- Abdominal Aortic Aneurysm
- What is an abdominal aortic aneurysm?
- Abdominal Aortic Aneurysm Shapes
- What causes an abdominal aortic aneurysm to form?
- What are the symptoms of abdominal aortic aneurysms?
- How are aneurysms diagnosed?
- What is the treatment for abdominal aortic aneurysms?
- What is aortic dissection?
- What causes aortic dissection?
- Abdominal Aortic Aneurysm | Johns Hopkins Division of Vascular and Interventional Radiology
- What are the symptoms for AAA?
- How common are abdominal aneurysms?
- Why do AAA occur?
- Treatment for Abdominal Aortic Aneurysms
- How are these devices used to treat AAA?
- How can you treat AAA with this technique?
- Who performs the procedure?
- How many patients are eligible for this procedure?
- What is the recovery period for this method?
- How effective is the treatment?
- How new is this technique?
- About Abdominal Aortic and Thoracic Aneurysms | Johns Hopkins Heart and Vascular Institute
- What is a thoracic aneurysm?
- What causes aneurysms?
- How is an aneurysms diagnosed or detected?
- What are the symptoms of a thoracic aneurysm?
- What are the symptoms of an abdominal aneurysm?
- Who is at risk for developing aneurysms?
- Are there other risk factors?
- What role to high cholesterol and genetic disorders play in aneurysms?
- When are aneurysms treated?
- What are the tests to determine treatment for aneurysms?
- What causes an aneurysm to form?
- What are the symptoms of an aneurysm?
- What is the treatment for aneurysms?
- Abdominal Aortic Aneurysm Repair
- What are the risks of AAA repair?
- Open repair
- How is AAA open repair done?
- How is EVAR done?
- In the hospital after AAA open repair
- In the hospital after EVAR
- At home
- Next steps
Abdominal Aortic Aneurysm
An aneurysm is a weak section of an artery wall. Pressure from inside the artery causes the weakened area to bulge out beyond the normal width of the blood vessel. An abdominal aortic aneurysm is an aneurysm in the lower part of the aorta, the large artery that runs through the torso.
- Abdominal aortic aneurysm is sometimes known as AAA, or triple A.
- Older, long-term smokers are at especially high risk for abdominal aortic aneurysm.
- Many people have no symptoms and don’t know they have an aortic aneurysm until it ruptures, which is often quickly fatal.
- Symptoms, when they do occur, include pain in the back or near the naval. An extremely sharp and severe pain may indicate rupture, requiring emergency medical treatment.
- Smaller, slow-growing aortic aneurysms may be treated with watchful waiting, lifestyle changes and medication. Large or fast-growing aortic aneurysms may require surgery.
What is an abdominal aortic aneurysm?
The aorta is the largest blood vessel in the body. It delivers oxygenated blood from the heart to the rest of the body. An aortic aneurysm is a bulging, weakened area in the wall of the aorta. Over time, the blood vessel balloons and is at risk for bursting (rupture) or separating (dissection). This can cause life threatening bleeding and potentially death.
Aneurysms occur most often in the portion of the aorta that runs through the abdomen (abdominal aortic aneurysm). An abdominal aortic aneurysm is also called AAA or triple A. A thoracic aortic aneurysm refers to the part of the aorta that runs through the chest.
Once formed, an aneurysm will gradually increase in size and get progressively weaker. Treatment for an abdominal aneurysm may include surgical repair or removal of the aneurysm, or inserting a metal mesh coil (stent) to support the blood vessel and prevent rupture.
Abdominal Aortic Aneurysm Shapes
The more common shape is fusiform, which balloons out on all sides of the aorta. A bulging artery isn’t classified as a true aneurysm until it increases the artery’s width by 50 percent.
A saccular shape is a bulge in just one spot on the aorta. Sometimes this is called a pseudoaneurysm. It usually means the inner layer of the artery wall is torn, which can be caused by an injury or ulcer in the artery.
What causes an abdominal aortic aneurysm to form?
Many things can cause the breakdown of the aortic wall tissues and lead to an abdominal aortic aneurysm. The exact cause isn't fully known. But, atherosclerosis is thought to play an important role.
Atherosclerosis is a buildup of plaque, which is a deposit of fatty substances, cholesterol, cellular waste products, calcium, and fibrin in the inner lining of an artery.
Risk factors for atherosclerosis include:
- Age (older than age 60)
- Male (occurrence in males is 4 to 5 times greater than that of females)
- Family history (first degree relatives such as father or brother)
- Genetic factors
- High cholesterol
- High blood pressure
Other diseases that may cause an abdominal aneurysm include:
- Connective tissue disorders such as Marfan syndrome, Ehlers-Danlos syndrome, Turner's syndrome, and polycystic kidney disease
- Congenital (present at birth) defects such as bicuspid aortic valve or coarctation of the aorta
- Inflammation of the temporal arteries and other arteries in the head and neck
- Infection such as syphilis, salmonella, or staphylococcus (rare)
What are the symptoms of abdominal aortic aneurysms?
