Overview of Abdominal Aortic Repair

An abdominal aortic aneurysm, or AAA, is when the large blood vessel that supplies blood to the abdomen, pelvis, and legs becomes abnormally large or balloons outward. It occurs when the abdominal aorta enlarges to more than 3 cm or is 50% larger than normal at the area of the diaphragm, the muscular area that helps with breathing. If it isn’t treated, the AAA can stretch and thin the blood vessel wall, and may eventually burst.

Fewer people have been getting AAA over the past 20 years, in both developed and developing countries. This could be partly because fewer people smoke now. AAAs are rare in people under 60, but become more common as people get older. What’s more, men are four times more likely to have an AAA than women.

The risk of an AAA bursting depends on how large it is. The larger it is, the riskier. For instance, if it’s smaller than 5 cm, there’s only a 1-2% chance it’ll burst within five years. However, if it’s larger than 5 cm, there’s a 20-40% chance it’ll burst within five years. AAAs are incredibly dangerous if they burst, causing over 80% of people who suffer a rupture to die. As such, if you’re diagnosed with an AAA, it’s very important to get it treated as soon as possible.

There are two main surgical treatments for AAA. One is an open operation where surgeons remove the enlarged part of the blood vessel and replace it with a graft. The other treatment, known as endovascular stent grafting, involves placing a graft within the aneurysm to seal it off from blood flow, leaving the aneurysm in place.

If an AAA is smaller than 5 cm, it could be safe enough to monitor it via regular ultrasound checks instead of operating on it right away. The ultrasound tests should be done every three years for AAAs measuring 3 to 3.9 cm wide, or every year for AAAs measuring 4.0 to 4.9 cm wide.

Unfortunately, there aren’t any medications or therapies that have been found to be effective at slowing the growth of AAAs. Exercise and beta-blockers, drugs that control heart rate, have not been proven to slow down aneurysm growth. However, quitting smoking can slow the growth of the AAA and lower the risk of it bursting.

If you have an AAA, it’s also important to be aware of your overall heart health. Doctors can help recommend lifestyle changes, such as regular exercise and a healthy diet, to help manage your blood pressure. In addition, medications like statins, which help control cholesterol, and antiplatelet drugs, which help prevent blood clots, may be recommended.

Anatomy and Physiology of Abdominal Aortic Repair

An abdominal aortic aneurysm is a kind of swelling in the main blood vessel in your abdomen, called the abdominal aorta. The way we categorize these aneurysms is based on where this swelling happens. If it’s called a “suprarenal” or “para-visceral” aneurysm, the swelling involves the blood vessels that supply your organs. If it’s called a “para-renal” aneurysm, the swelling includes the area where your kidney arteries start.

But you should know that most abdominal aortic aneurysms happen below the kidney arteries, which is why they’re often referred to as “infrarenal” aneurysms.

Why do People Need Abdominal Aortic Repair

If you have a condition called abdominal aortic aneurysm (AAA), which is an enlarged area in the lower part of the major vessel that supplies blood to the body (the aorta), you might have to undergo a preventative surgery to treat it under certain conditions.

Here are the conditions when the surgery, known as AAA repair, might be considered:

– If the AAA is larger than 5.5 cm in diameter in men, or 5.0 cm in women.
– If the AAA is causing symptoms.
– If the AAA is quickly getting bigger (growing more than 1 cm per year), regardless of its current size.

Before surgery, it’s important to assess your general health including your heart and lung function. This can involve tests such as cardiopulmonary exercise testing, an echocardiogram (a scan of the heart), and lung function tests. If you have problems with your heart’s blood supply, a procedure to improve it may be considered before the aneurysm repair.

However, some patients may not be suitable for the AAA repair, including those with other serious health conditions or if their life expectancy is limited. For these patients, methods to lessen the risk of heart disease and regular health check-ups are usually recommended.

In cases where the AAA has ruptured, causing life-threatening internal bleeding, immediate surgery is typically required. This condition can often be diagnosed based on symptoms and a Doppler ultrasound, which uses sound waves to create a picture of the blood flow. If the patient is too critically unwell, a CT scan is usually avoided, and they are taken directly to the operating room for surgery. However, if the patient is stable, a CT scan can help to confirm the diagnosis and determine if emergency Endovascular Aneurysm Repair (EVAR), a type of less invasive aneurysm repair, is possible.

When a Person Should Avoid Abdominal Aortic Repair

Sometimes, a person may not be a suitable candidate for a technique called OSR (open surgical repair). It is usually reserved for patients who aren’t fit for a process called EVAR (endovascular aneurysm repair). The main reasons that a person may not be suited for EVAR is due to their specific body shape and structure.

