Heart: An American Medical Odyssey

by Cheney, Dick

  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 h
as 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.

  When you have recovered adequately from the sedation, you will be transported to your overnight room on the VIP ward. Although exact times are difficult to predict, we anticipate that you will be fully alert by 1430.

  Here is a summary of your operative and medical team:

  Dr. Jonathan Reiner

  Dr. Ryan Bosch

  Dr. Paul Dangerfield, Cardiac Anesthesiologist

  Dr. Cynthia Tracy, ICD Cardiologist

  Dr. Anthony Venbrux, Interventional Radiologist

  Dr. Barry Katzen, Interventional Radiologist

  Dr. Peter Gloviczki, Vascular Surgeon

  Dr. Joseph Giordano, Vascular Surgeon

  I know you are in the best of hands. . . .

  Very Respectfully

  Lewis A. Hofmann, MD, FAAFP

  White House Physician

  • • •

  When the motorcade bearing Vice President Cheney arrived at George Washington University Hospital early Saturday morning on September 24, 2005, the news media had already assumed their familiar vigil. The aneurysm repair had taken two months to plan and involved dozens of physicians, nurses, technologists, administrators, and security personnel. The VIP wing of the telemetry floor was configured for the vice president’s planned overnight stay with freshly painted walls, polished floors, hotel-like furniture, rugs, and new linens. Operating room personnel were placed on standby, just in case, and Secret Service agents were posted throughout the hospital. Dr. Gloviczki and Dr. Katzen were granted temporary DC medical licenses and GW clinical privileges, and they returned to Washington to lend a hand.

  The procedure to treat Vice President Cheney’s right leg was complex but uncomplicated. After numbing the upper leg with lidocaine, Tony Venbrux placed a large sheath (about the diameter of a soda straw) into the superficial femoral artery. A thin wire was then advanced through the upper leg, into and beyond the aneurysm behind the knee and down to the level of the calf, using X-ray guidance. Two stent grafts were then slid, one at a time, over the wire, positioned within the aneurysm, and deployed by pulling a “rip cord” that released a constraining stitch, allowing the stent with “memory metal” to expand on its own.

  Although typically we would opt to treat one leg at a time and separate the procedures by at least a week or two, we had discussed the possibility of repairing both legs during the same session because the logistics for treating the vice president were so intricate. Since Cheney was clinically doing fine, we made the decision to treat the left leg as well, which took another couple of hours to accomplish and again required two stent grafts.

  When we were done, I called my wife, Charisse, who asked how it went. Before I could answer, I heard Tony Venbrux, who was speaking nearby into his own phone, respond to the same question.

  “It was a triumph,” he said.

  • • •

  In early January 2006, only three months after the repair of the popliteal aneurysms, the vice president developed a painful flare of gout in his left foot, a condition he had experienced before. Gout is an inflammatory arthritis, often involving the big toe, caused by the deposition of uric acid crystals in the joint. Nonsteroidal anti-inflammatory drugs (NSAIDs) are usually effective in reducing both the pain and the inflammation of the acute episode, and the vice president had an old supply of indomethacin, which he began.

  NSAIDs, a class of drugs that also includes ibuprofen and naproxen, are widely used but not without some risks. The familiar medications can cause gastric irritation or, less commonly, ulcers; they also may increase the risk of a cardiac event, mediated in part by adverse effects on kidney function. In patients with existing heart disease, these agents can result in substantial fluid retention.

  Late at night, a few days after beginning the indomethacin, the vice president called the physician’s assistant on duty for the WHMU and reported that he was having trouble breathing. He stated that he had gained seven to ten pounds over the prior few days, his legs were swollen, and around midnight he developed shortness of breath. Now, three hours later, his breathing was getting worse.

