Surgical Aneurysm Repair

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What is surgical aneurysm repair?
In surgical aneurysm repair, your vascular surgeon repairs or removes an aneurysm through an incision in your skin. An aneurysm is an enlarged and weakened section of an artery. An aneurysm is a serious health concern, because as it increases in size, it can rupture. Besides rupturing, aneurysms carry another risk. Blood clots can form in an aneurysm and block blood flow to parts of your body. Fortunately, aneurysms can be repaired safely. It is also fortunate that more than one method to repair aneurysms is available. These include surgical, sometimes called "open" aneurysm repair, and endovascular, sometimes called "stent graft" aneurysm repair. The best method to repair each aneurysm depends upon several factors, including the location and shape of the aneurysm as well as the overall health of the patient.

Although aneurysms can involve other arteries, most aneurysms occur in your aorta, which is the largest artery in your body. It runs from your heart through your chest and abdomen. An aneurysm that occurs in your abdomen is called an abdominal aortic aneurysm, or AAA (see illustration to the right). An aneurysm that occurs in your chest is called a thoracic aortic aneurysm, or TAA (see illustration of Normal Aorta and Thoracic Aortic Aneurysm below). Aneurysms also occur in the arteries located in your thigh, knee, spleen, liver, kidneys, or stomach. AAA is the most common type of aneurysm.

Not all aneurysms need immediate treatment. If your aneurysm is small and not causing symptoms, your physician might recommend "watchful waiting," which means monitoring your aneurysm for signs of problems, such as enlargement.

When an aneurysm causes symptoms or grows to a size that it can threaten your health, your physician might recommend surgical aneurysm repair. A vascular surgeon performs this procedure, while you are under anesthesia, by making an incision in your body to reach the aneurysm. In some cases, depending upon the type and location of the aneurysm, your surgeon may repair or replace your artery affected by an aneurysm using tissues from your body or synthetic fabric patches or tubes called grafts. Less commonly, your surgeon may use clips or clamps to stop blood from flowing into your aneurysm. If endovascular aneurysm repair is indicated, a vascular surgeon will place a "stentgraft," a wire tube covered with a synthetic fabric, within the aneurysm to exclude flow within it. The stentgraft is placed within the artery through an incision at a site remote from the aneurysm being repaired.

How do I prepare?

First your physician obtains a medical history by asking you questions about your general health and symptoms. Your physician will also want to know if and when your symptoms occur and how often. In addition, your physician conducts a physical exam. Together these are known as a patient history and exam. As part of your physical exam, your physician will gently feel the aneurysm through skin over the suspected aneurysm and listen to your arteries through a stethoscope.

Next, your physician may order some tests to measure the size of the aneurysm and determine its location. Although not all the tests may be required for each patient, they usually include:

Duplex ultrasound

Computed tomography (CT) scan

Magnetic resonance angiography (MRA)

Angiography

Your physician or vascular surgeon will give you the necessary instructions you need to follow before the surgery, such as fasting. Usually, your physician will ask you not to eat or drink anything at least 8 hours before your procedure. Your physician will discuss with you whether to reduce or stop any medications that might increase your risk of bleeding or other complications.

When do I need aneurysm repair?

Your physician may schedule you for surgical aneurysm repair or you may need it in an emergency. Scheduled surgery is called elective repair. You may need elective repair if your aneurysm grows to a certain size, depending on where it is in your body, or if your aneurysm grows quickly. Less commonly, you may also require elective repair if your aneurysm interferes with blood flow to a part of your body, such as your legs.

You may need emergency surgery if your aneurysm is about to rupture or burst or it has already ruptured. Your physician may recommend emergency surgery if your aneurysm is causing symptoms, such as abdominal or back pain, because your aneurysm may be close to bursting.

Am I at risk for complications during procedure?

Serious health problems, which may be more likely in some individuals especially if they are very elderly, may increase the chances of having complications during aneurysm surgery. If your general health is good, however, your age alone is not a reason to avoid necessary aneurysm repair. Other factors that may increase your chances of complications include:

Congestive heart failure

Diabetes

Cardiopulmonary obstructive disease (COPD), in which airflow through your lungs is decreased

A previous heart attack, which may indicate coronary artery disease (CAD)

Recurring chest pain, called angina pectoris, which may also indicate CAD

These risk factors should be evaluated and treated by your physician before elective aneurysm repair to lessen your chances of complications associated with aneurysm repair.

What happens during surgical aneurysm repair?

You will be given anesthesia to eliminate pain during your aneurysm operation and your vascular surgeon will make an incision in your skin and muscle over the artery with the aneurysm. For AAA, for example, your surgeon will work through your abdominal wall. If your aneurysm is in your knee, your surgeon will operate in your leg.

Once your surgeon exposes the aneurysm site, he or she will clamp the artery above the aneurysm to stop blood from flowing through the area. Your surgeon next opens the aneurysm and removes the clotted blood and plaque deposits.

