Endovascular Repair of Abdominal Aortic Aneurysm

The Aorta, the largest artery in the body, branches from the left ventricle of the heart and descends through the chest into the abdomen delivering oxygen rich blood to the body. An aortic aneurysm is a weakening of the artery wall in the aorta causing the artery wall to bulge out like a balloon. Aneurysms can occur anywhere along the aorta but 75% of aortic aneurysms occur in the abdominal region. These are referred to as abdominal aortic aneurysm (AAA).

If an aneurysm becomes too large, there is a risk of rupture. A ruptured aneurysm is a medical emergency due to life threatening bleeding.

Endovascular graft repair is a minimally invasive non-surgical medical procedure to treat abdominal aortic aneurysms. Endovascular graft repair involves inserting a catheter into the groin areas and advancing it to the site of the aneurysm to place a stent-graft, a small tube made of fabric with metal stents. The stent-graft is placed at the site of the aneurysm creating a new blood channel effectively reducing pressure on the aneurysm and reducing the risk of rupture. This procedure may be performed on an emergency basis following a rupture of an abdominal aortic aneurysm, or an elective basis when conservative treatment measures have failed to relieve symptoms of Abdominal Aortic Aneurysm or there is a risk of rupture due to the size of the aneurysm.

What is an Abdominal Aortic Aneurysm?

 

An Abdominal Aortic Aneurysm is an aneurysm located in the Aorta in the abdominal area. Aneurysms are usually caused from a disease process called atherosclerosis. Atherosclerosis is a condition in which fatty material is deposited along the walls of arteries. This fatty material (often called plaque) thickens and hardens causing a narrowing of the artery and may eventually completely block blood flow within the arteries. Atherosclerosis is the main contributing factor in the development of an aneurysm as it damages the lining of the artery increasing the risk of aneurysm development.

Risk factors for Abdominal Aortic Aneurysm include the following:

  • Cigarette Smoking increases your risk 8x
  • Untreated Hypertension (High Blood Pressure)
  • High Cholesterol or other fat levels in blood
  • Males are 5-10 times more likely than women to have an AAA
  • Increasing age: 60-80 years old are at higher risk than the younger population
  • More prevalent in whites
  • Atherosclerosis: fatty deposit builds up in arteries
  • Family history of AAA
  • Inactive lifestyle- Obesity/ overweight/ lack of exercise
  • Diabetes (High blood sugar)
  • Non-compliance with medicines to treat hypertension, diabetes, and high cholesterol

Abdominal Aortic Aneurysm: Signs and Symptoms

Abdominal Aortic Aneurysms can develop slowly over a period of years and do not usually cause symptoms in the early stages of development. Usually, when the aneurysm becomes larger or ruptures is when symptoms occur. Often AAA’s are discovered during routine physical exams or when having scans or x-rays for unrelated illnesses.

When symptoms do occur, they can include:

  • Pulsating mass in the abdomen
  • Pain in the abdomen, back or side
  • Strong feeling of fullness even after eating a small meal
  • Frequent nausea and vomiting
  • Continuous pain in the abdomen lasting hours or days
  • Decreased circulation to the lower extremities: coldness, numbness, tingling

If an AAA ruptures this is a medical emergency and 911 should be called. Symptoms of a ruptured AAA include:

  • Sudden severe pain to the abdominal area and lower back
  • Nausea and vomiting
  • Clammy, sweaty skin
  • Lightheadedness
  • Loss of Consciousness
  • Rapid heart rate

Abdominal Aortic Aneurysm: Diagnosis

A Cardiologist should evaluate all cardiovascular conditions for proper diagnosis and treatment.