  Five minutes later, Lieutenant Jerald Jarvi, a Coast Guard physician’s assistant on call for the WHMU and sleeping in another building on the Observatory grounds, was standing at the vice president’s bedside. Jarvi’s examination of Mr. Cheney was significant for coarse breath sounds called rales, caused by accumulation of fluid in the lungs, as well as significant edema in both lower legs. Jarvi called me and we agreed that the vice president had congestive heart failure. I said I would meet them at the GW emergency room.

  In the ER, Cheney was stable but clearly fluid overloaded. Blood tests showed no evidence of a heart attack, and there were no EKG changes. After a dose of the IV diuretic furosemide (Lasix), the vice president’s breathing eased considerably. Although the CHF likely was precipitated by the indomethacin, the episode did vividly illustrate the fragility of Mr. Cheney’s clinical balance. It also validated our approach to the aneurysms a few months before. If a few tablets of indomethacin could tip Cheney into heart failure, what might have happened if he had undergone vascular bypass surgery?

  VICE PRESIDENT CHENEY

  During my time as vice president, the one instance where the job clearly had a direct impact on my health occurred in February 2007. I was scheduled to make a trip to the western Pacific with stops in Japan, Guam, and Australia. At each stop, I visited with senior government officials and US military personnel. While I was in Australia with Prime Minister John Howard, one of our best allies and friends, President Bush asked me to continue on around the world and add stops in Pakistan and Afghanistan. I was scheduled to see President Musharraf in Islamabad and President Karzai in Kabul. When I arrived in Afghanistan, I first made a stop at our major base at Bagram, north of Kabul, for briefings and meetings with our senior military leaders in the country. Unfortunately, I got snowed in at Bagram and had to spend the night. I planned to continue to Kabul the next day.

  As I was preparing to leave the next morning, I heard a loud explosion: a suicide bomber had detonated his bomb at the front gate of the base, killing twenty-three people, including two Americans. When the bomb went off, my security detail took me to a bunker near the room where I had spent the night. A short time later, we resumed my schedule as planned. After the attack, a Taliban spokesman claimed the attack had been aimed at me. That was not credible since I was about a mile away from the site of the explosion, and I was on the base only because of a last-minute schedule change the night before. But it was a demonstration of the kind of violence the Taliban and their allies were visiting on the people of Afghanistan. And it was evidence of the danger our military personnel faced every day.

&n
bsp; When I returned to Washington, I had been gone nine days, traveled some twenty-five thousand miles, and spent sixty-five hours in the air. After I had been home a day or two, I noticed a pain in the lower part of my left leg. I reported it to my doctors and arranged for an exam, which included an ultrasound of my left leg. It showed I had developed a blood clot in a vein—a deep vein thrombosis (DVT). It was apparently the result of all those hours on a plane during my recent trip. It was potentially dangerous if it migrated to my lungs or heart and caused a pulmonary embolism. We treated it with regular injections of enoxaparin and oral doses of warfarin, powerful anticoagulants, and over time it dissolved. But managing my medications became more difficult as we had to strike a balance between using the blood thinners to avoid clotting, while at the same time not using so much that we created problems with bleeding.

  DR. REINER

  In 2007 Vice President Cheney embarked on a nine-day, twenty-five-thousand-mile trip that included stops in Afghanistan, Pakistan, Oman, Australia, and Japan. A few days after returning, following a speech at the national legislative council of the Veterans of Foreign Wars, he called to tell me he was experiencing some discomfort in his left calf. There are many potential reasons for discomfort in the leg, but calf pain after extensive air travel is a DVT until proven otherwise, and I recommended that the vice president come to our offices right away for further evaluation.

  Medical Faculty Associates

  The George Washington University

  March 5, 2007

  Dr. Lew Hofmann called late this morning to report that Vice President Richard Cheney had informed him that he had developed discomfort in his left calf. The vice president then presented to the MFA [Medical Faculty Associates] for evaluation at 1:30PM. The vice president was seen with Drs. Lew Hofmann, Ryan Bosch, Joe Giordano, and Michael Hill.