Abdominal
Aortic Aneurysm Screening & Treatment Options
Treatment Options
Treatment Overview
Treatment Background
Treatment Overview
Watchful Waiting for Aneurysms
less than 5 centimeters
Surgical Repair for Aneurysms greater than 5 centimeters
Endovascular Repair for Aneurysms greater than 5 centimeters
- Watchful Waiting for Aneurysms
less than 5 centimeters
- Aortic diameter
less than 3cm, no further testing.
- AAA 3 to 4 cm in diameter, yearly ultrasound examination
- AAA 4 to 4.5 cm in diameter, ultrasound examination every
6 months
- AAA greater than 4.5 cm, referral to a vascular specialist.
- Surgical Repair for Aneurysms greater than 5 centimeters
What is an open surgical repair?
In this approach, surgery is performed to repair the section
of the aorta that has an aneurysm. To reach the aneurysm,
a doctor makes a cut through the abdomen or the side of
the patient. The doctor repairs the aorta by replacing
the aneurysm section with a fabric tube called a "graft." The "graft" is
sewn into place and acts as a replacement blood vessel. The
blood flow through the aorta is stopped while the graft
is put in place. The surgery takes about 2 to 4 hours
to complete.
Open surgical repair is a proven medical procedure that
works. However, it also has a long recovery period. Patients
usually stay overnight in the intensive care unit, and
stay another 5 to 9 days in the hospital. Many patients
are unable to eat normally for 5 to 7 days after the
surgery. The overall recovery period can last up to 3
months.
- Endovascular Repair for Aneurysms greater than 5 centimeters
What is an endovascular repair?
Endovascular Repair is relatively
new. "Endovascular" means "inside
or within a blood vessel." Instead of making a large incision
in the abdomen, the doctor makes a small cut near each hip
(near the crease between the abdomen and thigh) to get to the
femoral arteries (blood vessels).
Through these small cuts, a graft (fabric tube) is inserted
into the arteries and positioned inside the aorta. The endovascular
graft seals off the aneurysm. The graft makes a new path
through which the blood flows. The graft remains inside the
aorta permanently. Endovascular repair typically takes 1
to 3 hours to complete.
Because there are smaller cuts, endovascular repair may result
in less discomfort, shorter hospital stay and faster recovery.
Patients may have a hospital stay of only a few days. They
can usually return to normal activity within 4 to 6 weeks
after the procedure.
As with any medical procedure, endovascular repair has
a risk of complications. Endovascular repair also requires
routine follow-up visits with your doctor. Tests are
done to evaluate the procedure and monitor success of the treatment.
There is also a possibility that additional treatment
or surgery may be required after the initial endovascular repair.
Treatment Background
What are the Treatment Options for a AAA?
Watchful waiting for aneurysms less than five centimeters (cm).
These are the guidelines from The Society of Vascular Surgery
- Aortic diameter less than 3cm, no further testing.
- AAA
3 to 4 cm in diameter, yearly ultrasound examination
- AAA 4 to 4.5 cm in diameter, ultrasound examination
every 6 months
- AAA greater than 4.5 cm, referral
to a vascular specialist.
Surgical 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 5 centimetres, 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 graft. This graft is made of
man-made material, such as plastic, in the size and shape of
the healthy aorta. The tube strengthens your aorta and allows
blood to pass easily through it. Following the surgery, you
may stay in the hospital for 5 to 10 days. You may also require
2 to 3 months for a complete recovery. More than 90 percent
of open aneurysm repair are successful for the long term.
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.
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 (AAA). An aneurysm
that occurs in your chest is called a thoracic aortic aneurysm
(TAA). Aneurysms also occur in your thigh, your knee, your
head or neck, or your spleen, liver, kidneys, or stomach.
AAA is the most common type of aneurysm.
Not all aneurysms need immediate treatment. If your aneurysm
is small, your physician might recommend "watchful waiting," which
means monitoring your aneurysm for signs of problems, such
as enlargement.
When an aneurysm causes problems or grows to a size that
it can threaten your health, your physician might recommend
surgical aneurysm repair. A vascular surgeon performs this
procedure. Your vascular surgeon makes an incision in your
body to reach the aneurysm. In some cases, your surgeon
may repair your artery using blood vessels from your body or
synthetic fabric patches or tubes called grafts. In other
situations, your surgeon may use clips or clamps to stop
blood from flowing into your aneurysm.