Your Cardiologist will perform the following:

  • Medical History
  • Physical Examination

If your doctor suspects Abdominal Aortic Aneurysm either from your risk factors or from the physical exam they will usually perform some of the following tests:

  • Doppler Ultrasound – This is a painless, non-invasive test where a small ultrasound probe is placed over the abdominal area. This test shows your physician blood flow within the arteries and how open the arteries are
  • Chest or Abdominal X-Ray – A form of electromagnetic radiation that is used to take pictures
  • CT Scan – A special x-ray that uses computers to show cross sections of body tissues and organs allowing visualization of the blood flow in the Aorta
  • MRI – Magnetic Resonance Imaging or MRI is a non-invasive test that provides a detailed picture of the arteries through the use of magnetic fields and radio waves

Conservative Treatment Options

Your physician will base his treatment plan on the size and location of the aneurysm. If the aneurysm is small (less than 5 cm), you don’t have symptoms, and the aneurysm is not growing rapidly, your physician may monitor your condition with regular checkups with imaging to monitor the size of the aneurysm. This is referred to as a “wait and see” approach.

Conservative management of Abdominal Aortic Aneurysm also includes:

  • Lifestyle Modifications
  • Medications

Lifestyle Modifications

Healthy life choices will improve your overall health and can help you slow the progression of your cardiovascular disease. Some heart healthy choices include:

  • Healthy Diet Choices – Eating a low fat, low salt, low cholesterol diet
  • Don’t Smoke – If you do smoke, talk to your doctor about available options to help you quit. You will immediately lower your risk of heart disease and stroke as soon as you quit as well as your risk of aneurysm rupture
  • Exercise – Increasing your physical activity is a great way to reduce stress, improve sleep, lose weight, and improve your overall sense of well-being. Always discuss with your doctor before beginning any new exercise program
  • Weight Loss – Being
  • Cholesterol Control – Keep cholesterol within normal limits through diet, exercise and cholesterol lowering medications

Medications

Along with life style modification, medications may be needed to control symptoms and improve your overall health. More than one medication may be prescribed. Some common medications are listed on the left. Move your cursor over the medications to find out more.

  • Betablockers – Betablockers are used to treat high blood pressure. They work by decreasing the force of the blood ejected from the heart. By decreasing blood pressure the risk of the aneurysm expanding is lessened
  • Statins – Statins are cholesterol-lowering medications to control lipid or fat levels in the blood

Abdominal Aortic Aneurysm Endovascular Repair: Introduction

If conservative treatment options are unsuccessful at treating your aneurysm or the aneurysm is larger than 5 cm, growing rapidly, or at risk of rupture, your Cardiologist may recommend a non-surgical procedure called Abdominal Aortic Aneurysm Endovascular Repair.

The traditional surgical procedure for abdominal aortic aneurysm is an open surgical repair. This procedure is major surgery involving general anesthesia and a long abdominal incision, a 4-5 day hospital stay, and a recovery period of 6-8 weeks before the patient can resume normal activity.

Endovascular graft repair is a newer, minimally invasive procedure performed under local anesthesia through tiny incisions in the groin. Although the procedure is not without risks, the benefits of this procedure include shorter hospital stay, usually 1-2 days, and shorter recuperation time, usually about 2-3 weeks.

Endovascular graft repair may be indicated for patients who are at high risk of experiencing adverse events while undergoing a major surgery such as an open surgical repair of the aneurysm.

It is important that you understand and discuss the benefits and risks for your particular situation with your doctor before deciding which procedure is best for you.

Abdominal Aortic Aneurysm Endovascular Repair: How is it done?

Abdominal Aortic Aneurysm Endovascular Repair is performed by an Interventional Cardiologist in the Cardiac Catheterization Lab of the hospital under local, regional, or general anesthesia. You may be awake but drowsy during the procedure. During an Endovascular Repair procedure, the patient is placed lying on their back on an x-ray table. The doctor uses a fluoroscope, a special X-ray machine, to view the entire procedure on a monitor similar to a television. The catheter insertion areas, the right and left groin, are shaved, disinfected, and injected with a local anesthetic to numb the area.

