What is surgical aneurysm repair?
In surgical aneurysm repair, we repair or remove 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)
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
- 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