The part of the aorta that a doctor would work on during EVAR is called the aortic neck. The length of this neck and its angle can significantly affect how successful the repair is. The aortic neck is the length between the lowest kidney artery and the top of the aneurysm, or blood vessel balloon. A successful EVAR process requires a longer aortic neck (more than 1.5 cm) and a larger angle (over 150 degrees). It is also considered favorable if there are no hardened or clotting areas in that neck.

The shape of the aneurysm (the ballooned blood vessel) can be determined by different factors, such as its angle in relation to the aorta’s long axis, if there is a blood clot, and if there are other arteries branching out from the aneurysm. If the aneurysm’s angle is too small, it makes it harder to deliver a stent graft (a tube inserted to support the aorta). Similarly, a clot in the aneurysm or branches from the inferior mesenteric artery, lumbar arteries, or median sacral artery, can cause problems after EVAR.

Finally, the shape and health of other arteries, like the iliac and common femoral arteries, also come into play for EVAR. If these arteries have atherosclerotic plaque (a buildup that hardens arteries) or are twisted, it may increase the risk for the graft to get blocked.

How is Abdominal Aortic Repair performed

Open aortic repair and Endovascular Aneurysm Repair (EVAR) are two types of procedures doctors use to fix aortic issues. Open aortic repair is considered a high-risk procedure because it carries a chance of risk for heart attack or death due to cardiovascular problems of 5% or more within a month. EVAR, on the other hand, is a bit safer with a risk between 1% and 5%. Most research shows that EVAR is better for people’s survival in the short-term compared to open surgery. Despite similar long-term results, EVAR is safer and more effective with lesser immediate risks and lower rates of illness and death. So, European professionals often recommend EVAR for patients who are good candidates for it.

Open aortic repair involves replacing a problem area in the aorta with a man-made tube. During this surgery, doctors make a cut in the belly to reach the aorta. The doctor can choose between a few types of cuts based on what’s best for the patient and their own preference. Once the aorta is reached, they put a clamp below the kidney arteries and another on the iliac arteries, which are located in the pelvis. The problem aorta segment is then removed and replaced. Usually, a type of material called polyethylene terephthalate is used. The new artificial aorta section should be as close as possible to the kidney arteries to prevent future issues. Sometimes, doctors may choose to reconnect a blood vessel in the lower belly region called the inferior mesenteric artery. This step is only needed in some cases where there’s a suspicion of lack of blood supply to the pelvic organs or risk of gut disease due to poor blood supply. Finally, the cut in the belly is closed up.

On the other hand, EVAR involves putting a stent graft, a kind of tiny mesh tube, inside the aorta to prevent blood from flowing into a problem area. This is done under guidance from a special kind of x-ray, and can be done under full or local anesthesia. The doctor first gets to the patient’s common femoral artery, a large artery located in the thigh, either through a small cut or a needle prick. This could be done either on one side or both sides. Special tubes called vascular sheaths are then put into these arteries, which allow the passage of guidewires, catheters, and the stent graft. Special x-ray pictures are taken during the procedure to guide the placement of the graft and to locate the kidney arteries. The main part of the stent graft is deployed above the problem aorta segment, and extensions are added to reach down till the arteries in the pelvis. The graft is then adjusted to sit correctly with the help of a balloon, and final x-ray images are taken to check the position and to make sure there are no leaks. Finally, all the devices are removed and the artery in the thigh is sealed.

Possible Complications of Abdominal Aortic Repair

The risk of death after open surgery repair (OSR) for Abdominal Aortic Aneurysms, which are bulges in the main blood vessel leading from the heart, has dropped over time. This rate varies from study to study but is generally thought to be less than 50% these days. On the other hand, the less invasive endovascular aneurysm repair (EVAR) has a lower short-term death rate compared to OSR.

There can be several complications following OSR, with some studies showing different results. After the surgery, issues might involve the lungs (42%), heart (18%), kidneys (17%), large intestine (9%), and the operation site or wound (7%). Obstruction of blood flow to different organs, leading to damage (ischemia), including the colon, lower limbs, or spinal cord, are rare but severe complications to be aware of. The risks are similar for the EVAR procedure, although there is a lower rate of these issues occurring. For EVAR, there are complications unique to it, namely graft migration and endoleaks.

Graft migration is when the graft – which is like a patch – loses its grip and shifts from its original position. Anchoring structures called hooks and barbs are put to increase friction and prevent the graft from moving. On the other hand, an endoleak happens when the graft doesn’t fully stop blood from flowing into the bulging area. These leaks can be categorized into five types based on their source and the issue causing them. Though in the past EVAR was linked with complications like tear, hole, lumps of clotted blood (hematoma), or abnormal connection (fistula) at the site the surgeon uses to insert the graft, such advancements have minimised these issues.