About 3 4 abdominal aortic aneurysms don't cause symptoms. An aneurysm may be found by X-ray, computed tomography (CT or CAT) scan, or magnetic resonance imaging (MRI) that was done for other reasons. Since abdominal aneurysm may not have symptoms, it's called the “silent killer” because it may rupture before being diagnosed.
Pain is the most common symptom of an abdominal aortic aneurysm. The pain associated with an abdominal aortic aneurysm may be located in the abdomen, chest, lower back, or groin area. The pain may be severe or dull. Sudden, severe pain in the back or abdomen may mean the aneurysm is about to rupture. This is a life-threatening medical emergency.
Abdominal aortic aneurysms may also cause a pulsing sensation, similar to a heartbeat, in the abdomen.
The symptoms of an abdominal aortic aneurysm may look other medical conditions or problems. Always see your doctor for a diagnosis.
How are aneurysms diagnosed?
Your doctor will do a complete medical history and physical exam. Other possible tests include:
- Computed tomography scan (also called a CT or CAT scan). This test uses X-rays and computer technology to make horizontal, or axial, images (often called slices) of the body. A CT scan shows detailed images of any part of the body, including the bones, muscles, fat, and organs. CT scans are more detailed than standard X-rays.
- Magnetic resonance imaging (MRI). This test uses a combination of large magnets, radiofrequencies, and a computer to produce detailed images of organs and structures within the body.
- Echocardiogram (also called echo). This test evaluates the structure and function of the heart by using sound waves recorded on an electronic sensor that make a moving picture of the heart and heart valves, as well as the structures within the chest, such as the lungs and the area around the lungs and the chest organs.
- Transesophageal echocardiogram (TEE). This test uses echocardiography to check for aneurysm, the condition of heart valves, or presence of a tear of the lining of the aorta. TEE is done by inserting a probe with a transducer on the end down the throat.
- Chest X-ray. This test uses invisible electromagnetic energy beams to make images of internal tissues, bones, and organs onto film.
- Arteriogram (angiogram). This is an X-ray image of the blood vessels that is used to assess conditions such as aneurysm, narrowing of the blood vessel, or blockages. A dye (contrast) will be injected through a thin, flexible tube placed in an artery. The dye makes the blood vessels visible on an X-ray.
What is the treatment for abdominal aortic aneurysms?
Treatment may include:
- Monitoring with MRI or CT. These tests are done to check the size and rate of growth of the aneurysm.
- Managing risk factors. Steps, such as quitting smoking, controlling blood sugar if you have diabetes, losing weight if overweight, and eating a healthy diet may help control the progression of the aneurysm.
- Medicine. Used to control factors such as high cholesterol or high blood pressure.
- Abdominal aortic aneurysm open repair. A large incision is made in the abdomen to let the surgeon see and repair the abdominal aorta aneurysm. A mesh, metal coil- tube called a stent or graft may be used. This graft is sewn to the aorta, connecting one end of the aorta at the site of the aneurysm to the other end. The open repair is the surgical standard for an abdominal aortic aneurysm.
- Endovascular aneurysm repair (EVAR). EVAR requires only small incisions in the groin. Using X-ray guidance and specially-designed instruments, the surgeon can repair the aneurysm by inserting the stent or graft inside the aorta. The graft material may cover the stent. The stent helps hold the graft open and in place.
A small aneurysm or one that doesn't cause symptoms may not require surgery until it reaches a certain size or is rapidly increasing in size over a short period of time.
Your doctor may recommend “watchful waiting.
” This may include an ultrasound, duplex scan, or CT scan every 6 months to closely monitor the aneurysm, and blood pressure medicine may be used to control high blood pressure.
If the aneurysm is causing symptoms or is large, your doctor may recommend surgery.
Surgery may be necessary if the aneurysm is large or fast growing, increasing chances of rupture. Women with large aneurysms are more ly than men to suffer a rupture.
For suprarenal (above the kidneys) AAA, only open surgery is available in the U.S.
right now, though Johns Hopkins vascular surgeons are involved in endovascular device trials that may be a suitable option.
However, AAA at or below the kidneys may be treated by open or endovascular surgery. Endovascular means “within the blood vessel” and is considered minimally invasive.
Not all patients can tolerate the risk of open surgery, so endovascular repair is a great option. Unfortunately, not all patients have the anatomy to qualify for endovascular repair. Consult your vascular surgeon about which technique is best for you.
