Background Information:

What are the other Names for the Procedure?

• Abdominal Aneurysmectomy
• Aortic Aneurysm Repair involving Abdominal Aorta
• Endovascular Aneurysm Repair (EVAR)

What is Abdominal Aortic Aneurysm Repair surgical procedure?

• The aorta is the largest artery in the human body originating from the heart (left ventricle) and extending to the lower abdomen. It carries blood to the belly, pelvis, and legs
• An aneurysm is an abnormal widening or bulge in the artery caused by weakening of the arterial wall
• Abdominal Aortic Aneurysm (AAA) Repair is a surgical procedure involving the removal or repair of an aortic aneurysm

What part of the Body does the Procedure involve?

The procedure involves the abdominal portion of the aorta.

Why is the Abdominal Aortic Aneurysm Repair surgical procedure Performed?

• An Abdominal Aortic Aneurysm Repair procedure is performed to prevent rupture and hence, hemorrhaging of the aneurysm
• Additionally, if the aneurysm enlarges to the extent of causing pressure on the neighboring tissues and organs, it is better to have it repaired as early as possible

What are some Alternative Choices for the Procedure?

• If the aneurysm has grown to a size that there is a possibility of imminent rupture, then surgery is the best and most effective option
• The type of surgery depends on the condition of the aneurysm, and this is decided after consulting a physician

What are the Recent Advances in the Procedure?

The recent advancement in Aneurysm Repair is the use of endovascular surgical techniques; known as Endovascular Aneurysm Repair (EVAR). This technique is a more recent development, as compared to Open Aneurysm Repair.

What is the Cost of performing the Abdominal Aortic Aneurysm Repair surgical procedure?

The cost of Abdominal Aortic Aneurysm Repair procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused by the information regarding Abdominal Aortic Aneurysm Repair and on what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist and also recommend another physician, if required
• They can also choose to approach another physician independently. Besides, if the procedure has many alternatives, the patient may take a second opinion to understand and choose the best one

What are some Helpful Resources?

http://www.ohsu.edu/xd/health/health-information/topic-by-id.cfm?ContentTypeId=92&ContentId=P08291

http://www.nlm.nih.gov/medlineplus/ency/article/007392.htm

http://stanfordhospital.org/clinicsmedServices/COE/surgicalServices/vascularSurgery/patientEducation/abdominalAorticAneurysmRepair.html

http://www.stmaryhealthcare.org/body.cfm?id=555857

Complete Guide to Symptoms, Illness & Surgery; Written by H Winter Griffith, M.D.; Revised and updated by Stephen Moore, M.D. and Kenneth Yoder, M.D.; The Berkley Publishing Group, 5th Edition, New York, 2006

Prior to Abdominal Aortic Aneurysm Repair surgical procedure:

How is the Abdominal Aortic Aneurysm Repair surgical procedure Performed?

• Abdominal Aortic Aneurysm Repair is performed under general anesthesia
• Treating an aneurysm is completely dependent upon its size and location. These factors also dictate the kind of repair the medical experts will adopt

Open Repair:

• The surgeon makes an incision through the skin, fat, muscles, neighboring tissue, and body organs to locate the aneurysm on the artery
• The affected artery is isolated and clamped, just above and below the aneurysm spot
• The aneurysm is then opened to remove blood clots and plaque, and replaced with a synthetic graft
• The graft is sewn to the healthy stumps of the artery and it is checked to ensure proper blood flow
• The incision is closed layer by layer and finally the skin closed, with sutures or staples and bandaged

Endovascular Aneurysm Repair:

• This is a less invasive procedure performed with the help of x-ray imaging
• It involves the insertion of a catheter through the femoral artery in the groin
• Graft (a metal mesh stent) is deployed in the aneurysm with the help of the catheter
• It is guided through the artery with the aid of x-ray imaging (fluoroscopy) and a radio contrast solution, injected in the blood
• Once the stent is placed on the arterial wall with the support of hooks, the catheter is withdrawn. The skin is then closed and bandaged
• The stent acts as an artificial lumen (hollow inside space in an artery) for blood to flow, and not into the surrounding aneurysm sac
• Thus, the chance of aneurysm expansion and rupture is decreased significantly

Where is the Procedure Performed?

