Aortic Aneurysm Repair

Aortic Aneurysm Repair is the surgery done to remove the aortic aneurysm , which is the bulge in the aorta ( major blood vessel of the heart ). This procedure is done either by open chest repair method or endovascular repair method.

Aortic aneurysm is the bulge in the aorta, the main blood vessel of the heart. This happens when the artery wall becomes weak due to chronic illnesses. The blood flow force constantly pushes the weakened blood vessel walls, which makes them swell up. This leads to formation of balloon- like bulges called aneurysms. This bulge if becomes very large can burst, and lead to serious life threatening complications. 

The 2 types of Aortic aneurysm repair surgeries are- 

• Open Abdominal or Open Chest repair surgery
• Endovascular repair surgery

Endovascular Aortic Aneurysm Repair Surgery (EVAR) is the minimally invasive method to treat the aortic aneurysm. In this method instead of opening the chest or abdomen surgically using large incisions, in EVAR a small stent graft ( fabric tube with metal stents) is inserted into the aneurysm area via small cuts in the groin region. This method requires smaller incisions thus the recovery time is faster. 

The various causes that forms aortic aneurysm, which requires Aortic Aneurysm Repair Surgery are- Atherosclerosis ( hardening of the arteries ), high blood pressure, blood vessel diseases, infections of the aorta, or trauma to the aorta ( for example- car accident injury , etc ).

The tests done before Aortic Aneurysm Repair Surgery are-

• Abdominal ultrasound- Common test done to diagnose, locate the abdominal aneurysms by passing sound waves to get the images.
• Abdominal CT scan- Here X Rays are used to get cross sectional images of the aorta, site and size of the aneurysm, sometimes a contrast medium dye is injected into the vessels to get more clearer images. 
• Abdominal MRI- Here magnetic fields and radio waves are used to get detailed images of the aorta structure, site and size of the aneurysm. 

In Open Abdominal Aortic Aneurysm Repair Surgery, a large incision is made in the upper abdomen or chest area, damaged part of the aorta is removed, and replaced with a graft that is stitched to the region. 

 Cost of Aortic Aneurysm Repair Surgery in India varies across different cities and hospitals.

The risks of Aortic Aneurysm Repair Surgery can be divided as-

1. Risks of Open repair surgery- heart attack, irregular heart rhythms, bleeding during and after the surgery, bowel vessels damage, blood clots, kidney failure, lung complications, spinal cord injury. 
2. Risks of EVAR- Kidney damage, damage to surrounding blood vessels, groin wound infections, groin hematoma, bleeding, endoleaks, etc. 

The Aortic Aneurysm Repair Surgery is needed for the following reasons- 
Prevent aorta rupture, relieve cardiac symptoms, restore good blood flow, when the aneurysm size is bigger than 5 cms, when the growth rate of aneurysm is > 0.5 cms per year, emergency life dangering bleeding. 

The different types of aortic aneurysm repair surgeries are:

1. Abdominal aortic aneurysm repair (AAA): This type of surgery repairs an aortic aneurysm that occurs in that portion of the aorta that exists in the abdomen (stomach). 
2. Thoracic aortic aneurysm repair: This type of surgery is performed in that portion of the aorta that exists in the chest region.
3. The aortic aneurysm repair surgery can be performed in the following different ways:
4. Open abdominal or open chest repair surgery: This is the most common and invasive type of surgery done for repairing an aortic aneurysm. In this procedure, a weakened portion of the aorta is replaced with a graft made of a special fabric by making a cut or incision on the chest or abdomen, depending on where the aneurysm is located.
5. Endovascular repair surgery: This procedure involves inserting a flexible wire frame sewed onto a special fabric tube called stent graft into the aorta by using a very thin, flexible tube known as a catheter.

An aortic aneurysm may occur due to the following reasons:
Atherosclerosis (a condition in which there is a buildup of fat and cholesterol inside the arteries)
Trauma or injury
High blood pressure
Congenital defects (defects present at birth)
Smoking

Many cases of aortic aneurysm show no symptoms. However, a few cases of aortic aneurysm surgery show the following symptoms:

• Belly pain
• Low pack pain
• Chest pain
• Jaw or neck pain
• Hoarseness
• Coughing
• Breathing problems
• The doctor is more likely to recommend an aortic aneurysm repair surgery in the following cases:
• Aneurysm is larger than 2 inches
• Aneurysm is growing rapidly, that is, approximately ¼ inch over the last six to twelve months
• Aneurysm interferes with the blood flow to the other areas of the body
• If there is a leakage of blood into the walls of the aorta, known as aortic dissection 
• In case of a ruptured or burst aortic aneurysm, which may lead to the following symptoms:
• Severe back pain or abdominal pain
• Nausea
• Vomiting
• Anxiety
• Dry mouth
• Pale and clammy skin
• Excessive thirst
• Shock (when there is an interrupted blood supply to the brain) causing dizziness, fainting, weakness, sweating, rapid heartbeat, and tremors

