Saturday, January 31, 2015

Weighing Our Options

Part 2 of 3 about my most recent blood clotting ordeal. Go here for part 1.

Dr Foley ordered an echocardiogram bubble test to check if there was a hole in my heart between the two upper chambers. It's actually a common occurrence that affects upwards of 25% of the population and is referred to as PFO, or Patent Foramen Ovale. It can lead to a DVT (deep vein thrombosis clot) moving from the venous side of the heart to the arterial side which appears to possibly be what happened in my case.

Without a PFO the chances for a DVT posing a stroke risk just aren't there. The clot moves via the veins back to the heart and into the lungs where it's stopped and results in a pulmonary embolism or PE. Where a PFO is present the clot may migrate to the arterial side of the heart and work its way to the brain and cause a stroke or it may become lodged in any number of places as the clot is carried along via the arteries. In my case a clot became wedged in the popliteal artery.

My bubble test was positive for PFO but it shouldn't pose a risk to me now that I'll be anticoagulated the rest of my life. More than anything it's simply important information to have when trying to sort out the puzzle of my clots.

Keith came by Tuesday afternoon just as I was being wheeled back from Interventional Radiology. He spent over an hour with us. It was really nice to see him. I've always felt that I wouldn't be one to want to have all that many visitors if I were to ever find myself in the hospital as I was but I've changed my mind. Visitors are now welcome!

By Tuesday evening I'd been flat on my back for 55 hours but I was about to be given the go-ahead to sit up. The catheter used to deliver the TPA to two of my clots had been removed and was no longer a concern for being crimped if I were to sit up. What a relief!

In Dr Foley's search for clues about my clotting he turned up the CT-scan taken after my bike crash back in September and something leapt out at him. He noticed what appeared to be aneurysms in my left and right common iliac arteries. The scan wasn't definitive so he ordered a nearly full body CT-scan to have a better look at that particular area and whatever else the scan would reveal.

The scan was performed Wednesday morning and not long after it was completed Dr Foley came into my room, stood before us and announced, "I know the reason for your clotting: you have iliac arterial aneurysms!" Say what? This sounded like good news but I couldn't be sure. Good news in the sense that he was on to something more than just the fact that I have Factor V Leiden. He talked briefly to us about the surgery involved in remedying this problem but he preferred to leave most of that discussion for us to have with the surgeon who would be performing the operation.

He told us that the scan I'd just had done showed a new clot in my common iliac artery that wasn't there last September. I picked up on a sense of urgency to not delay in moving forward with the surgery and Tammy and I were both all-in. He told me that my arteries were otherwise pristine and that given my health, I was an excellent candidate to tolerate the surgery. We cooled our heels the rest of the day and into the late afternoon waiting for the meeting with our surgeon in anticipation of surgery the next day.

Dr Johnstone showed up at our room around 6:30 that night and began our meeting by telling us that all of the doctors on the cardiovascular floor know who I am and are familiar with my situation. She had been talking about my case throughout the day with all of them, getting input to be able to better weigh the options for how best to proceed.

She sat down with us and drew a diagram of what's going on inside me. Tammy (more than I) had been studying up on that particular area of the body throughout the day with hopes of being able to fully follow along so we weren't just a couple of bobbleheads with glazed looks over our eyes not grasping any of what was being said. Not to worry. Dr Johnstone was very thorough in her explanations. She said the clots I have in both the left and right common iliac arteries are smooth and don't appear to be fractured. She couldn't say with 100% certainty that the clots that broke free in my body had come from this area. There was a likely chance they did but she couldn't be sure.

She then described the two surgical procedures used to fix the problem. The first would involve the use of a stent to cover over the blood clots by sealing them between the stent and the walls of the artery. The main risk with this method was a possibility that some of the clot would ooze out at either end of the stent and get into my bloodstream, posing a risk for stroke I would guess should the clot matter make it to my brain.

