Abdominal Aortic Aneurysm (AAA) Repair

When the wall of a blood vessel weakens, a balloon-like dilation called an aneurysm sometimes develops. This happens

FAIRLY COMMON

Every year, 200,000 people in the U.S. are diagnosed with an abdominal aortic aneurysm (AAA).

A ruptured AAA is the 15th leading cause of death in the country, and the 10th leading cause of death in men older than 55.

FAMILY HISTORY IS IMPORTANT

Aneurysms run in families. If a first-degree relative has had an AAA, you are 12 times more likely to develop an abdominal aortic aneurysm. Of patients in treatment to repair an AAA, 15–25% have a first-degree relative with the same type of aneurysm.

SYMPTOMS MAY BE ABSENT

In most cases, abdominal aortic aneurysms cause no symptoms and are found when you are being evaluated for another medical condition.

SUDDEN, SEVERE ABDOMINAL OR BACK PAIN

If you have a family history of AAA and feel sudden, severe pain in your abdomen or back, seek immediate care. These symptoms may signal that you have developed an AAA, possibly one in process of rupturing.

PAIN, DISCOLORED SKIN, SORES ON FEET AND TOES

A small percentage of patients with AAA have these symptoms when plaque or blood clots from elsewhere in the body collect in the feet and toes. 

Causes

  Many factors contribute to AAA formation.

  • Some type of inflammation that causes a weakening of the wall of the aortic artery.
  • Men older than 60
  • Smokers
  • Caucasians and anyone with a first-generation relative who has developed an AAA are at highest risk for an abdominal aortic aneurysm
  • Age (50+ for men, 60+ for women) and a history of atherosclerosis, high blood pressure, elevated cholesterol, heart or peripheral vascular disease and tobacco use are all associated with AAA formation.
  • Other potential factors associated with AAA formation include tears in the arterial wall, infections, and congenital connective tissue disorders.

Diagnosis  

YOU MAY NEED TO SEE A VASCULAR SURGEON.

Most AAAs cause no symptoms and are found incidentally, during an evaluation for another medical condition. If you are affected, see a vascular surgeon.

IMAGING TESTS MAY BE NEEDED

An abdominal ultrasound is painless, cost-effective, safe and the most frequently utilized test to screen for and measure the size of an AAA.

Computed tomographic angiography (CTA) will assess aneurysm size, location and the extent of impact. This study requires exposure to radiation and injection of an intravenous contrast agent. However, a CTA provides valuable anatomic information and can help your vascular surgeon determine the optimal type of repair. 

Treatments

Treatment depends on the size of the aneurysm.

SMALL AAAs (LESS THAN 5 CM IN DIAMETER) – have a very low risk of rupturing but should be watched.

  • It is important to have an ultrasound test every 6–12 months to monitor for aneurysm growth and risk of rupture.
  • Lifestyle changes that help control blood pressure and medication may help you. 
  • If you smoke, ask your vascular surgeon to help you find a smoking cessation program that will work for you.
  • Daily exercise is also beneficial.

LARGER (MORE THAN 5.0-5.5 CM IN DIAMETER) – rapidly enlarging and AAAs causing symptoms are usually repaired.

  • Open surgery requires placement of a prosthetic graft.
  • The vascular surgeon accesses the affected portion of the aortic artery through an incision in your abdomen.
  • Most patients stay in the hospital 4–10 days. 
  • Recovery time may be up to 3 months.

Endovascular aneurysm repair (EVAR) – is a less invasive treatment.

  • Two small groin incisions are made. Guided by X-ray imaging, the vascular surgeon introduces a tiny device into the artery. The device is used to reinforce the artery wall and exclude the aneurysm. 
  • Most patients stay in the hospital 1–3 days. Recovery time is shorter than with open surgery. 

EVAR
Endovascular Repair of Abdominal Aortic Aneurysms (AAA)

Endovascular repair is a preferred treatment for many people with an abdominal aortic aneurysm (AAA), and an alternative for some who do not qualify for open surgery.

How an AAA is repaired varies depending on location, which then classifies the procedure as either STANDARD or COMPLEX. (Refer to “Description” below.)

Why It’s Done
Endovascular repair is less invasive than open surgery because it avoids a large incision in your abdomen or chest; only very small incisions are required. That means you are able to recover more quickly.
In deciding whether to recommend repair your surgeon will consider the size of the aneurysm, its location, how fast it is growing, how complicated it is to repair and your overall health.

STANDARD REPAIR for an aneurysm located below the arteries to the kidney (infra-renal AAA):

  • Through a needle puncture or small incision in one or both of your groin arteries and guided by X-ray images, a thin tube (catheter) is inserted and advanced to the aneurysm site.
  • A guide wire and an expandable stent graft (a fabric-covered wire frame) are advanced through the thin tube.
  • When positioned correctly, the stent graft is allowed to expand within the artery. The wire frame pushes against the healthy portion of the aorta to seal the device in place.
  • Once in place, blood flows through the stent graft and cannot enter the aneurysm.
  • Some patients may also require a puncture or small incision into an artery in the upper arm.
  • The procedure usually takes 1.5–2.5 hours and most patients leave the hospital in 1–5 days.

COMPLEX REPAIR for an aneurysm affecting one or more of the important arteries that branch off the aorta.  Following the same steps as above, a different type of graft is placed.

  • A fenestrated graft gets its name from tiny cutouts that allow the graft to flex and align with the branching of arteries, and also be modified to accommodate your specific anatomy. 
  • It is important that the graft fit your anatomy. 
  • Sometimes a standard commercially manufactured, FDA-approved device can be used. If you are not eligible for a standard device, you may qualify for a research device that is custom-made specifically for you
  • The procedure usually takes from 3–8 hours.

Risks
There is less risk of developing lung, heart or abdominal problems during or after surgery.
There is less risk developing an infection.

How to Prepare

IMAGING TESTS MAY BE NEEDED
  • An abdominal ultrasound is painless, cost-effective, safe and the most frequently utilized test to screen for and measure the size of the AAA.
  • Computed tomographic angiography (CTA) will assess for aneurysm extent, size and location. This study requires exposure to radiation and injection of an intravenous contrast agent. However, a CTA will provide valuable anatomic information and help your vascular surgeon determine the optimal type of repair.  

Staying Healthy

  • If you have an aortic aneurysm it is important to do all you can to stay healthy.
  • Stop smoking. Ask your vascular surgeon to help you find a smoking cessation program that will work for you.
  • Exercise regularly.
  • Carefully manage your blood pressure and cholesterol levels.
  • Take a daily anti-platelet medicine (aspirin) and cholesterol-reducing medicine (statin).