Aortic Aneurysm Repair

Aortic [ay-ORE-tik] aneurysm [AN-yur-is-m] repair is a surgery to fix a weak, bulging, or torn section of the aorta [ay-ore-tuh]. The aorta is the largest artery in the body. It leaves your heart and travels through the chest and then down through the abdomen (belly) before splitting into smaller arteries that go to the legs. When an aneurysm happens in the section of the aorta that goes from your heart to your abdomen, it is called a thoracic [thoh-RAS-ik] aortic aneurysm, or TAA. If it happens in the section of the aorta that travels through the abdomen, it’s called an abdominal [ab-DOM-uh-nl] aortic aneurysm, or AAA.

An aortic aneurysm can be very dangerous, especially if it’s large or it’s growing. If it ruptures (bursts), it can cause bleeding, and death can happen within minutes.

If the aneurysm is large (over 2 inches across) or growing rapidly, it should be repaired. There are two ways to repair an AAA:

• Abdominal surgery. A large incision (cut) is made in your abdomen. The weakened section of the aorta is taken out and replaced with a tube made of a special synthetic (man-made) material.
• Endovascular aneurysm repair (EVAR or TEVAR, also called “stent grafting”). Two catheters (thin, flexible tubes) are used to place a tube called a stent graft (narrow, mesh tube) at the area of the aneurysm. The stent graft “lines” the aorta like an inner sleeve, and stays in place after the procedure.

The most common risks and potential complications for surgery to repair an aortic aneurysm. There may be other risks in your unique medical situation. Talking with your doctor is the most important way to learn about these risks. If you have questions, be sure to ask.

Risks and potential complications include:

• Problems that can happen with any surgery. These include infection, bleeding that requires a blood transfusion, blood clots, or reactions to general anesthesia (including vomiting, trouble urinating, sore throat, cut lips, headache, heart problems, stroke, or pneumonia).
• Respiratory problems, such as pneumonia
• Injury to internal organs (liver, stomach, intestines, kidneys, bladder, uterus, or ovaries).
• Injury to the spinal cord or nerves. This could harm leg sensation or movement, impair ejaculation or erection, or cause other problems.
• Death (extremely rare).

Complications are rare. However, the risk may be higher if the surgery is done in an emergency (because an aneurysm has burst) or if you have heart disease, lung disease, cancer, or a history of stroke.

Alternatives to surgery include watching and waiting, with regular tests to see how large your aneurysm is and how fast it’s growing. (If surgery is recommended, it may be too late for this.)

Potential benefits of aortic aneurysm repair include relieving the pressure on the weakened section of the aorta and greatly reducing the risk of rupture (bursting).

How you prepare for your procedure depends on if you are having open surgery or an EVAR. In general, you should:

• Give your doctor a list of all your current medicines. Be sure to include all prescriptions, over-the-counter medicines (such as allergy pills or cough syrup), inhalers, patches, vitamin supplements, and herbal remedies. Tell your healthcare providers if you have allergies to any medicines.
• Follow all instructions about what medicines to stop or to take before the procedure. You may be asked to stop taking certain blood thinners before the procedure. Always check with your healthcare providers before stopping any medicines.
• Arrange to take some time off of work and get some help at home. Depending on your procedure, you may need several weeks, or even months, to recover completely.
• Tell your doctor if you have a cold, flu or fever.
• Follow all instructions from your medical team about eating and drinking in the hours before your procedure to avoid complications with anesthesia.
• Follow instructions on bathing with infection-fighting soaps or antiseptic wipes if asked to do so before your procedure.

For open surgery, the steps may vary depending on the location of the aneurysm. In general:

1. General anesthesia is given to make you sleep. You won’t feel anything and won’t remember it afterward.
2. An incision (cut) is made in the area to be reached by the surgeon.
• For AAA surgery, the cut is made in the abdomen.
• For TAA surgery, the cut is made in the chest and side.
3. Clamps are placed on the aorta above and below the weakened section to stop the flow of blood.
4. The graft is sewn into the aorta, above and below the weakened section. The graft is made of a strong, flexible material.
5. The clamps are removed so blood can flow again.
6. The walls of the weakened aorta are wrapped around the graft and sewn into place.
7. The incisions are closed with stitches or staples and you are moved to recovery.

