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Avoiding the Chest Cutters

The May 20 edition of The New England Journal of Medicine carries three reports updating the long-term outcomes of patients who underwent endovascular abdominal aortic aneurysm repair compared with those who had open surgical repair. Consistent with prior findings, a median of 6 years out endovascular and open repairs produced similar survival rates.  

A comment in the Journal’s editorial on this caught my eye: Dr. K. Craig Kent, chairman of surgery at the University of Wisconsin, said, “The finding of an early mortality advantage followed by long-term equivalence will probably lead most patients to select endovascular repair. Currently in the United States, more than 60% of infrarenal aneurysms are repaired by endovascular techniques (unpublished data).”  

I’d love to know where Dr. Kent got this statistic, but it sounds very believable. Given the choice of roughly equivalent outcomes, who wouldn’t prefer to have their deformed aorta fixed without cutting holes in the chest wall. I’m only surprised that the percent favoring endovascular isn’t even higher.  

Avoiding chest cuts, be it for heart surgery or other thoracic operations, has been the goal since Dr. Andreas Gruentzig 35 years ago first adapted endovascular catheters for use in coronary arteries as an alternative  to coronary bypass surgery.  

A couple of months ago, at the annual meeting of the American College of Cardiology, I covered the report by Dr. Ted Feldman of the EVEREST II results, the pivotal trial of an endovascular clip for mitral valve repair, an alternative to open-chest valve surgery. Several aspects of the EVEREST II study received sharp criticism from thoracic surgeons, including the on-scene discussant, thoracic surgeon Dr. J. Scott Millikan, who provocatively noted that the high radiation exposure to endovascular patients might have been an adverse event. In a touché moment, Dr. Feldman parried, “In that spirit, sternotomy might be considered an adverse event as well.”  

image courtesy Flickr user Joseph A. Ziemba

 Thinking about surgeons slicing open a patient’s chest, I can’t help but recall the scene in MASH where Hawkeye Pierce (Donald Sutherland) pleads with Col. Blake to get his unit a “chest cutter,” who soon after arrives in the person of Trapper John (Elliott Gould). 

 When that line hit my medically-naive teenage ears  in 1970, it took me a couple of beats to understand what Hawkeye meant, and realize, possibly for the first time and with some shock and revulsion, what thoracic surgery entailed. Part of Altman’s genius in MASH was portraying surgery, and war too, in starkly grisly but off-handed ways. leaving the audience to later ponder the implications of what chest cutters do. 

 —Mitchel Zoler (on Twitter @mitchelzoler) 

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Filed under Cardiovascular Medicine, IMNG, Internal Medicine, Surgery, Thoracic Surgery