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322 Hackmann et al.
ACKNOWLEDGMENTS
The authors gratefully acknowledge Rebecca A. Bartow, Ph.D., for providing
editorial support and Scott Weldon, MA, for assistance with illustrations.
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330 Hackmann et al.
DISCUSSION AND COMMENTARY
Questions for the Authors
What are the key pathobiologic features of abdominal aortic aneurysm formation?
Extracellular matrix proteolysis, chronic inflammation, cytokine activity, and
smooth muscle cell loss all play a role in the development of abdominal aortic
aneurysms.
What is the goal of currently available pharmacologic treatment options?
Current options focus entirely on reducing hemodynamic stress on the aortic wall.
What is the goal of the potential pharmacologic treatment options currently under
investigation?
Future treatment options will address the cellular and molecular aspects of aortic
degeneration in order to stabilize the mechanical properties of the aortic wall.
Why is doxycycline being studied as a potential treatment for abdominal aortic
aneurysms?
Doxycycline broadly inhibits matrix metalloproteinases and prevents aneurysm
formation in several animal models.
Why is losartan being studied as a potential prophylactic treatment for patients
with Marfan syndrome?
Losartan is an angiotensin II type 1 receptor antagonist that also inhibits trans-
forming growth factor-beta, an important mediator in aortic matrix degeneration.
Losartan effectively prevents aneurysm formation in a mouse model of Marfan
syndrome.
How important is it that a new treatment completely halts aneurysm expansion?
Although stopping aortic dilatation would be ideal, even modest reductions in the
rate of aneurysm expansion would substantially delay the need for surgical inter-
vention in many patients.
Is long-term suppressive therapy needed after aneurysm repair?
Yes. Patients who have had aneurysm repair remain at risk for degeneration of
adjacent segments of aorta, which can cause the repair to fail. Long-term
suppressive therapy may improve the durability of both open and endovascular
aortic repairs.
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331
18
Legal Considerations in Acute
Aortic Diseases
†
John A. Elefteriades
Section of Cardiothoracic Surgery, Yale University,
New Haven, Connecticut, U.S.A.
INTRODUCTION
Most of this book concentrates on pathogenesis, imaging, diagnosis, and treat-
ment of acute aortic diseases. There is, however, another major dimension to the
care of patients with acute aortic diseases that it behooves us not to ignore—
the medical-legal dimension.
As is well known, we in the United States find ourselves in the midst of a
worsening crisis of medical malpractice litigation. This crisis is said to contribute
to cost of healthcare through increased liability insurance expenses and through
excess “defensive” patient testing (1,2). This crisis is said to be driving physi-
cians out of high-cost states and high-risk specialties (3). Malpractice-related
psychological forces are said to cause major emotional stress to physicians,
manifest both at work and at home (1,4–7). Residency training is affected mark-
edly by medico-legal concerns (4). Liability concerns and related expenses are
thought to be among the major factors affecting choice of specialty for physicians
in training (4,8). This is thought to be a factor in the alarming fall in applicants
for residencies in Cardiothoracic Surgery. Among the six medical disciplines that
face the highest frequencies of litigation and the highest malpractice rates (1,3,8),
four are involved intimately in the assessment and treatment of acute presenta-
tion of aortic diseases: surgical specialties (cardiothoracic), radiology, emergency
medicine, and anesthesiology.
†
Adapted from an article in press in the journal Cardiology, with permission.
SECTION V: LITIGATION IN AORTIC ANEURYSM DISEASE
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