Canada Vascular

Aortic Aneurysms (TAA & AAA)

Background

Diagnosis

Screening

Treatment Options

Common Questions & Answers

Glossary

Bibliography

 

 


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

 

  1. Watchful Waiting for Aneurysms less than 5 centimeters
  1. Aortic diameter less than 3cm, no further testing.
  2. AAA 3 to 4 cm in diameter, yearly ultrasound examination
  3. AAA 4 to 4.5 cm in diameter, ultrasound examination every 6 months
  4. AAA greater than 4.5 cm, referral to a vascular specialist.
  1. 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.

  1. 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.

Endograft Deployment  


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

  1. Aortic diameter less than 3cm, no further testing.
  2. AAA 3 to 4 cm in diameter, yearly ultrasound examination
  3. AAA 4 to 4.5 cm in diameter, ultrasound examination every 6 months
  4. 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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