.
In your case, there was a tear
between the inner intima and the middle media layer due to weakening of the
walls of your aorta which is the main artery of your body. This weakening may
be due to age as in your case, free radical damage, high blood pressure, or all
3 combined plus other causes as well.
The tear in the inner layer in
your aorta caused the blood to enter between the inner and middle layers
of the aorta to split (dissect) as shown in diagram from your CT scan. If the
blood goes through the outside aortic wall, aortic dissection is often fatal as
it will cause massive bleeding. However, in your case what I saw in the CT scan
(I suppose it was a CT scan you showed without telling me further), the blood
did not go any further into the tear along a long segment of your aorta. It
stopped after a short segment. This may finally cause a blood clot to be formed
in this area to block the blood from flowing any further into the segment
between the intima and media (inner and middle walls of the aorta)
In other words, the weakening of
your aorta walls caused a tear in the intima and resulted in blood flowing
between these two walls. In other words, this caused blood to seep in
between the walls of your aorta causing a bulge (aneurysm) there. The
weakening may also have caused that part of your aorta to bulge out like a
balloon which your doctor there in Singapore initially reported as a
pseudoaneurysm using ultrasound (Duplex ultrasound scan), but later confirmed
it as a tear in the inner wall using CT scan.
A pseudoaneurysm is the result of
an injury such as a tear to the blood vessel in your case. The artery then
leaks out blood, which then pooled near the damaged spot. It's different from
a true aneurysm, which happens when the wall of a blood vessel stretches
and forms a bulge which may not necessarily bleed.
As far as your question your
doctor in Singapore wanted to follow up using CT for you, I do not
suggest that, because it is NOT safe to use CT scans all the time as CT
is actually x-rays, a prolonged exposure to this harmful radiation, often as
long as 20 -30 minutes which is not safe especially for your age,
compared to ordinary x-rays that is just 1- 2 seconds of exposure.
CT scans means a
computerized tomography that combines a series of X-ray images taken from
different angles around your body and uses computer processing to create
cross-sectional images (slices) of the bones, blood vessels and soft tissues
inside your body. CT scan images provide more-detailed information than plain
X-rays but are less sensitive than magnetic resonance imaging (MRI) that
uses strong magnetic fields and radio waves to produce detailed images of the
inside of the body. MRI though much safer like ultrasound (ultrasonography such
as Duplex) where harmful radiation is used in CT, it is more expensive.
Since we now know your case using
a CT scan, is a tear in the inner lining of your aorta causing blood to flow
between the intima and media, causing a pseudoaneurysm, I suggest you follow
this up using only Duplex ultrasound to see if the bulge gets bigger over a
short time. Initially, maybe you follow this up on a monthly basis for only 6
months, and if stable, follow it up only at a 3-month period, and if there is
no further enlargement, follow it up 2 or 3 times more over a 6-month period.
If it is still stable, a yearly
ultrasonography will suffice. Then after a year, if it is still stable,
you may do another CT scan (but much safer to use MRI) to see the condition of
the tear and haemodynamic (blood flow) in that part of the lesion after a year.
If during this period of monitoring,
if the aneurysm becomes bigger which can easily be measured using the much
cheaper and safer ultrasonography (Duplex), you can then consider using
minimally invasive (keyhole) surgery (laparoscopy) to put a stent over that
area to strengthen that part of the aortic wall. However, an aortic aneurysm
stenting may also carry some risk of graft infection and possibly also
narrowing of that part of the aorta (aortic stenosis) unless they use a
drug-eluting stent which may only provide short-term solution after the
anticoagulant drug is washed off by the continuous flow of blood through the
main artery (aorta) of the body. Here we may have another problem.
Furthermore, a clear patency
benefit of a drug-eluting stent over bare metal stents for treating artery
disease has not been definitively demonstrated.
In this surgical procedure, a cut
is made in the upper thigh through which a catheter carrying the stent is
inserted. The stent graft is then guided using x-rays or
by multi-detector CT Imaging through the arteries to the location of
the aortic aneurysm. The stent graft is placed at the site and opened
up. Sometimes, they may use a fluoroscope which is also x-rays to guide
the catheter in. Whichever the procedure, you cannot avoid exposure to
the radiation of x-rays.
Dye may then be injected into the
blood after the stent graft is placed to make sure the entire procedure is in
order and the stent is in place and working properly, and that blood is not
leaking into the aneurysm. Injecting radiopaque dyes for x-ray monitoring
itself is also not safe since your kidney functions are currently slightly
below normal. Your blood creatinine and urea levels from the blood tests you
showed me are slightly higher than normal, plus your glomerular filtration rate
(GFR) is also lower than normal now. All these indicate your kidneys are less
efficient now, and exposure to all these procedures may compromise your kidneys
further. The dye needs to be seen by X-rays which is yet another problem
with the radio-opaque dye.
So, you need also to consider all
these benefit / risk ratios for surgical options if the aneurysm becomes more
pronounced on ultrasonographic measurements.
Aortic aneurysm besides aging is
also linked to uncontrolled high blood pressure, and most common among elderly
males. If left untreated, the wall can fatally rupture which in the
United States has 10,000 deaths annually. But I have no statistics in
Singapore.
Consider all these first if you
opt for surgery. But if I were you, I would just leave it and just monitor
using Duplex ultrasonography.
Later, I shall find out if there
are other alternative options such as the application of dietary and nutrition
approaches to strength the blood vessels from further damage or the use
of botanical medicines such as the application of yarrow, garlic, ginger,
hawthorn, Centella asiatica (Indian pennywort, pegaga, goto kola, etc),
horse chestnuts, pine bark extracts, Butcher’s broom…etc, etc. that can
support vascular health. But let me search the literature first to
review studies done conclusively on these. their dosages, period of
application as much safer alternative therapeutic options.
Kindest regards,
Your brother Lim ju boo
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