How do I prepare?
First your physician asks you questions about your general
health, medical history, and symptoms. 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 feel the skin above the suspected
aneurysm and listen to your arteries through a stethoscope.
Your physician will also want to know if and when your symptoms
occur and how often.
Next, your physician may order tests to measure the size
of the aneurysm and determine its location. These tests
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?
In some individuals, being older than 80 may increase
your chances of having complications during aneurysm
surgery if you also have serious health problems. If
your general health is good, however, your age alone
is not a reason to avoid necessary aneurysm repair. Other
factors that 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
- Recurring chest pain, called angina pectoris
What happens during surgical aneurysm
repair? Your
vascular surgeon will make an incision in your skin and
muscle above 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, your surgeon will not completely remove your
aneurysm. Instead, he or she may cut through the wall
of the 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 just above where the aneurysm begins and the other
end 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, your surgeon may remove the aneurysm
and replace it with a piece of a vein from your leg,
or a man-made graft, if necessary.
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 the aneurysm deflates.
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, you may stay in the hospital for about
7 to 10 days. 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 any special instructions you need to
follow after the surgery, such as not lifting anything more
than 10 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 rare following abdominal AAA surgery but more common 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 as well as its erection. If you are a man, you
might experience retrograde ejaculation or possibly difficulty
with erection. 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 and must be
balanced against the risk of not treating the aneurysm.
Endovascular Repair
Instead of open aneurysm repair, your vascular specialists
may consider a newer procedure called an endovascular stent
graft. Endovascular means that the treatment is performed
inside your body using long, thin tubes called catheters that
are threaded through your blood vessels. This procedure is
less invasive, meaning that your surgeon will make only small
incisions in your groin area through which to thread the catheters.
During the procedure, your surgeon will use live xray pictures
on a video screen to guide a fabric and metal tube, called
a graft, to the site of aneurysm. Like the graft in open surgery,
the endovascular stent graft also strengthens the aorta. Your
recovery time for endovascular stent graft is much shorter
than surgery, and your hospital stay is reduced to 2 to 3 days.
However, this procedure is more likely to require periodic
maintenance than the open procedure. In addition, you may not
be suitable to have this procedure, since not all patients
are candidates for endovascular repair. In some cases, open
aneurysm repair may be the best way to cure AAA
What is an endovascular repair?
An endovascular stent graft is a fabric tube that reinforces
a weak spot in a blood vessel, called an aneurysm. Over time,
blood pressure and other factors can cause this weak area to
bulge like a balloon and eventually enlarge and rupture. The
stent graft seals tightly with your artery above and below
the aneurysm. The graft is stronger than the weakened artery
and allows blood to pass through it without pushing on the
bulge. Physicians typically use endovascular stent grafting
to treat abdominal aortic aneurysms (AAAs), but they also use
it to treat thoracic aortic aneurysms (TAAs).
Aneurysms often affect the aorta, your body’s largest artery.
Your aorta carries blood away from the heart and runs from
your heart through your chest and abdomen. The normal diameter
of the aorta is about 1 inch. An aneurysm forms if the aorta
grows to more than 1½ to 2 times its normal diameter.
Aneurysms are a potentially serious health condition. A burst
aorta results in internal bleeding that can be fatal unless
treated rapidly by an experienced emergency medical team. Endovascular
stent graft repair is designed to help prevent an aneurysm
from bursting. The term “endovascular” means "inside blood vessels." To
perform endovascular procedures, vascular surgeons use special
technologies and instruments. These procedures require only
a small incision or puncture in an artery or vein. Through these
punctures, a vascular surgeon inserts long thin tubes, called
catheters, which carry the devices through your blood vessels.
Generally, endovascular treatments allow you to leave the hospital
sooner and recover more quickly, with less pain and a lower
risk of complications and death than traditional surgery, because
the incisions are smaller. Sometimes traditional surgery is required,
however, if the shape or the location of the aneurysm is not
favorable for an endovascular treatment.
How do I prepare?