- Open aneurysm repair: A large incision is made in the abdomen to repair the aneurysm. Another incision is made in the aorta for the length of the aneurysm. A cylinder called a graft is used for the repair. Grafts are made of polyester fabric or polytetrafluoroethylene (PTFE, nontextile synthetic graft). This graft is sewn to the aorta, from just above the aneurysm site to just below it. The artery walls are then sewn over the graft.
- Endovascular aneurysm repair (EVAR): A small incision is made in the groin. Using X-ray guidance, a stent graft is inserted into the femoral artery and sent to the site of the aneurysm. A stent is a thin metal mesh framework shaped into a long tube, while the graft, a fabric covering the mesh, is made of a polyester fabric called PTFE. The stent holds the graft open and in place. EVAR is used only for an infrarenal (below the kidneys) AAA. It may be more easily tolerated by high-risk patients. However, the graft can sometimes slip place and may later need to be fixed.
- Fenestrated stent graft: When the aneurysm is juxtarenal (at the kidneys) or involves the arteries of the kidneys, the prior standard treatment has been open surgery. That’s because a traditional stent graft has no openings to accommodate the branching of the aorta to the kidneys. In 2012, the FDA approved a fenestrated stent graft, now available in a few vascular surgery programs, including Johns Hopkins. The fenestrated stent graft is made to the precise size of each patient’s aorta so the openings for the renal (kidney) arteries are in just the right place to maintain kidney circulation.
What is aortic dissection?
An aortic dissection starts with a tear in the inner layer of the aortic wall of the thoracic aorta. The aortic wall is made up of 3 layers of tissue. When a tear occurs in the innermost layer of the aortic wall, blood is then channeled into the wall of the aorta separating the layers of tissues.
This generates a weakening in the aortic wall with a potential for rupture. Aortic dissection can be a life-threatening emergency. The most commonly reported symptom of an aortic dissection is sudden, severe, constant chest or upper back pain, sometimes described as “ripping” or “tearing.
” The pain may move from one place to another.
When a diagnosis of aortic dissection is confirmed, immediate surgery or stenting is usually done.
What causes aortic dissection?
The cause of aortic dissection is unclear. However, several risk factors associated with aortic dissection include:
- High blood pressure
- Connective tissue disorders, such as Marfan's disease, Ehlers-Danlos syndrome, and Turner's syndrome
- Cystic medial disease (a degenerative disease of the aortic wall)
- Aortitis (inflammation of the aorta)
- Bicuspid aortic valve (presence of only 2 cusps, or leaflets, in the aortic valve, rather than the normal 3 cusps)
- Coarctation of the aorta (narrowing of the aorta)
- Excess fluid or volume in the circulation (hypervolemia)
- Polycystic kidney disease (a genetic disorder characterized by the growth of numerous cysts filled with fluid in the kidneys)
Abdominal Aortic Aneurysm | Johns Hopkins Division of Vascular and Interventional Radiology
An AAA is a weakening in the wall of the abdominal portion of the aorta, which leads from the heart to the rest of the body, and is the body’s largest blood vessel. AAA most commonly is caused by atherosclerosis, a gradual build-up of cholesterol and scar tissue that damages the walls of blood vessels.
People with high blood pressure, those who smoke and those who have a family history of AAA also are at risk. The aorta is an inch or less in diameter. Typically, aneurysms that cause a ballooning of the aorta smaller than 2 inches in diameter are not treated. Those 2-1/2 inches or larger are at risk for life-threatening rupture, and usually are repaired.
Patients whose aneurysms are detected at the smaller size typically are checked regularly by their physicians.
What are the symptoms for AAA?
There are no symptoms for AAA. About 90 percent are discovered by accident, when a physician is testing for another condition such as gall stones or kidney stones. Although a doctor can sometimes detect an AAA just by feeling the abdomen, ultrasound is the best method. “For someone over 60 who is at risk, it’s not a bad idea to have an ultrasound,” said Dr. Arepally.
How common are abdominal aneurysms?
Abdominal aortic aneurysms occur in 5 percent to 7 percent of people age 60 or older, and men are four times more ly to have AAA than women. Every year, more than 15,000 people die of AAA, making it the 13th leading cause of death in the United States.
Why do AAA occur?
Atherosclerotic disease, or “hardening of the arteries”, can result in aneurysm formation (ballooning) of the abdominal (belly) and/or thoracic (chest) aorta, the main blood vessel of the body. This disease can have profound effects on one's health and can even result in death should the aneurysm rupture.
