Heart: An American Medical Odyssey (28 page)

•  •  •

In 2005, the standard approach to repairing a popliteal aneurysm was
surgery to open the back of the leg, excise the diseased vessel segment,
and then restore arterial continuity with a bypass composed of
either a vein from the patient or a synthetic vascular graft. The surgery usually
required general anesthesia and a few days in the hospital. Overall, vascular surgery is
considered a high-risk procedure, in large part because it is frequently performed on
patients who also have heart disease, and I thought Vice President Cheney was
particularly high risk for surgery.

Although Cheney had not had any recent angina or overt episodes of
congestive heart failure, I knew that he was delicately balanced. Earlier in the summer,
an echocardiogram estimated his ejection fraction at 25 to 30 percent, somewhat lower
than when he took office. Surgery to repair the aneurysm was going to require the
harvesting of a vein, but surgeons had used the vein from his left leg during the
coronary bypass surgery in 1988 and it wasn’t clear how much of the remaining vein
in the right leg would be usable. A synthetic graft was less desirable. Anesthesia
places a stress on the heart, as does the tachycardia that may result from pain or blood
loss, and the surgical procedure itself makes it more likely that blood will clot, not a
good thing for a patient with severe coronary disease. To make matters worse, Cheney was
going to need
two
operations.

I consulted Dr. Anthony Venbrux, GW’s director of interventional
radiology, an internationally renowned physician who had come to George Washington
University Hospital five years earlier after spending the first part of his career at
Johns Hopkins. Tony is a brilliant radiologist and a truly gifted teacher, and one of
the kindest people I have ever known. He proposed a new, less invasive method to treat
the aneurysms. The procedure, called endovascular repair, would involve placing a
Gore-Tex–covered stent inside the vessel (an “endograft’) to connect
the relatively normal upstream and downstream arterial segments, thereby functionally
excluding the aneurysm. The potential advantage of this technique was that it could be
performed without general anesthesia, would not require the surgical excision of a vein,
and should be safer. Also, recovery would be quicker, and if all went well, it might be
possible to treat both legs during the same procedure.
The major
negatives of this approach were its newness and the scarcity of long-term safety and
efficacy data.

Tony told me that Dr. Barry Katzen, the founder and medical director of
Baptist Cardiac & Vascular Institute in Miami, was one of the world’s experts
in this technique, and Tony said he would reach out to him and solicit his opinion
without disclosing the identity of the patient. Barry agreed that endovascular popliteal
aneurysm repair was a very reasonable option, particularly for high-risk patients, and
that although it was relatively new, the evolving data were very favorable.

Tony subsequently drafted a long document, basically a medical brief, in
which he outlined the rationale for his proposed strategy to repair the vice
president’s aneurysms with endografts:

There are several clinical factors to consider regarding management of the
bilateral popliteal aneurysms in this patient. Clinical comorbidities include
significant cardiac history with previous harvesting of greater saphenous vein for CABG
from one of the lower extremities. The patient also has had coronary artery
interventions and placement of a pacemaker. The desire to preserve the remaining
saphenous vein for potential future cardiac surgery is an important
consideration. . . . Recognizing the lack of available longterm data,
percutaneous access from an antegrade approach with aneurysm exclusion with a stent
graft is a reasonable alternative given the medical conditions of this
patient. . . . Given the current “state of the art” imaging
available at GWUMC, percutaneous placement of such a device is feasible. The team at The
George Washington University Medical Center is multidisciplinary and available to treat
[the vice president] should he decide to proceed.

On July 23, 2005, we visited the vice president’s residence to
discuss our recommendations with Mr. and Mrs. Cheney. Lew arranged for a ride, and Tony
Venbrux, Dr. Joseph Giordano, GW’s chief of surgery, Dr. Ryan Bosch, an internist
who replaced Gary Malakoff after Gary’s departure from GW the year before, and I
piled into an unmarked
Secret Service van for the quick trip from
our offices in Foggy Bottom to the twelve-acre compound two miles away.