Your physician will ask you about your medical history and
perform a complete physical examination. In addition, your
physician may perform several tests, including electrocardiogram
(ECG), which measures your heart's electrical activity,
and stress testing, which will help to determine your heart
health. If your physician believes that you are a good candidate
for endovascular stent grafting, he or she will order one
or more of the following tests. These tests show detailed
images of your arteries and help your physician choose
the correct size and shape of the graft:
- Spiral computed
tomography (CT) scan: This test involves a rapid series
of x rays taken in a spiral pattern around your body. A computer
transforms the x ray data into three-dimensional images
of your blood vessels.
- Angiography: In these tests, your
physician inserts a catheter into one of your arteries.
Your physician then injects a dye called contrast through
the catheter and takes x rays.
Am I eligible for endovascular stent
grafting?
You may be eligible for endovascular stent grafting
if your aneurysm has not ruptured and your aorta is about
2 inches wide or more. However, if you have a long life
expectancy or a low risk of complications, your physician
may recommend surgical aneurysm repair instead. This treatment
has been used for a longer period of time than endovascular
stent grafting.
The physical characteristics of your aneurysm help your
physician determine if you are eligible for endovascular
treatment. For example, if you have a AAA located in the
section of the aorta just below your kidney arteries, you
may be eligible. Your blood vessels must be large enough
to allow the endovascular stent graft to pass through,
and the device must fit the shape and contour of your blood
vessels once it is in place.
Am I at risk for complications?
If you have kidney disease called chronic renal insufficiency,
your chances of complications from endovascular stent grafting
may be increased. If you have an unfavorable aneurysm shape,
associated arterial occlusive disease, or have already
had a AAA repaired, you also may be at increased risk for
complications. Other conditions, such as heart or lung
disease, may increase the risk for treatment.
What happens during endovascular stent grafting?
As the procedure begins, you will receive a sedative and
a regional anesthesia, or you may receive general anesthesia.
Your vascular surgery team will clean your skin and shave
hair around the insertion points to help decrease your
chances of infection. Your vascular surgeon will then cut
into the skin above the femoral artery in your groin. Your
vascular surgeon threads a guide wire into your femoral
artery and advances it to the aneurysm. Because you have
no nerve endings inside your arteries, you will not feel
the wires or catheters as they move through your body.
You may feel a slight pressure or a sensation of mild tugging
during this insertion.
Using x rays that appear as moving images on a screen,
your vascular surgeon inserts a catheter over the guidewire.
The catheter carries a compressed form of the graft
so it can move through your blood vessels. When the graft
has reached the aneurysm site, your physician withdraws
the catheter, leaving the graft in place. The graft
expands to fit snugly against the walls of your artery.
What can I expect after endovascular stent grafting?
Usually you will spend 2 to 3 days in the hospital. During
the first recovery day you will be permitted to eat and
perhaps walk.
After you leave the hospital, you should not drive until
your physician approves. You may be permitted to sponge bathe
around your incisions but you should avoid soaking your groin
incisions until they have healed. You should also avoid lifting
more than about 5 to 10 pounds for approximately 4 to 6 weeks
after the procedure.
Your physician will instruct you to return for a follow-up
visit after about 7 to 10 days. At that visit, your physician
will check your incisions and assess your overall condition.
Usually you will undergo follow-up imaging tests 1 and
6 months after the procedure to ensure that the stent is
still functioning and in the proper location. After the
first year, you will probably undergo yearly imaging tests
if your aneurysm is shrinking and no problems are found.
Are there any complications?
The potential complications of endovascular stent grafting
include:
- Leaking of blood around the graft
- Infection
- Movement of the graft away from the desired
location
- Graft fracturing
- Blockage of the blood flow through the graft
Sometimes fever and an increase in white blood
cell count can happen shortly after endovascular stent grafting.
These symptoms usually last 2 to 10 days and are treated
with medications such as aspirin and ibuprofen. Other
complications that are rare but serious include a burst artery,
injury to your kidney, paralysis, blocked blood flow to your
abdomen or lower body, and delayed rupture of AAA.
Endovascular stent grafts can sometimes leak blood through
the areas where the graft components join together, but
also they can allow blood to leak back into the aneurysm
sac through small arteries feeding the aneurysm sac. Some
of the leaks end by themselves and are not dangerous, but
others need to be treated immediately. These leaks can
even occur years after your procedure. Thus, physicians
require their patients to undergo yearly CT scans for life
to detect and treat problems before they become threatening.
If you suspect or experience any complications because
of the endovascular stent graft, contact your physician
immediately.
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