Treatment for Abdominal Aortic Aneurysms
These aneurysms have traditionally been treated with surgery, however this major operation can be associated with a significant recovery time and morbidity and mortality rate. Recently, another method of treating these aneurysms, combining the skills of both a vascular surgeon and interventional radiologist, has been developed.
How are these devices used to treat AAA?
The interventional radiology technique involves making a small nick in the groin and, under X-ray guidance, inserting a catheter into a blood vessel that leads to the aorta.
A collapsed stent-graft, also known as an endograft (a small fabric tube) is inserted through the catheter and moved to the site of the aneurysm, where it is deployed, reinforcing the aorta and creating a stronger pathway for the blood.
Blood flowing through the stent-graft no longer puts pressure on the ballooning walls of the aneurysm that are outside of the graft. Typically the patient is lightly sedated and has been given epidural anesthesia.
How can you treat AAA with this technique?
This technique involves the use of a “stent graft”. The stent graft is a piece of graft material (similar as to what would be used in the routine procedure), within which have been placed metal stents (a framework) to support and secure the device to the wall of the aorta.
Utilizing a surgical “cut-down” in the groin, the interventional radiologist and vascular surgeon work together to place the stent graft within the aorta at the location of the aneurysm to create a new channel for blood flow which effectively excludes the aneurysm from the circulation.
The aneurysm clots off, leaving blood flowing through the stent graft in the same fashion as if a “vascular graft” had been placed during the routine type of surgical procedure.
After placing the stent graft, the surgeon closes the access site in the groin and the patient is taken to the recovery room.
Who performs the procedure?
At Johns Hopkins, the procedure is performed by a stent graft team. This team is composed of an interventional radiologists, vascular surgeon and anesthesiologists. By combining the different medical expertise, the best and optimal care is provided for patients undergoing this procedure at Johns Hopkins.
How many patients are eligible for this procedure?
Nearly three-quarters of people with an abdominal aortic aneurysm (AAA), a common life-threatening condition, may be eligible for a non-surgical procedure to correct the dangerous ballooning in the body’s main artery.
Interventional radiologists at Johns Hopkins perform the procedure, called stent-grafting, which requires less anesthesia and a shorter hospital stay, and results in less overall risk to the heart than surgery.
“In the right patient, stent-grafts are very successful in treating these aneurysms,” said Dr. Lund. “Stent-grafting has many advantages over surgery, including a dramatic reduction in the complication rate.
What is the recovery period for this method?
The hospital stay usually is four days or less; recovery takes an average of 11 days and there are fewer complications than with surgical repair.
The alternative, surgical replacement of the damaged portion of the aorta, is performed under general anesthesia. A large incision is made in the abdomen to reach the site.
The aorta is clamped off, the aneurysm cut out and an artificial artery or graft is sewn into place. Typically, the hospital stay is 8 to 10 days and the average recovery time is 47 days.
How effective is the treatment?
About 15 percent to 20 percent of patients who have the stent-graft procedure experience leakage into the aneurysm sac. Many need no treatment, but are followed closely. Others may undergo embolization, an interventional radiological technique that cuts off blood flow to the problem area to prevent further leakage.
An interventional radiologist is a physician who has special training to diagnose and treat illness using miniature tools and imaging guidance.
Typically, the interventional radiologist performs procedures through a very small nick in the skin, about the size of a pencil tip.
Interventional radiology treatments are generally easier for the patient than surgery because they involve no surgical incisions, less pain and shorter hospital stays.
How new is this technique?
This device has been used successfully around the country and in Europe to treat aortic aneurysms, and certain grafts have been recently been approved by the FDA for the U.S.
Each patient is fully evaluated to see if they are a candidate for this procedure.
If you have been told that you have an “abdominal aortic aneurysm” or “thoracic aortic aneurysm” and are not a good surgical candidate, you may obtain further details concerning this state-of-the-art procedure. Please feel free to contact us at any time.
If you are interested in coming Johns Hopkins Hospital for this procedure, please feel free to contact us.
Drawing of an abdominal aneurysm. This technique is used to treat the abnormal dilatation of the blood vessel, called an aneurysm, by placing a graft in the blood vessel without the need for major surgery. This has been a significant development in the treatment of this condition.Picture of the aneurysm without the graft.Picture of the aneurysm with the graft. This graft is placed with minimally invasive techniques and has been considered a major breakthrough in the treatment of aneurysms.
About Abdominal Aortic and Thoracic Aneurysms | Johns Hopkins Heart and Vascular Institute
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Featuring Christopher Abularrage, MD, Assistant Professor of Surgery and James Black, MD, Associate Professor of Surgery
What is a thoracic aneurysm?
A thoracic aortic aneurysm is a bulging, or weakening, of the aorta within the chest. The aorta within the chest is generally about the size of a garden hose, but over time, with aging and structural abnormalities of the thoracic aorta, it can begin to dilate and enlarge towards an aneurysm.