To understand the complications better, they can be divided as follows:

– For OSR, immediate issues can be heavy bleeding and heart attack; early issues can be heavy bleeding, a type of severe constipation (ileus), damage to the colon, heart attack, lung infection (pneumonia), kidney failure, wound infection, while late issues might include bulging of the operation site (incisional hernia).
– For EVAR, immediate issues can be bursting causing a switch to open surgery, wrong placement of the stent, and heart attack; early issues could involve a specific type of kidney damage due to the dye used to visualise the vessels (contrast nephropathy), and endoleaks; while late issues might include endoleaks, and stent migration.

What Else Should I Know About Abdominal Aortic Repair?

Repairing an abdominal aortic aneurysm – a swelling in the main blood vessel that leads away from your heart – is a procedure that can save your life. If this condition isn’t treated, and the blood vessel ruptures, the risk of death is incredibly high – about 90%.

Besides emergency situations, this operation is also essential as a planned (elective) procedure. One study followed patients who chose not to have this surgery for ten years and discovered that a ruptured aortic aneurysm was the cause of death in 36% to 55% of these individuals.

Comparatively, patients who did elect to have this surgery had a much lower risk of death from a rupture after the repair. Specifically, the risk of death was 8% for patients undergoing endovascular aneurysm repair (EVAR, a less invasive procedure performed inside the blood vessel) and it was 2% for patients undergoing open surgical repair (OSR, a more traditional open surgery).

Frequently asked questions

1. What are the risks and benefits of the different surgical treatments for Abdominal Aortic Repair? 2. How do I know if my AAA is large enough to require surgery? 3. What tests will be done to assess my general health before the surgery? 4. Are there any alternative treatments or therapies for AAA? 5. What lifestyle changes should I make to manage my overall heart health and reduce the risk of AAA?

Abdominal Aortic Repair will depend on the type and location of the aneurysm. If the aneurysm is infrarenal, meaning it is below the kidney arteries, the repair procedure will involve replacing the weakened section of the abdominal aorta with a synthetic graft. If the aneurysm is suprarenal, para-visceral, or para-renal, the repair procedure will be more complex and may involve additional steps to preserve blood flow to the organs or kidneys. It is important to consult with a healthcare professional to understand the specific implications of the repair procedure for your individual case.

You may need Abdominal Aortic Repair if you are not a suitable candidate for Endovascular Aneurysm Repair (EVAR) due to specific body shape and structure factors. These factors include the length and angle of the aortic neck, the shape of the aneurysm, the presence of blood clots or branching arteries, and the health of other arteries. Abdominal Aortic Repair is an alternative surgical technique used when EVAR is not feasible.

You should not get Abdominal Aortic Repair if you are not a suitable candidate for EVAR (endovascular aneurysm repair) due to factors such as specific body shape and structure, the length and angle of the aortic neck, the shape of the aneurysm, and the shape and health of other arteries.

The recovery time for Abdominal Aortic Repair can vary depending on the specific procedure performed and the individual patient. However, in general, the recovery period for Abdominal Aortic Repair can range from a few weeks to several months. It is important for patients to follow their doctor's post-operative instructions and attend any necessary follow-up appointments to ensure proper healing and recovery.

To prepare for Abdominal Aortic Repair, the patient should undergo assessments of their general health, including heart and lung function, which may involve tests such as cardiopulmonary exercise testing, echocardiogram, and lung function tests. If there are problems with the heart's blood supply, a procedure to improve it may be considered before the aneurysm repair. It is also important to be aware of overall heart health and make lifestyle changes, such as regular exercise and a healthy diet, as recommended by doctors.

The complications of Abdominal Aortic Repair include issues with the lungs, heart, kidneys, large intestine, and the operation site or wound. Rare but severe complications can involve obstruction of blood flow to different organs, such as the colon, lower limbs, or spinal cord. For the less invasive endovascular aneurysm repair (EVAR) procedure, there are also unique complications such as graft migration and endoleaks. Immediate complications for open surgery repair (OSR) can include heavy bleeding and heart attack, while early complications can include severe constipation, damage to the colon, lung infection, kidney failure, and wound infection. Late complications for OSR might include bulging of the operation site. Immediate complications for EVAR can include bursting, wrong placement of the stent, and heart attack, while early complications can include kidney damage and endoleaks. Late complications for EVAR might include endoleaks and stent migration.

Symptoms that require Abdominal Aortic Repair include an abdominal aortic aneurysm larger than 5.5 cm in diameter in men or 5.0 cm in women, the presence of symptoms caused by the aneurysm, and rapid growth of the aneurysm (more than 1 cm per year) regardless of its current size.

There is no specific information provided in the given text about the safety of Abdominal Aortic Repair in pregnancy. It is recommended to consult with a healthcare professional for personalized advice and guidance regarding this matter.

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