The steps are somewhat different for EVAR (abdominal) or TEVAR (thoracic) procedures. In general:

1. Local or general anesthesia is given to help you relax, or sleep.
2. Two small incisions (cuts) are made in the groin.
3. A sheath (a short plastic sleeve) is placed in each incision. The sheath holds the artery open just enough to let guide wires or catheters through.
4. Dye may be injected into the blood vessel. This creates a “road map” of the blood vessels for the doctor.
5. A guide wire is placed into one of the sheaths and moved to the aneurysm. A special X-ray camera will show the location of wire as it moves through the body.
6. Catheters are moved to the aneurysm to place the stent graft. The graft expands to form a seal against the artery wall on either side of the aneurysm.
7. The incisions are closed with stitched or a closure device and you are moved to recovery.

The length of recovery will depend on the type of procedure you have.

For open surgery:

• Expect to stay in the hospital for several days. You can go home when the doctor feels you are ready to finish your recovery at home.
• Specific education will be given on how to manage your:
• Medicines
• Activity and exercise
• Wound care
• Diet
• Symptoms

It can take six to eight weeks to recover from open surgery for aneurysm repair.

For EVAR or TEVAR:

• Expect to stay in the hospital for one to two days. This is to make sure the stent graft and your health remain stable.
• Follow all instructions on caring for your incisions at home.
• Avoid baths, swimming pools, and hot tubs until your doctor says it’s safe to use them.
• Don’t drive until your doctor says it’s okay. This may be one to two weeks.
• You can go back to work when the doctor says it’s okay – usually within two weeks.

After open surgery, your doctor will want to check on your incision to make sure it’s healing. Regular visits with a primary care provider will help you keep your blood pressure and weight down, which will help your blood vessels stay healthy.

After EVAR or TEVAR, you will need to go to regular follow-up appointments to make sure the stent graft is still in the right place. This is usually done with X-ray or a CT scan.

• Quit smoking. This is the single biggest difference you can make in your health. Ask your doctor or nurse for a copy of Intermountain’s booklet, "Quitting Tobacco: Your Journey to Freedom". You can also call 1-800-QUIT-NOW for the Utah Tobacco Quit Line, or go to waytoquit.org.
• Manage your blood glucose. Keep your blood glucose (blood sugar) between 70 to 130 mm/dL before a meal, and keep your HbA1c below 7%.
• Control high blood pressure. Aim to keep your blood pressure at less than 120/80 mm Hg. Medicine, exercise, and weight loss can help you meet this goal.
• Control your cholesterol. Work with your healthcare providers to keep your total cholesterol under 200 and your LDL (“bad”) cholesterol under 100. If you have diabetes, you may need to take cholesterol medication, even if your cholesterol is normal.
• If you’re carrying extra weight, lose it — slowly and safely. Ask your healthcare provider for a referral to see a dietitian. You can also go to the Weigh to Health classes offered by Intermountain.
• Eat a “heart smart” diet. Choose foods that are low in saturated fats, cholesterol, and salt. Fill up on fresh fruits and vegetables and high-fiber grains.
• Be more active. Physical activity will help you lower your cholesterol levels, lower your blood pressure, strengthen your heart, and help you feel better overall.
• Follow your doctor’s instructions for taking medicines. Certain medicines are especially helpful for vascular disease. They include aspirin and other antiplatelet (anti-clot) medicines, cholesterol-lowering medicine, and blood pressure medicine.
• Check with your doctor before taking supplements. While you might need to take a multivitamin, some supplements can cause problems when used with other medicines. Talk to your doctor first before you start taking any vitamin or herbal supplement.

• National Heart, Lung, and Blood Institute
• Society for Vascular Surgery