A 75-Year-Old Woman With an Abdominal Aortic Aneurysm and Emphysema

DR PARKER: Mrs H is a 75-year-old woman weighing the risks and benefits of proceeding with an elective surgical repair of an abdominal aortic aneurysm. She lives in the greater Boston area with her husband and has her health care insurance through Medicare. Mrs H’s physicians have followed the size and extent of her thoracic and abdominal aortic aneurysms carefully for several years. By angiogram, the aneurysm involved the origin of the celiac and superior mesenteric arteries, down to the level of the renal arteries. An arteriogram in 1992 revealed a diameter of the thoracic section at 5 cm to 6 cm. An ultrasound in 1995 showed an increase to 6.5 cm. The abdominal aortic aneurysm was measured at approximately 5 cm. By 1996, a magnetic resonance angiogram estimated the thoracic aneurysm at 9 cm, and a computed tomographic (CT) scan estimated its size at 8 3 12 cm. Mrs H remained asymptomatic during this period with regard to the dilated aorta. Her medical history is extensive and complex. She has severe emphysema requiring long-term supplemental oxygen use. She had a transient ischemic attack and a central retinal artery occlusion with resulting partial blindness. In 1995, she had pneumococcal pneumonia complicated by septic shock, acute renal failure, encephalopathy, and gastrointestinal bleeding. She has had “chest pain” with a negative workup for coronary artery disease. In 1997, she complained of the acute onset of severe back pain, and suspected correctly a rupture of her aorta. She was rushed to the local hospital where she was initially resuscitated with fluids, diagnosed as having a ruptured thoracic aortic aneurysm, and transferred to a Boston teaching hospital. She survived a repair of the ruptured thoracic aorta and had a lengthy recovery. She is a former smoker. She currently lives at home and still enjoys activities with her husband, children, and grandchildren even though she is limited by her emphysema. Her current medications include metoprolol tartrate, 50 mg twice daily; aspirin, 325 mg daily; dipyridamole, 75 mg twice daily; and ipratropium bromide, salmeterol xinafoate, and albuterol sulfate inhalers. Physical examination reveals a thin, tired-appearing woman who is able to walk 60 m with supplemental oxygen. Her respiratory rate is 22/min, her heart rate is 58/min, and her blood pressure is 118/70 mm Hg. Her lungs are clear, and her heart sounds are regular and distant. She has palpable femoral and pedal pulses bilaterally. Routine laboratory test results are unremarkable. Pulmonary function tests from 1995 revealed a forced expiratory volume in 1 second (FEV1) of 1.15 L, with an FEV1 to forced vital capacity ratio of 53%. Diffusing capacity was markedly reduced at 38%. There was no reversibility with bronchodilator. Mrs H most recently had her abdominal aortic aneurysm measured at 6 cm by ultrasound and 4 cm by CT scan. Mrs H expressed ambivalence about having surgery on the abdominal aortic aneurysm. She and her family continue a dialogue with her physicians about the merits of further “watchful waiting” vs proceeding with surgery. A vascular surgeon reviewed her case.