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The Globe and Mail

Less risky aneurysm surgery only spottily available

The condition, an abdominal aortic aneurysm, is not painful, but it is dangerous. The stretching weakens the walls of the artery and it can tear open at any time. If that happened, Mr. Bower would bleed to death in minutes.

"When this thing goes, I'm done," the retired businessman from Peterborough, Ont., said stoically. "But I'm not ready to go yet."

What Mr. Bower is ready -- and eager -- for is surgery to repair the aneurysm so he can get back on the golf course. But he is stuck in administrative limbo.

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At his age, 85, and with his medical history -- this is his second aneurysm, and it is very large -- traditional surgery is deemed too risky. The operation consists of cutting the patient open from the heart to the bellybutton and replacing the weakened artery with a piece of Dacron tubing.

For a high-risk patient like Mr. Bower, the risk of dying during surgery is almost 20 per cent, and that does not take into account the risk of postsurgical infection.

According to guidelines published earlier this week in the Canadian Medical Association Journal, Mr. Bower is a prime candidate for a form of surgery called endovascular aneurysm repair (EVAR).

This form of minimally invasive surgery requires only two tiny incisions in the groin, through which surgeons insert a fabric-covered stent that looks like a miniature Slinky. The stent serves as a form of scaffolding that takes the pressure off the bulging part of the artery.

"For us, EVAR is a revolution," Dr. Thomas Lindsay, president-elect of the Canadian Society for Vascular Surgeons, said in an interview. "It's a much better option for patients." Fewer will die, he said, and patients will "have fewer complications and return to normal life a lot more quickly after surgery."

For a high-risk patient like Mr. Bower, the risk of dying during surgery would fall to below 5 per cent, and recovering time would drop to three weeks from three months, according to research comparing the two procedures. In lower risk patients, the mortality rate drops to 0.8 per cent from 4.2 per cent with minimally-invasive surgery.

"This should now be the standard of care in Canada," said Dr. Lindsay, who is also chairman of the division of vascular surgery at Toronto General Hospital. "Patients with these aneurysms should insist on EVAR."

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Insist as they may, however, the procedure is offered only spottily around the country. In Toronto, it is not offered at all. That is why Mr. Bower has been unable to get surgery, even though his case is deemed high priority.

The problem is money. EVAR surgery costs about $15,000 more than traditional surgery, and requires more follow-up care, including annual CT scans.

"It is more expensive," Dr. Lindsay said. "But governments can't just see the dollars, they have to see the better outcomes for patients."

Dr. Lindsay said there is also the matter of equity. "One of the main issues is access to care. Patients who can benefit from EVAR should be able to get the procedure, regardless of where they live."

Abdominal aortic aneurysms are silent killers, often not discovered until they burst. There is no systemic screening for aneurysms, but it is estimated as many as 200,000 Canadians suffer from the condition.

Despite the large number, there were only 2,780 abdominal aortic aneurysmectomies performed last year, according to the Canadian Institute for Health Information. (The data, however, do not include Quebec and parts of Manitoba.)

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Aneurysms are most likely to occur in men over the age of 60, especially if they were smokers, suffer from cardiovascular disease, or have a family history of aneurysms. The condition is generally caused by atherosclerosis (hardening of the arteries), which can weaken the artery wall and allow bulges and catastrophic tears to occur.

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