What causes aneurysms?
It’s not completely understood how aortic aneurysms develop. In some cases, it’s related to a history of smoking; in other cases it’s related to genetic disorders such as Loeys-Dietz syndrome or Marfan syndrome, where there’s an abnormal breakdown of the aortic wall which results in a ballooning of the aorta itself.
How is an aneurysms diagnosed or detected?
Aortic aneurysms are typically found incidentally, meaning that the patient didn’t know that they had it. It can be felt on a physical exam of the abdomen as a pulsatile mass or it can be seen on an ultrasound or a CAT scan.
What are the symptoms of a thoracic aneurysm?
An aneurysm within a chest, those being thoracic aortic aneurysms, give patients chest pain. The chest pain itself can be rather pulsatile in nature, a pounding sort of pain, often times in the front of the chest or between the shoulder blades towards the spine.
What are the symptoms of an abdominal aneurysm?
In the abdominal aorta, the symptoms can also be quite diverse, but in general usually it’s low back pain, or perhaps pain in the center of the abdomen, again quite classically it tends to be pulsatile in nature, or pounding with every heartbeat, more so than a typical ache and pain that one might experience with raking the leaves or shoveling too much snow.
Who is at risk for developing aneurysms?
Smoking is the greatest risk factor both for the establishment of aneurysms as well as their growth once an aneurysm has been diagnosed.
The correlation between smoking and aneurysm is quite great, to the point now, that in the past several years, Medicare has allowed a one-time screening for patients at age 65 years of age who have a history of smoking to rule out an abdominal aortic aneurysm before, of course, it becomes symptomatic and leads to trouble.
Are there other risk factors?
People at risk for aortic aneurysmal disease include patients who are over the age of 50; it’s more ly to be found in men than women; and it can also be found in certain genetic disorders such as Loeys-Dietz syndrome or Marfan syndrome.
What role to high cholesterol and genetic disorders play in aneurysms?
The most common cause of aneurysms in general is related to smoking and hypertension. We also now are beginning to understand that high cholesterol also plays a role in the development of aneurysms.
At Hopkins, we have a very long and established track record of dealing with patients who have genetic disorders which lead them to inherited weaknesses of the aorta as it runs through the chest and the abdomen and require surgery at earlier ages than we would typically see in patients who are smokers or who have high blood pressure who are coming to require aneurysm treatment in their 60s.
When are aneurysms treated?
Treatment for thoracic aortic aneurysms, in terms of the threshold when we move forward with the repair, whether it’s an endovascular or open repair, are different than those of an abdominal aortic aneurysm. Abdominal aortic aneurysms have been much more studied, have longer term data to support the treatment thresholds we use for the abdominal aorta.
In the thoracic aorta, we generally draw the line at six centimeters to repair a thoracic aortic aneurysm whether we are doing it with an open repair or an endovascular repair.
However, if we see a thoracic aortic aneurysm as growing rapidly, such as growing 5 millimeters in six months, or even a centimeter in a year, we may very well intervene upon that patient at a diameter less than six centimeters in size, for fear that the rapid growth rate of the aneurysm is predicting a higher risk for rupture in the future.
What are the tests to determine treatment for aneurysms?
Ultrasound is the most common screening test for abdominal aortic aneurysms. Once you get close to having an aneurysm that needs to be repaired, CAT scans are ordered, because these tell us more definition about the anatomy and whether you are a suitable candidate for a minimally invasive, endovascular repair.
Linkedin Pinterest Cardiovascular Aneurysm Treatment Abdominal Aortic Aneurysm
An aneurysm is a bulging, weakened area in the wall of a blood vessel resulting in an abnormal widening or ballooning greater than 50% of the vessel's normal diameter (width). An aneurysm may occur in any blood vessel, but is most often seen in an artery rather than a vein.
An aneurysm may be located in many areas of the body, such as blood vessels of the brain (cerebral aneurysm), the aorta (the largest artery in the body), the neck, the intestines, the kidney, the spleen, and the vessels in the legs (iliac, femoral, and popliteal aneurysms).
The most common location of an aneurysm is the aorta, which carries oxygenated blood from the heart to the body. The thoracic aorta is the short segment of the aorta in the chest cavity. The abdominal aorta is the section of the aorta that runs through the abdomen.
An aneurysm can be characterized by its location, shape, and cause.
The shape of an aneurysm is described as being fusiform or saccular, which helps to identify a true aneurysm. The more common fusiform-shaped aneurysm bulges or balloons out on all sides of the blood vessel. A saccular-shaped aneurysm bulges or balloons out only on one side.