Our meeting was held in the residence’s first-floor library amid
books about trout and hunting and a Gilbert Stuart painting of John Adams, the first
vice president of the United States, above the fireplace. Over coffee, we spoke about
the CT findings and the implications of the popliteal aneurysms, the treatment options,
and, finally, why we were recommending the novel, less invasive approach. The vice
president appeared quite relaxed as he and Mrs. Cheney asked questions; after about an
hour, they thanked us for taking the time to come to their home to discuss this with
them.

About a week later, I received a request to send a copy of the vice
president’s scan to Dr. Peter Gloviczki, the chief of vascular surgery at the Mayo
Clinic. Dr. Gloviczki was a well-known vascular surgeon who had been asked by the WHMU
to review the vice president’s case. A few days later, a Mayo cardiologist called
and wanted to know the details of the vice president’s history and recent cardiac
testing.

I spoke by phone with Mr. and Mrs. Cheney to again explain why I thought
endovascular repair was the best procedure for the vice president.

“At the risk of being tedious, please allow me, one more time, to
explain why I think repairing the aneurysms with stents is a better idea than
surgery,” I said.

“Dr. Reiner, why do all the other doctors say you’re
wrong?” Mrs. Cheney asked.

The answer to Mrs. Cheney’s question had less to do with specific
organ systems or objective data from stress tests, echocardiograms, or heart
catheterizations, and more to do with the holistic
cura
personalis,
“care for the whole person.” The vice president was
remarkably well compensated for someone with his level of cardiac impairment, but I
thought the stress of open surgery would endanger his stability. I knew that the
surgeons at Mayo were focused on how best to repair the legs but couldn’t have had
a good sense for the nuances of his condition. An old adage in medicine goes, “If
you go to a baker, you get a loaf of bread.”
If you show a
vascular surgeon a popliteal aneurysm, he or she will tell you that surgery is the best
way to fix it (and it often is). Just not in this patient.

“They don’t know the vice president as well as I do,” I
replied.

•  •  •

The WHMU has a budget item to cover the expense of bringing physicians
to Washington for the purpose of consulting in the care of the president or vice
president, and Lew Hofmann felt this was the time to do that. At the end of August, Drs.
Peter Gloviczki and Barry Katzen graciously took time away from their busy practices in
Minnesota and Florida, respectively, and flew to DC to present their recommendations to
the vice president.

On Thursday, August 25, Lew, Bosch, and I met Gloviczki and Katzen for
dinner at Old Ebbitt Grill near the White House. After dinner, we made the five-minute
walk down Pennsylvania Avenue to the Eisenhower Executive Office Building, where Lew had
reserved a conference room. I had hoped that by reviewing together Mr. Cheney’s
clinical data and hashing out the pros and cons of both techniques, we would reach a
consensus to present to the vice president the next day. Unfortunately, despite meeting
for hours, with Lew acting as facilitator, positions remained unchanged, with Peter
Gloviczki advocating surgical repair and Barry Katzen recommending the less invasive
endovascular stent graft treatment, which Ryan Bosch and I also strongly supported.

When we called it quits around 11:00 p.m., we were no closer to a unified
plan than we were when we started hours before. Walking back to my office along the
quiet, late-night streets of downtown DC, I thought about how complicated the treatment
of this one patient had become.

•  •  •

Ninety minutes were set aside for our meeting in the West Wing with the
vice president and Mrs. Cheney, a huge block of time in their schedules. The
consultation had the air of a court proceeding, and I began
with an
opening statement explaining why the aneurysms needed to be repaired. I then introduced
Dr. Gloviczki, who would address the surgical approach to the problem.

Peter had a broad and reassuring smile. His accent was tinged with the
Budapest of his youth, but he spoke with precision he’d cultivated in the
operating room. Medical illustrators at the Mayo Clinic had produced large, beautiful
color drawings that were works of art, and as Peter spoke, he deftly used the exhibits
to make his case. One panel showed the vascular anatomy of Cheney’s legs and the
large clot-filled sacs behind each knee. Another sketch illustrated how the proposed
surgery would be accomplished by sewing a segment of vein into the leg to bypass the
aneurysm. Gloviczki was an impressive advocate. There was no arrogance about him, just
competence and confidence.

