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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