A pseudoaneurysm, or false aneurysm, is not an enlargement of any of the layers of the blood vessel wall. A false aneurysm may be the result of a prior surgery or trauma. Sometimes, a tear can occur on the inside layer of the vessel. As a result, blood fills in between the layers of the blood vessel wall creating a pseudoaneurysm.
A dissecting aneurysm is an aneurysm that occurs with a tear in the artery wall that separates the 3 layers of the wall, rather than ballooning out the entire wall.
Because an aneurysm may continue to increase in size, along with progressive weakening of the artery wall, surgical intervention may be needed. Preventing rupture of an aneurysm is 1 of the goals of therapy. The larger an aneurysm becomes, the greater the risk for rupture (bursting). With rupture, life-threatening hemorrhage (uncontrolled bleeding), and possibly death, may result.
What causes an aneurysm to form?
An aneurysm may be caused by multiple factors that result in the breaking down of the well-organized structural components (proteins) of the aortic wall that provide support and stabilize the wall.
The exact cause isn't fully known. Atherosclerosis (hardening of the arteries with a sticky substance called plaque) is thought to play an important role in aneurysmal disease.
Risk factors associated with atherosclerosis include, but are not limited to:
Other specific causes of aneurysms are related to the location of the aneurysm. Examples of aneurysms in the body and their additional causes may include, but are not limited to:
|Abdominal Aortic Aneurysm (AAA)||
|Common Iliac Artery Aneurysm||
|Femoral and Popliteal Artery Aneurysm||
What are the symptoms of an aneurysm?
Aneurysms may be asymptomatic (no symptoms) or symptomatic (with symptoms). Symptoms associated with aneurysms depend on the location of the aneurysm in the body.
Symptoms that may occur with different types of aneurysms may include, but are not limited to:
|Abdominal Aortic Aneurysm (AAA)||Constant pain in abdomen, chest, lower back, or groin area|
|Cerebral Aneurysm||Sudden severe headache, nausea, vomiting, visual disturbance, loss of consciousness|
|Common Iliac Aneurysm||Lower abdominal, back, and/or groin pain|
|Femoral and Popliteal Artery Aneurysm||Easily palpated (felt) pulsation of the artery located in the groin area (femoral artery) or on the back of the knee (popliteal artery), pain in the leg, sores on the feet or lower legs|
The symptoms of an aneurysm may resemble other medical conditions or problems. Always consult your doctor for more information.
What is the treatment for aneurysms?
Specific treatment will be determined by your doctor :
- Your age, overall health, and medical history
- Extent of the disease (location, size, and growth rate of the aneurysm)
- Your signs and symptoms
- Your tolerance of specific medications, procedures, or therapies
- Expectations for the course of the disease
- Your opinion or preference
Treatment options for an aneurysm may include one or more of the following:
- Routine ultrasound procedures. These procedures will monitor the size and rate of growth of the aneurysm every 6 months to 12 months as part of a “watchful waiting” approach for smaller aneurysms.
- Controlling or modifying risk factors. Steps such as quitting smoking, controlling blood sugar if diabetic, losing weight if overweight or obese, and controlling dietary fat intake may help to control the progression of the aneurysm.
- Medication. Medication can control factors such as hyperlipidemia (elevated levels of fats and cholesterol in the blood) and/or high blood pressure.
- Aneurysm open repair. An incision is made to directly visualize and repair the aneurysm. A cylinder- tube called a graft may be used to repair the aneurysm. Grafts are made of various materials, such as Dacron (textile polyester synthetic graft) or polytetrafluoroethylene (PTFE, nontextile synthetic graft). This graft is sewn to the involved blood vessel, connecting 1 end of the artery at the site of the aneurysm to the other end. The open repair is considered the surgical standard for an abdominal aortic aneurysm repair
- Endovascular aneurysm repair (EVAR). EVAR is a procedure that requires only small incisions in the groin along with the use of X-ray guidance and specially-designed instruments to repair the aneurysm. With the use of special endovascular instruments and X-ray images for guidance, a stent-graft is inserted via the femoral artery and advanced up into the aorta to the site of the aneurysm. A stent-graft is a long cylinder- tube made of thin metal mesh framework (stent), while the graft is made of various materials, such as Dacron or PTFE. The graft material may cover the stent. The stent helps to hold the graft open and in place.
#TomorrowsDiscoveries: Johns Hopkins researchers have identified the genes responsible for aortic ballooning and the sequence of events leading to aortic aneurysms. Dr. Hal Dietz currently conducts clinical trials of therapies for people with inherited aortic aneurysms to improve health and quality of life for these patients.