An Abdominal Aortic Aneurysm Repair procedure is performed in a hospital. The patient gets admitted, undergoes the procedure and is discharged, as per the instruction of the physician.

Who Performs the Procedure?

• AAA Repair is generally performed by a vascular or a cardiovascular surgeon, assisted by an anesthesiologist, a radiologist and a pathologist
• Endovascular Repair can also be performed by an interventional cardiologist

How long will the Procedure take?

The procedure may take anywhere between 3-6 hours.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the surgical procedure and helps avoid unnecessary complications.

• Provide a complete list of medications you are currently, taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you or your family members, have a history of bleeding disorders, or if there is a tendency to bleed more than normal
• If you have diabetes, high blood pressure, chest pains, or have previously suffered from a heart attack
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• If you have a history of frequent bone fractures (this may affect bone-healing, if bones are involved as part of your procedure)
• A list of all previous surgical procedures you have undergone, like for example: Removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

• The physician may evaluate the individual’s medical history to gain a comprehensive knowledge of the overall health status of the patient including information related to the medications that are being currently taken
• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Inform the physician if you are allergic to any local anesthetics, lidocaine, etc.
• Avoid application of any cosmetics, deodorant, or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the surgery
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• The patient must avoid eating or drinking at least 8 hours prior to the surgical procedure, depending on when the procedure is arranged
• For persons suffering from diabetes, it is important that the blood sugar stays within the normal range; if not their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

What is the Consent Process before the Procedure?

A physician will request your consent for the Abdominal Aortic Aneurysm Repair procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is your approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

You must sign the forms only after you are totally satisfied by the answers to your questions. In case of minors and individuals unable to personally give their consent, the individual’s legal guardian or next of kin, shall give their consent for the procedure.

What Tests are needed, before the Abdominal Aortic Aneurysm Repair surgical procedure?

Prior to an Aneurysm Repair, the physician may recommend any of the following tests:

• Angiography
• CT scan or X-ray
• Magnetic resonance angiography (MRA)
• Duplex ultrasound
• Routine blood test

The physician may suggest further tests depending on the health of the patient and their medical history.

What are some Questions for your Physician?

Some of the basic questions that you might ask your physician are as follows:

• What is the cause for an aneurysm?
• How often should I screen for aneurysm? (in case the aneurysm is still small)
• Can the aneurysm subside with medication?
• What is an Abdominal Aortic Aneurysm Repair procedure?
• Why is this procedure necessary? How will this procedure help?
• What does the procedure involve?
• How soon should I get it done? Is there an emergency?
• What are the alternatives to Aneurysm Repair surgery?
• What are the risks involved?
• Is there a possibility for the surgery to fail?
• Would the surgery ensure that I would not get an aneurysm again?
• Are there any specialists, or is there a particular hospital for the treatment, that you would recommend?
• How long will it take to recover? When can I resume normal work?
• Are there any lifestyle restrictions or modifications required, after the procedure is performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• Is there any medication that needs to be taken for life, after the procedure?
• What are the costs involved?

During the Abdominal Aortic Aneurysm Repair surgical procedure:

What kind of Anesthesia is given, during the Procedure?

During the procedure, general anesthesia is administered.

How much Blood will you lose, during the Procedure?

• The amount of blood loss is generally controlled and depends on the type of procedure adopted
• In an Endovascular Aneurysm Repair, the blood loss is minimal, compared to an Open Aneurysm Repair

What are the possible Risks and Complications during the Abdominal Aortic Aneurysm Repair surgical procedure?