Usually, depending upon the location of the aneurysm, your surgeon will not completely remove your aneurysm. Instead, he or she may cut through the wall of the weakened artery and open it like a butterfly. He or she may then insert a graft that is the same size and shape of your healthy artery. Your surgeon will attach one end of this graft by sewing it to the healthy artery just above where the aneurysm begins and sewing the other end to your normal artery below the end of the aneurysm. Another less common option is for your surgeon to attach a fabric patch to the artery wall to decrease its size and strengthen it.

In some cases, if the aneurysm involves a smaller artery in your leg or other location, your surgeon may remove the aneurysm and replace it with a piece of a vein from your leg. For aneurysms involving larger arteries, such as your aorta, a man-made graft is necessary because your vein would not be large enough for this location.

Less commonly, neurosurgeons treat certain types of aneurysms, such as those in the head, with clips or small clamps. The neurosurgeon places the clip or clamp where the aneurysm attaches to your artery. This prevents blood from entering the aneurysm, and relieves pressure on it.

If your surgeon cannot clip the aneurysm because of its location, he or she may fill the aneurysm with tiny metal or plastic coils. Your surgeon uses a long, thin tube called a catheter threaded through your blood vessels to insert the coils. The coils fill the inside of the aneurysm and block blood from flowing into it.

What can I expect after surgical aneurysm repair?

After your surgery, depending on the location of your incision and your general health, you may need to stay in the hospital for about 7 to 10 days until you are recovered enough to go home. Again, depending upon the location of your incision and your general health, you may require care in intensive care until you recover sufficiently.

Your physician or vascular surgeon will give you the special instructions you need to follow after the surgery, such as not lifting anything more than 10 to 15 pounds, until your incision heals adequately.

Periodically, depending upon its location, your physician may schedule you for an imaging study to make sure that your aneurysm is not redeveloping and that the graft, patch, or clips are functioning correctly.

Are there any complications?

You may have complications following any major surgical procedure. Less serious complications that you may experience following aneurysm surgery include swelling, respiratory or urinary infections, or infections at the incision site. More serious complications that you may experience include:

Heart problems

Breathing problems

Kidney problems

Colon problems

Paralysis in the lower half of the body is very rare following abdominal AAA surgery but can occur more commonly following extensive thoracic aortic aneurysm operations. Surgery for AAA can sometimes lead to scar formation that can interfere with the nerves that control the flow of semen into the penis and your ability to obtain an erection. If you are a man, and if you have normal sexual function before the procedure, you might experience retrograde ejaculation or possibly difficulty getting and maintaining an erection after the operation. Retrograde ejaculation means that the semen travels up into your bladder instead of coming out your penis, but it does come out later when you urinate.

These complications are relatively unusual after elective aneurysm AAA surgery but more frequent after emergency AAA repair and must be balanced against the risk of not treating the aneurysm.

What can I do to stay healthy?

To help maximize the long-term benefits of aneurysm surgery, you may have to change some of your lifestyle habits. Because some researchers believe that hardening of the arteries is associated with aneurysms, lowering your blood pressure and lowering your cholesterol may reduce your risks of developing another aneurysm or associated heart or vascular disease. Other recommended changes include:

Eating foods lower in fat, cholesterol, and calories

Exercising aerobically, such as walking briskly, for 20 to 30 minutes 5 times each week

Quitting smoking

Maintaining your ideal body weight

What is an abdominal aortic aneurysm (AAA)?
The aorta is the largest artery in your body, and it carries oxygen-rich blood pumped out of, or away from, your heart. Your aorta runs through your chest, where it is called the thoracic aorta. When it reaches your abdomen, it is called the abdominal aorta. The abdominal aorta supplies blood to the lower part of the body. In the abdomen, just below the navel, the aorta splits into two branches, called the iliac arteries, which carry blood into each leg.

When a weak area of the abdominal aorta expands or bulges, it is called an abdominal aortic aneurysm (AAA). The pressure from blood flowing through your abdominal aorta can cause a weakened part of the aorta to bulge, much like a balloon. A normal aorta is about 1 inch (or about 2 centimeters) in diameter. However, an AAA can stretch the aorta beyond its safety margin as it expands. Aneurysms are a health risk because they can burst or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or even death.

Less commonly, AAA can cause another serious health problem called embolization. Clots or debris can form inside the aneurysm and travel to blood vessels leading to other organs in your body. If one of these blood vessels becomes blocked, it can cause severe pain or even more serious problems, such as limb loss.

Each year, physicians diagnose approximately 200,000 people in the United States with AAA. Of those 200,000, nearly 15,000 may have AAA threatening enough to cause death from its rupture if not treated.

Fortunately, especially when diagnosed early before it causes symptoms, an AAA can be treated, or even cured, with highly effective and safe treatments.

What are the symptoms?

Although you may initially not feel any symptoms with AAA, if you develop symptoms, you may experience one or more of the following:

A pulsing feeling in your abdomen, similar to a heartbeat

Severe, sudden pain in your abdomen or lower back. If this is the case, your aneurysm may be about to burst

On rare occasions, your feet may develop pain, discoloration, or sores on the toes or feet because of material shed from the aneurysm

If your aneurysm bursts, you may suddenly feel intense weakness, dizziness, or pain, and you may eventually lose consciousness. This is a life-threatening situation and you should seek medical attention immediately.