Abdominal Aortic Aneurysm Repair
Your doctor may recommend abdominal aortic aneurysm (AAA) repair to treatan aneurysm. An aneurysm is a bulging, weak spot in the aorta that may beat risk for rupturing. In this case, the aneurysm is in part of the aortathat is in the abdomen. Repair of an AAA may be done in one of two ways:
Open repair. For this surgery, your doctor makes a large incision in the abdomen to expose the aorta. Once he or she has opened the abdomen, a graft can be used to repair the aneurysm. Open repair remains the standard procedure for an abdominal aortic aneurysm repair.
Endovascular aneurysm repair (EVAR). This is a minimally invasive option. This means it is done without a large incision. Instead, the doctor makes a small incision in the groin.
He or she will insert special instruments through a catheter in an artery in the groin and thread them up to the aneurysm.
At the aneurysm, your doctor will place the stent and graft to support the aneurysm.
The doctor will determine which procedure is right for y
Johns Hopkins’ expert vascular surgeons can provide minimally-invasive aneurysm repair, with shorter hospital stays and quicker recovery. They even perform a hybrid surgery for those who aren’t eligible for the least invasive procedure but can’t have open surgery.
An AAA may need repair for the following reasons:
To prevent the risk of rupture
To relieve symptoms
To restore a good blood flow
Size of aneurysm greater than 5 centimeters in diameter (about 2 inches)
Growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over 1 year
When risk of rupture outweighs the risk of surgery
Emergency life-threatening bleeding
There may be other reasons for your doctor to advise an AAA repair.
What are the risks of AAA repair?
As with any surgical procedure, complications can occur. Some possiblecomplications may include:
Irregular heart rhythms
Bleeding during or after surgery
Injury to the bowel
Loss of blood flow to legs or feet from a blood clot
Infection of the graft
Spinal cord injury
Damage to surrounding blood vessels, organs, or other structures
Loss of blood flow to leg or feet from a blood clot
Groin wound infection
Groin hematoma (large blood-filled bruise)
Endoleak (continual leaking of blood the graft and into the aneurysm sac with potential rupture)
Spinal cord injury
Tell your doctor if you are allergic to or sensitive to any medicines,contrast dyes, iodine, or latex.
There may be other risks depending on your specific medical condition. Besure to discuss any concerns with your doctor before the procedure.
Ask your healthcare provider to tell you what you need to do before yourprocedure. Below is a list of common steps that you may be asked to do.
Your doctor will explain the procedure to you and let you ask questions.
If you smoke, stop smoking as soon as possible before the procedure. This will improve your recovery and your overall health.
Tell your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medicines, aspirin, or other medicines that affect blood clotting. You may be told to stop these medicines before the procedure.
Tell your doctor if you are pregnant or think you might be.
Tell your doctor if you are sensitive to or are allergic to any medicines, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).
Tell your doctor of all medicines (prescribed and over-the-counter) and herbal supplements that you take.
You will be asked to fast for 8 hours before the procedure, generally after midnight.
Your doctor may do a physical exam to be sure you can safely undergo the procedure. You may also undergo blood tests and other diagnostic tests.
You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
You may receive a sedative before the procedure to help you relax.
How is AAA open repair done?
You will lie on your back on the operating table.
The anesthesiologist will monitor your heart rate, blood pressure, breathing, and oxygen level during the surgery. Once you are sedated, your doctor will insert a breathing tube through your throat into your lungs and connect you to a ventilator. This will breathe for you during the surgery.
A healthcare provider will insert a catheter into your bladder to drain urine.
A healthcare provider will clean the skin over the surgical site with an antiseptic solution.
Once all the tubes and monitors are in place, the doctor will make an incision (cut) down the center of the abdomen from below the breastbone to below the navel. Or, across the abdomen from underneath the left arm across to the center of the abdomen and down to below the navel.
The doctor will place a clamp on the aorta above and below the site of the aneurysm. This will temporarily stop the flow of blood.
The doctor will cut open the aneurysm sac and suture into place a long tube called the graft. This will connect both ends of the aorta together.
Your doctor will remove the clamps and he or she will wrap the wall of the aneurysm around the graft. Your doctor will then suture the aorta back together and close the chest with stitches.
Your provider will apply a sterile bandage.
After an open procedure, your doctor may insert a tube through your mouth or nose into your stomach to drain stomach fluids.
You will be moved from the operating table to a bed, then taken to the intensive care unit (ICU) or the postanesthesia care unit (PACU).
How is EVAR done?
You will be placed on your back on the operating table.
The anesthesiologist will monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, your doctor may insert a breathing tube through your throat into your lungs and connect you to a ventilator. This will breathe for you during the surgery.
The doctor may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medicine delivered through an epidural (in the back) to numb the area to be operated on.