Your surgeon will make a tiny cut or “stab wound” over the insertion site in each groin and insert a small tube called a sheath into the artery in the groin.

With the help of X-ray imaging, the Cardiologist slowly advances a flexible tube called a catheter through the sheath and into the artery until the aneurysm site is reached in the aorta. The catheter contains a small tube made of fabric with metal stents. This tube is called a stent-graft and once in place will decrease pressure on the aneurysm site by directing blood through the graft.

Using X-Ray imaging the cardiologist deploys the stent-graft in place against the artery wall using small hooks or pins to secure its location. Some stents are self expanding once released from the catheter while others require balloon inflation to place the stent-graft in the proper location.

  • Once your doctor is satisfied with the results, the balloon, if used, is deflated and the guide wire and catheter are withdrawn.
  • The stent-graft remains in place within the artery.
  • The stent-graft acts as a reinforcement of the vessel walls decreasing pressure on the aneurysm site thereby reducing the risk of rupture.
  • Pressure will be applied to the groin insertion sites for 15 minutes followed by a tight pressure bandage to prevent bleeding.
  • Abdominal Aortic Aneurysm Endovascular Repair: Post Operative Guidelines
  • After the Endovascular Repair procedure you will be taken to the recovery room and be told to lie still for 6-8 hours to prevent bleeding from the puncture site.
  • Recovery time varies. You may be discharged the same day or, depending upon your recovery, spend one or two nights in the hospital.

Common post-operative guidelines following AAA Endovascular Repair include the following:

  • You will need someone to drive you home after you are released. You should not drive for 1-2 days after the procedure
  • Do not remove the dressing over the puncture site until instructed to do so. Keep the area clean and dry
  • You will be encouraged to drink fluids to flush the dye used for the X-rays out of your body
  • Your surgeon may give you activity restrictions such as no heavy lifting for a few days to prevent bleeding from the insertion site
  • You may have soreness and bruising around the puncture site
  • Your doctor will prescribe blood-thinning medicines to prevent blood clots from forming around the stent. It is very important that you adhere to your prescribed medications to prevent blood clots from forming

Contact your doctor immediately if you have a fever, chills, redness, bleeding, irregular heart beat, chest pain, shortness of breath, weakness, or dizziness.

Abdominal Aortic Aneurysm Endovascular Repair: Risks & Complications

  • As with any medical procedure there are potential risks involved. The decision to proceed with the procedure is made because the advantages outweigh the potential disadvantages
  • It is important that you are informed of these risks before the procedure takes place

Most patients do not have complications after AAA Endovascular Repair; however complications can occur with any procedure and depends on the type of procedure your doctor performs as well as the patient’s health status. (i.e. obese, diabetic, smoker, etc.)

Complications can be medical (general) or specific to AAA Endovascular Repair.

Medical complications include those of the anesthesia and your general well being. Almost any medical condition can occur so this list is not complete. Complications include:

  • Allergic reaction to medications or dye
  • Blood loss requiring transfusion with its low risk of disease transmission
  • Heart attack, strokes, kidney failure, pneumonia, bladder infections
  • Complications from insertion site such as infection or nerve damage
  • Serious medical problems can lead to ongoing health concerns, prolonged hospitalization, or rarely death

Specific complications for Endovascular Repair include:

  • Thrombosis – Clots can occur and move to other parts of the body causing heart attack or stroke
  • Bleeding
  • Internal leaks
  • Blockage of the stent-graft
  • Infection
  • Blood vessel damage from the catheter
  • Migration of the stent-graft requiring repeat surgery
  • Ischemia – Deprivation of blood supply to colon or spinal cord requiring surgery

Risk factors that can increase the chance of complications following Endovascular Repair include:

  • Diabetes
  • History of kidney disease
  • Poor cardiac function
  • Extensive heart disease
  • Poor nutrition
  • Smoking
  • Obesity
  • Age (over 75)
  • Alcoholism
  • Chronic Illness
  • Steroid Use