She went on to talk about the size of my arteries being a concern. I have fairly large arteries throughout my body she said but the arteries in this part of my body are twice the normal size. What she couldn't be sure about was whether or not this was because they've always been large or are they still growing in size? If they're still growing in diameter this would pose a problem for the stent as it would eventually become too small for the artery. It's a very non-invasive procedure that would allow me to leave the hospital the next day but its drawbacks were making it an unlikely choice.

The 2nd surgical option, what she described as the "gold standard" to remedy my condition is a major surgery involving cutting me open from just below my heart to a point just above my pubic area. She would then go in and perform a bypass of the clotted area. Recovery from this procedure would be 5 to 7 days post-op in the hospital with 2 of those days spent in ICU (intensive care unit) followed by months of recovery. She said it's a surgery that my body will never fully stop reminding me of. This procedure comes with its own list of risks as well that I'll touch on later.

The 3rd option we discussed was for me to wear a Holter monitor for the next 30 days to see if my heart is experiencing any atrial fibrillation. It's doubtful that it is but she would like to rule it out. If my heart is going into afib there's a chance that it's producing clots in this condition and this could be a source for them.

There was a lot on the table to consider but the short-term decision as to what to do for now was a no-brainer. I chose to wear the Holter monitor for the next month. I also told her, and Tammy agreed, that should I need surgery I would opt for the bypass. It seemed to be the one that would hold up best over time.

She said that if we're able to rule out atrial fibrillation as a cause and I come back and tell her that I'd like the surgery now, she would say that I'm making the right decision but then she added that if I were to tell her that I'd like to wait on the surgery, she would tell me that that too is a right decision. They both have their pros and cons to consider.

This is getting a little lengthy and I've got more to say about our final meeting with Dr Foley so I'll finish this tomorrow.


Vannevar said...

man I am so happy you're getting this level of care and are able to participate in the inquiry/ decision making. When I think about situations like this I wonder about folks who use English as a second language (if at all) and what a difficult experience this would be in that context.

It's really amazing what capabilities and knowledge exist among skillful people. (for instance, right now some amazing folks are making sure airplanes don't bump into each other)

Vannevar said...

also, your hand-drawn sketch looks like a humanoid-lizard morph wearing bike shorts and holding dumbbells. (Somehow, I lost the ability to combine transmissions when I retired)

Kevin Gilmore said...

We do our best to keep up with all that's coming at us. It helps that Tammy is a registered nurse and much more familiar with the terminology than I am. I'll often look to her to recap what the doctor has just told us once they've left. Writing it all out in my blog is helpful as well as I try my best to reconstruct everything that's happened. It's not always easy though because of the pain meds I was on for much of the first couple days.

I can't imagine not having english as my primary language and trying to keep up.

Haha to your last comment! :)

Jim Knoll said...

Wow. Those are a lot of options. My father in law had an aortic aneurysm six months ago. He's 86 and in good health. He was cut open from the heart to the pelvis. That aneurysm is above the kidneys in your picture. His recovery was good but slow. He lost 30 pounds. I'm saying this because when one is cut open through muscles and ribs the recovery takes some time. BUT with that said, his too was the gold standard. He should be good for the rest of his life. In your case, kevin, you have 30+ or 40+ years left. Getting these arteries fixed for the long run might be the best. But be advised you may not feel like yourself for months. However, with all the exercise you do, your recovery might be much faster. I'll be praying for your best decision. Best, -Jim Knoll

John Hill said...

Any thoughts of re-evaluating that retirement date?

Kevin Gilmore said...

Jim...that's amazing that an 86 year old could handle such a surgery. Good for him!

One of the things we need to consider when talking about having the surgery is its long we can expect the veins to do the job without occluding. I'll be writing a little about that in the final piece about this.

Yes, I was telling Tammy that I'd like to work myself into my best shape possible before going forward with this whenever that may be with hopes that that will aid in my recovery.

Thanks, Jim!

John...for's been sort of a recurring discussion I've been having with myself this past week. For all I know I may already be done. It's not the way I want to go out though. I'm planning on staying out one month and then reevaluating where I'm at. I wouldn't mind going back, recertifying then leaving on my own terms but maybe not through the end of 2015 like I'd intended to.