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Babysitting Potential Time Bomb Urged

Watchful waiting best for small aortic aneurysms, studies say

WEDNESDAY, May 8, 2002 (HealthDayNews) -- Abdominal aortic aneurysms, weak spots in the heart's main artery that can kill quickly if they burst, don't necessarily need immediate surgical repair.

Careful medical babysitting works just as well, two new studies say.

An estimated 6 percent of Americans over 50 are walking around with abdominal aortic aneurysms, which are the circulatory system's equivalent of a bubble on the side of a bicycle tire. For a long time, doctors have debated the best strategy to follow -- immediate surgery to patch the weak spot or "watchful waiting," doing surgery only when the aneurysm becomes large enough that a rupture might be imminent.

The studies, one in England and one in the United States, now come down on the side of watchful waiting. In both studies, the five-year survival rate was the same for patients who had immediate surgery as those who were kept under surveillance.

"We set up the trial to show that early surgery would be better," acknowledges Dr. Janet T. Powell, a professor of clinical sciences at the University Hospitals of Coventry and Warwickshire, and lead author of one of the two reports in tomorrow's New England Journal of Medicine.

However, the study, in which more than 1,000 patients with small aneurysms -- from 4 to 5.5 centimeters (1.6 to 2.2 inches) in diameter, found "no long-term difference in mean survival between the early surgery and surveillance group," says the journal report.

The American study, done by Department of Veterans Affairs medical centers, set out with no such defined goal, says lead author Dr. Frank Lederle, of the Veterans Affairs Medical Center in Minneapolis.

"When we had a meeting, we would have one person saying that surgery was clearly preferable and another saying he would prefer not to do surgery," Lederle remembers. So, 569 VA patients 50 and older with the same size aneurysms as in the British study were operated on immediately, while another 567 were assigned to watchful waiting.

After five years, Lederle says, "In all the ways we divided our results, for all the subgroups we had the same finding -- no significant difference in survival and a trend favoring waiting, slightly."

Financial considerations also seem to favor waiting, he says. Patients in the surveillance group came in every six months for an ultrasound or computerized tomography test, whose billed cost is $100 to $200.

"Since surgery costs over $25,000, it would be reasonable to assume that surveillance reduces the costs," Lederle says.

In both studies, surgery was done when the aneurysm became large enough to arouse concern. One worry about surgery is that some patients die on the operating table. The surgical death rate in both studies was low -- 2.7 percent in England, 2 percent in the VA centers.

"If surgery for smaller abdominal aneurysms isn't advisable with our excellent surgery survival rates, it's hard to imagine it being justifiable anywhere else," he says.

One reason for the good results for the watchful waiting group in the British study, Powell says, is that "perhaps because when people feel they are being looked after, they take better care of themselves."

Many smokers in the surveillance group gave up the habit, she notes.

What To Do: You can learn more about aneurysms from the American Heart Association or MedicineNet.

SOURCES: Janet T. Powell, M.D., professor, clinical sciences, University Hospitals of Coventry and Warwickshire, England; Frank Lederle, M.D., Veterans Affairs Medical Center, Minneapolis; May 9, 2002, New England Journal of Medicine
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