AAA Stent Benefit Risk Assessment

My distal aorta situation – Is Ironman training safe? Benefits – healthy exercise reduces my hyperlipidemia and stent-induced hypertension, and I love the sport. Risks – (1) AAA stent graft can be displaced, it did (2013 bike wreck), (2/3) – excessive movement of iliac stents can kink the stent at (4), which is another stent inserted to repair such a kink (2017), (5) right iliac artery now enlarging with blood heading back towards the aneurysm, and (6) the right popliteal artery is partially blocked, causing claudication in the right calf (isn’t aging fun!).

Physician (veterinarian) heal thyself.

Modified from Luke 4:23 (King James Version)

Time for me to do my own Sport Benefit-Risk assessment.

But first an important little story, from an excellent book on how to prepare for old age, by Bernard Otis. A tale that many of you probably know already, but it was new to me:

“What better example can I provide than the poem my friend and mentor, Rabbi Harold Schulweis, a legend in the Jewish Rabbinate, wrote about the famous violinist Itzhak Perlman in his “Playing with Three Strings.”

We have seen Itzhak Perlman

Who walks the stage with braces on his legs

On two crutches

He takes his seat, unhinges the clasps on his legs,

Tucking one leg back, extending the other,

Laying down his crutches, placing the violin under his chin.

On one occasion one of his violin’s strings broke,

The audience grew silent but the violinist did not leave the stage.

He signaled the maestro, and the orchestra began its part,

The violinist played with power and intensity on

Only three strings.

With three strings he modulated, changed and

Recomposed the piece in his head

He re-tuned the strings to get different sounds,

Turned them upward and downward.

The audience screamed with delight,

Applauded their appreciation.

Asked later how he had accomplished this feat,

The violinist answered

It is my task to make music with what remains.

A legacy mightier than a concert,

Make music with what remains.

Complete the song left us to sing,

Transcend the loss

Play it out heart, soul, and might

With all remaining strength within us.

“What a beautiful way to live out our lives until death do us part.

We live life as a performer.”

Well! I’m no Itzhak Perlman, just an old guy who loves training for the Ironman.

Let’s run my Benefit-Risk Equation for continuing Ironman.

I like a benefit/risk of >1.5 (not very risk averse). The real value of this crude equation is the fact that it considers all major variables, not just the last thing you think of – like Oh! Sh*t!

AAA stent benefit risk assessment is no simple matter. Get it wrong and you don’t have a life or you die prematurely (74+ isn’t really premature, as I’m in the capon-lined phase of life!)

Let’s run the numbers, here we go! You’re guess is as good as mine, right now! For details see the relevant blog post. I’m sure a better scientist could do a better job, but it’s the best I have, for now.

Benefit estimate = Health and happiness = 0.8

Risk estimate = [(doctors opinion+family opinion+modifying risk factor+my feelings)/4]*adjusted behavior factor

Risk estimate = [(0.7 + 0.8 + 0.8 + .6)/4]*0.95 = .69

Estimated Benefit/Risk = 0.8/0.69 = 1.16 = Pretty Damn Risky, unless something changes.

The real risk is area 5 in the diagram at the top of this post. The rest is doable. Let’s consider the pressures, and decide what to do!

For area 5, the right common iliac back-leak towards the aneurysm, consider competing pressures:

Intra-vascular pressure (effect of exercise): clearly a non-trivial problem, but let’s say 80-140 mm Hg.

Intra-abdominal pressure (keeping the aneurysm intact): 5-9 mm Hg – Um! Not good. How about water running, with my abdomen about three feet under, water pressure is 67 mm Hg. Giving me a combined pressure of about 85 mm of Hg. Guess I could use a device to increase intra-abdominal pressure?

My Plan: Until my follow-up scan in June, 2018, when the leak may have scarred over (quoting head surgeon), I’ll confine my training to long walks, lots of swimming, including distance competitions, weight training, not weight lifting, and zero impact shuffle-running.

If area 5 has scarred over, and thus sealed itself (best of luck with that!), I’ll return to Ironman, with lots of reflection, on other aspects of sensible risk taking.

Thoughts, ideas?

No! I don’t want to age gracefully, whatever Andrew Weil recommends (his book is excellent, by the way).

Until then, I’ll just dance to the music of the strings I have available. I’m damned lucky to be alive, thanks to those wonderful vascular surgery teams, and the tools that researchers and businesses have delivered to their hands.

Wishing you happy trails, and NEVER give up!

kev