You will receive medicine to help you relax and analgesic medicine for pain relief. The doctor will be able to talk to you during the procedure.
The doctor will determine which type of anesthesia is appropriate.
The doctor will make an incision in each groin to expose the femoral arteries. Using fluoroscopy (a type of X-ray “movie” that sends images to a TV- monitor), the doctor will insert a needle into the femoral artery. Then he or she will thread a guide wire to the aneurysm site. Your doctor will remove the needle and slide a sheath over the guide wire.
Your provider will inject contrast dye to see the position of the aneurysm and the blood vessels next to it.
The doctor will use special endovascular instruments and X-ray images for guidance. He or she will insert a stent-graft through the femoral artery and advance it up into the aorta to the site of the aneurysm.
He or she will expand the stent graft and attach it to the wall of the aorta.
Your provider will inject dye again to check for blood leaking out into the aneurysm area.
If your doctor sees no leaks, he or she will remove all of the instruments.
Your doctor will suture the incisions back together and apply a sterile bandage or dressing.
In the hospital after AAA open repair
After the procedure, a member of the surgical team will take you to therecovery room or the intensive care unit (ICU) to be closely watched. Youwill be connected to monitors that will display your heart activity, bloodpressure, breathing rate, and your oxygen level.
You may have a tube in your throat to help you breathe until you canbreathe on your own.
As you continue to wake up from the anesthesia andstart to breathe on your own, a healthcare provider will adjust thebreathing machine to allow you to take over more of the breathing.
When youare awake enough to breathe completely on your own and you are able tocough, the healthcare provider will remove the breathing tube.
After the breathing tube is out, your nurse will help you cough and takedeep breaths every 2 hours. This may be uncomfortable due to soreness, butit is very important that you do this to keep mucus from collecting in yourlungs. This can lead to pneumonia. Your nurse will show you how to hug apillow tightly against your chest while coughing to help ease thediscomfort.
Your nurse may give you pain medicine as needed.
You may be on IV medicines to help your blood pressure and your heart, andto control any problems with bleeding. As your condition stabilizes, yourdoctor will gradually decrease then discontinue these medicines as yourcondition allows.
Once your provider removes the breathing tube and your condition hasstabilizes, you may start liquids to drink. Your diet will move graduallyto more solid foods as you are able to handle them.
If you have a drainage tube in your stomach, you will not be able to drinkor eat until the tube is removed. Your provider will remove the drainagetube when your intestines work again. This is usually a few days after theprocedure.
When your doctor decides that you are ready, you will be moved from the ICUto a postsurgical nursing unit. Your recovery will continue here. Youractivity will be gradually increased as you get bed and walk aroundfor longer periods.
Arrangements will be made for discharge from the hospital. This willinclude prescriptions for new medicines and directions for a follow-upvisit with your doctor.
In the hospital after EVAR
A member of the surgical team may take you to the intensive care unit (ICU)or a postanesthesia care unit (PACU). You will be connected to monitorsthat will display your heart activity, blood pressure, breathing rate, andyour oxygen level.
You will remain in either the ICU or PACU for a time and then moved to aregular nursing care unit.
Your nurse will give you pain medicine or you may have had an epidural.This is anesthesia that is infused through a thin catheter into the spacethat surrounds the spinal cord in the lower back. It causes numbness in thelower body, abdomen, and chest.
Your activity will be gradually increased as you get bed and walkaround for longer periods. You will start solid foods as you can handlethem.
Arrangements will be made discharge from the hospital. This may includeprescriptions for new medicines and directions for a follow-up visit withyour doctor.
Once you are home, it will be important to keep the surgical area clean anddry. Your doctor will give you specific bathing instructions. Your doctorwill remove the sutures or surgical staples during a follow-up officevisit, if they were not before leaving the hospital.
The surgical incision may be tender or sore for several days after ananeurysm repair procedure. Take a pain reliever for soreness as advised byyour doctor.
You should not drive until your doctor tells you it's OK. Other activityrestrictions may apply.
Tell your doctor if you have any of the following:
Fever or chills
Redness, swelling, or bleeding or other drainage from the incision site
Increase in pain around the incision site
Your doctor may give you other instructions after the procedure, dependingon your particular situation.
Before you agree to the test or the procedure make sure you know:
The name of the test or procedure
The reason you are having the test or procedure
What results to expect and what they mean
The risks and benefits of the test or procedure
What the possible side effects or complications are
When and where you are to have the test or procedure
Who will do the test or procedure and what that person’s qualifications are
What would happen if you did not have the test or procedure
Any alternative tests or procedures to think about
When and how will you get the results
Who to call after the test or procedure if you have questions or problems
How much will you have to pay for the test or procedure