Gloviczki concluded his remarks by saying to Vice President Cheney,
“If you were my father, I would recommend this surgery.”

“If you were my father?” the sixty-four-year-old vice
president said, taking mock offense at the fifty-seven-year-old surgeon’s
remark.

“I mean ‘brother,’ ” Gloviczki quickly
corrected, flashing a big, embarrassed smile.

Nothing cuts tension in a room better than laughter.

Next I introduced Dr. Katzen, an interventional radiologist who had helped
create the endovascular revolution. Barry’s five-day course, the International
Symposium on Endovascular Therapy, held annually for the last quarter century in Miami,
is the premier conference focusing on cutting-edge vascular therapies. He had brought
with him a sample of the kind of stent graft we would use to repair Mr. Cheney’s
aneurysms. The device, called a VIABAHN Endoprosthesis, manufactured by W. L. Gore &
Associates, has the appearance of a large, flexible stent with an integrated fabric
liner. The stent itself is constructed of Nitinol, a metal alloy of nickel and titanium
that, unlike Julio Palmaz’s original stainless-steel stent, has extreme
flexibility (superelasticity) and the ability to pop into a preconfigured form (shape
memory). The liner is made of Gore-Tex, the ubiquitous fabric that is essentially a
porous form of Teflon. Barry described how the stent would be delivered and
deployed and said that the procedure would be performed with only
sedation and local lidocaine, obviating the need for general anesthesia.

The Cheneys had many questions.

“What is the incidence of infection?”

“What do you use if there isn’t enough vein
available?”

“Can you do both legs the same day?”

“How long do the stents last?”

“What are the risks?”

“How long is the recovery?”

Before we concluded the meeting, I summarized the two proposals and
reiterated the reasons I favored the Venbrux/Katzen approach. Vice President Cheney
thanked us for all the time we had spent on this matter and said he would think about it
over the weekend and let us know what he wanted to do in a few days.

On Monday morning, Debbie Heiden called and asked if I had a few minutes
to talk with the vice president.

“Of course,” I said.

When Cheney got on the line, he thanked me again for arranging the meeting
and then cut right to the chase.

“I’ve decided to go with the stent option,” he said.

To go all-in in no-limit poker, to bet all your chips, is a sign of
either total confidence in your cards or a ballsy bluff. I had gone to great lengths to
convince the vice president to undergo the relatively untested endograft procedure. His
decision was an enormous demonstration of trust, the weight of which I suddenly felt. I
was confident that this was the right thing to do, but there was no denying that I was
now definitely all-in.

The White House

Washington

September 21, 2005

Mr. Vice President

Please find enclosed in this envelope a DVD which has
a three minute
video animation of the stent placement
procedure. The video does not include animation of the placement of one stent inside
another.

With regard to
Saturday . . .

Preparation

Please eat a good supper on Friday night. After
midnight you should only have water. Take all of your regular medications on
Saturday morning.

Remember to bring your “overnight kit” as
we discussed by phone on Monday. Attire will be provided for you throughout your
stay, however if you desire to have your own pajamas that will be fine. There is a
small chance that the groin sites could ooze for the first few hours, so it might
not be prudent to put your own clothes on right away.

Procedure

Plan to arrive at George Washington Hospital at 7:00.
You will be escorted to a room where you will change into hospital attire. From
there you will walk to the procedure lab, arriving around 0715.

In the procedure room, two intravenous lines will be
placed, blood will be drawn to prepare for the VERY unlikely possibility of
transfusion, and you will be asked to sign the consent form. Your ICD will be
disabled.

You will then receive sedation and local anesthesia.
We expect the actual procedure to begin by 0800. The procedure may take up to four
hours, we expect to be done by noon. Your ICD will be reactivated.