There are general factors that increase the risk of getting complications during the procedure, which include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during an Open Repair or an Endovascular Repair procedure are:

• Infection
• Bleeding
• Injury to the neighboring structures
• Pain
• Discomfort
• Anesthetic complications
• Need for further procedures
• Pneumonia
• Blood clot formation, affecting blood supply to the buttocks and lower extremities
• Heart problems

Please note that the complication and risks that may arise during the surgery, is governed by the location of aneurysm and type of clinical presentation.

What Post-Operative Care is needed at the Healthcare Facility after the Abdominal Aortic Aneurysm Repair surgical procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise. However, immediately following the surgery, the patient may be kept in an intensive care unit for observation.

After the Abdominal Aortic Aneurysm Repair surgical procedure:

What are the possible Risks and Complications after the Abdominal Aortic Aneurysm Repair surgical procedure?

Post Abdominal Aortic Aneurysm Repair procedure, the following complications may arise:

• Renal failure (if blood supply to the kidney is affected)
• Ischemic colitis (if blood supply to the colon is affected)
• Groin hematoma (swelling in the groin due to accumulation of blood clot)
• Dissection (blood spreading in between the layers of the arterial wall)
• Cardiac arrhythmias
• Congestive heart failure
• Migration of the stent
• Kinking of the stent
• Incisional hernia
• Endoleak

Endoleak: An endoleak is a condition where blood leaks into the aneurysm sac. It is seen after an Endovascular Repair. Five types of endoleaks exist:

Type I - Perigraft leakage at the upper or lower graft attachment sites
Type II - Retrograde flow from branches of the aorta
Type III - Leakage between overlapping parts of the stent
Type IV - Leakage through the graft wall
Type V - Leakage from an unknown origin

When do you need to call your Physician?

Do contact your physician if you notice any of the following symptoms:

• Worsening pain around the surgical wound
• Swelling and redness
• Bleeding or fluid drainage around the spot
• Fever
• Dizziness
• Signs of infection

What is the Prognosis after the Surgery?

• The outcome of a successful Open Repair surgical procedure is usually good
• Endovascular Aneurysm Repair however, is observed to have a lesser operative and post-operative mortality rate with faster recovery, as compared to an Open Surgery.
• The post-operative mortality rate increases with age (beyond 65 years)

What Post-Operative Care is needed at Home after the Abdominal Aortic Aneurysm Repair surgical procedure?

At home, the following post-operative care is recommended, after an Abdominal Aortic Aneurysm Repair procedure:

• Avoid any strenuous activity for 6-8 weeks
• Always keep the surgical wound clean and dry
• Early ambulation aids in a faster recovery
• Use heat pad or warm compress to relieve incision pain
• Take stool softeners to prevent constipation
• Take medications to keep blood pressure under control
• Complete the course of medication, and avoid non-prescription pain medication.
• Avoid sex till complete healing has taken place (under advice of the physician)

How long does it normally take to fully recover, from the Procedure?

It may take anywhere between 4-6 weeks for a complete recovery, from the procedure.

Additional Information:

What happens to tissue (if any), taken out during the Procedure?

The tissue (blood vessel) is taken for further examination and later disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

• The tissue removed is processed in the laboratory under a pathologist's supervision
• Slide(s) are prepared once the tissue is processed and this is examined by a pathologist and a pathology report issued
• Depending on the complexity of the case, issue of the report may take anywhere between 72 hours to a week's time

Who will you receive a Bill from, after the Abdominal Aortic Aneurysm Repair surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The hospital
• The physician who is performing the procedure
• An anesthesiologist
• A pathologist (if the tissue was sent for analysis)

The patient is advised to inquire and confirm the type of billing, before the Abdominal Aortic Aneurysm Repair procedure is performed.

Thanks and Gratitude:

We sincerely acknowledge and thank Dr. Douglas J. Jones for reviewing the article. His valuable input and feedback has helped enrich the contents of this article.

Douglas J. Jones, MD FACS
Board Certified General Surgeon and Faculty Member
University of Illinois, College of Medicine at Urbana-Champaign
506 S. Mathews Ave., Urbana, IL 61801, USA