The following tests are performed before an aortic aneurysm repair surgery:

1. Physical examination: The patient’s overall physical health is assessed by the doctor. The symptoms and medical history of the patient are noted by the doctor.
2. Blood tests: These tests help the doctor in diagnosing medical conditions like thyroid disorders and diabetes.
3. Chest x-ray: This x-ray helps in checking the condition of the heart and lungs before the procedure.
4. Electrocardiogram (EKG or ECG): This test helps in recording the electrical activity of the heart, and diagnosing the various heart disorders.
5. Echocardiogram: This test helps in obtaining the internal images of the heart and evaluating the blood pumping function of the heart using ultrasound.
6. Stress test: This test is performed by the doctor to check how well the heart works during physical activity.

The following preparation may be required before an aortic aneurysm repair surgery:
The doctor should know about any pre-existing medical conditions that you may be having.
The doctor should be told about any supplements, medications, or herbs that you are taking.
The doctor should be told about any allergies that you may be having.
Lose any excess weight that you may be having before the procedure by a well-balanced, controlled diet and exercising.
Quit smoking at least two weeks before the procedure.
You may be asked to stop taking any blood-thinning medicines like warfarin and aspirin a few days before the procedure.
You will be told to not drink or eat anything after midnight, the day before the surgery.

The doctor may perform the surgery under general anesthesia (the patient is put to sleep during the procedure) or regional anesthesia (a nerve block is given to numb a large area of the body).
One of the following approaches may be used to perform aortic aneurysm repair surgery:
1. Open surgery:
The surgeon makes a large cut or incision in the chest or abdominal area, depending on the location of the aneurysm.
The weakened part of the aorta is removed by the doctor and replaced by a synthetic graft.
The doctor may also cut open the aneurysm and then place the graft inside.
This type of surgery allows the doctor to view and access the surgical area directly.
This procedure has an increased risk of complications, a longer recovery, and is more painful than an endovascular surgery.
An open surgery involves more cutting and displacement of the tissues, organs, and muscles than an endovascular surgery.
Despite all the disadvantages, open surgery is still considered to be a more effective and safer method for some patients as compared to endovascular aortic aneurysm repair.

2. Endovascular aortic aneurysm repair:
The surgeon inserts a catheter and guidewire through an artery in the leg or groin region.
The catheter tip has a deflated synthetic graft.
This graft expands like a spring once the catheter is in place.
The aorta walls are reinforced by the synthetic graft.
The blood now flows through the graft.
This surgery is less painful, has fewer complications, and has less recovery time compared to open surgery, due to less trauma to the organs and tissues.
If one is not a candidate for open surgery, this procedure may be done. However, all types of aneurysms cannot be repaired by this procedure.

The following post-procedure steps are followed after an aortic aneurysm repair surgery:
The patient is sent to the recovery room after the procedure and the patient stays there till the vital signs are stable.
The patient is later moved to an intensive care unit (ICU) for 24-hour monitoring and care.
The anesthesia effect wears off after a couple of hours.
A breathing tube may be given in the patient’s mouth, which is normally removed after a few days.
The patient may have a sore throat for some days after the removal of the breathing tube.
The patient is later shifted to a normal room from the ICU.
The patient usually stays in the hospital for two to five days after the endovascular procedure. 
After open surgery, the patient may stay in the hospital for seven to ten days.
It is normal for the patient to have some pain and discomfort following the procedure.
The doctor may prescribe pain-relieving medicines to ease the pain and discomfort of the patient.
The recovery time depends on the type of procedure done, the age of the patient, and the overall health status of the patient.
An exercise rehabilitation program is recommended for a quicker recovery.
The patient should follow the lifestyle, diet, and activity restrictions that the doctor gives.
Inform the doctor if any unusual symptoms are noticed after the procedure.
Complete recovery from the surgery may take two weeks to a couple of months.
The doctor recommends follow-up visits and imaging tests to check the graft periodically.
Additional procedures may be needed later to maintain the graft.

The various complications associated with an aortic aneurysm repair surgery include:

• Irregular heart rhythms
• Heart attack
• Injury to the bowel
• Bleeding 
• Allergic reaction
• Blood clot formation
• Infection of the graft
• Kidney damage
• Lung problems
• Injury to the spinal cord (backbone)
• Damage to the surrounding organs, blood vessels, and other structures
• Groin infection
• Hematoma (large blood-filled bruise)
• Endoleak (continuous blood leakage out of the graft into the aneurysm sac)