What causes an abdominal aortic aneurysm?

Physicians and researchers are not quite sure what actually causes an AAA to form in some people. The leading thought is that the aneurysm may be caused by inflammation in the aorta, which may cause its wall to weaken or break down. Some researchers believe that this inflammation can be associated with atherosclerosis (also called hardening of the arteries) or risk factors that contribute to atherosclerosis, such as high blood pressure (hypertension) and smoking. In atherosclerosis fatty deposits, called plaque, build up in an artery. Over time, this buildup causes the artery to narrow, stiffen and possibly weaken. Besides atherosclerosis, other factors that can increase your risk of AAA include:

Being a man older than 60 years

Having an immediate relative, such as a mother or brother, who has had AAA

Having high blood pressure

Smoking

Your risk of developing AAA increases as you age. AAA is more common in men than in women.

What tests will I need?

Abdominal aortic aneurysms that are not causing symptoms are most often found when a physician is performing an imaging test, such as an ultrasound or CT scan, for another condition. Sometimes your physician may feel a large pulsing mass in your abdomen on a routine physical examination. If your physician suspects that you may have AAA, he or she may recommend one of the following tests to confirm the suspicion:

Abdominal ultrasound

Computed tomography (CT) scan

Magnetic resonance imaging (MRI)

How is an abdominal aortic aneurysm treated?

Watchful waiting

If your AAA is small, your physician may recommend "watchful waiting," which means that you will be monitored every 6-12 months for signs of changes in the aneurysm size. Your physician may schedule you for regular CT scans or ultrasounds to watch the aneurysm. This method is usually used for aneurysms that are smaller than about 2 inches (roughly 5.0 to 5.5 centimeters) in diameter. If you also have high blood pressure, your physician may prescribe blood pressure medication to lower the pressure on the weakened area of the aneurysm. If you smoke, you should obtain help to stop smoking. An aneurysm will not "go away" by itself. It is extremely important to continue to follow up with your physician as directed because the aneurysm may enlarge to a dangerous size over time. It could eventually burst if this is not detected and treated.

Open Surgical aneurysm repair

A vascular surgeon may recommend that you have a surgical procedure called open aneurysm repair if your aneurysm is causing symptoms, or is larger than about 2 inches (roughly 5.0 to 5.5 centimeters), or is enlarging under observation. During an open aneurysm repair, also known as surgical aneurysm repair, your surgeon makes an incision in your abdomen and replaces the weakened part of your aorta with a tube-like replacement called an aortic graft. This graft is made of a strong, durable, man-made plastic material, such as Dacron®, in the size and shape of the healthy aorta. The strong tube takes the place of the weakened section in your aorta and allows your blood to pass easily through it. Following the surgery, you may stay in the hospital for 4 to 7 days. Depending upon your circumstances, you may also require 6 weeks to 3 months for a complete recovery. More than 90 percent of open aneurysm repairs are successful for the long term.

Endovascular stent graft

Instead of open aneurysm repair, your vascular surgeon may consider a newer procedure called an endovascular stent graft. Endovascular means that the treatment is performed inside your artery using long, thin tubes called catheters that are threaded through your blood vessels. This procedure is less invasive, meaning that your surgeon will usually need to make only small incisions in your groin area through which to thread the catheters. During the procedure, your surgeon will use live x-ray pictures viewed on a video screen to guide a fabric and metal tube, called an endovascular stent graft (or endograft), to the site of the aneurysm. Like the graft in open surgery, the endovascular stent graft also strengthens the aorta. Your recovery time for endovascular stent grafting is usually shorter than for the open surgery, and your hospital stay may be reduced to 2 to 3 days. However, this procedure requires more frequent follow-up visits with imaging procedures, usually CT scans, after endograft placement to be sure the graft continues to function properly. Also, the endograft is more likely to require periodic maintenance procedures than does the open procedure. In addition, your aneurysm may not have the shape that is suitable for this procedure, since not all patients are candidates for endovascular repair because of the extent of the aneurysm, or its relationship to the renal (kidney) arteries, or other issues. While the endovascular stent graft may be a good option for some patients who have suitable aneurysms and who have medical conditions increasing their risk, in some other cases, open aneurysm repair may still be the best way to cure AAA. Your vascular surgeon will help you decide what is the best method of treatment for your particular situation.
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Surgical Aneurysm Repair

What is surgical aneurysm repair?

How do I prepare?

When do I need aneurysm repair?

Am I at risk for complications during procedure?

What happens during surgical aneurysm repair?

What can I expect after surgical aneurysm repair?

Are there any complications?

What can I do to stay healthy?

What are the symptoms?

What causes an abdominal aortic aneurysm?

What tests will I need?

How is an abdominal aortic aneurysm treated?

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