Abdominal Aortic Aneurysm

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EVAR Information Leaflet
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Open AAA Information Leaflet
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Open AAA Repair.pdf
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Back Pain and/or Bulging Tummy

An abdominal aortic aneurysm (AAA) is an abnormal swelling of the major artery from the heart that supplies the body with blood. The condition affects 5% of people over the age of 60 and men are four times more likely to develop one. It is very important that AAA is recognised because in a small percentage of cases the artery swells so much that it can burst which has an 80% risk of death.

 

How do I know if I have a AAA?

           

YOU MAY NOT 75% of AAAs have NO symptoms (asymptomatic).

 

IT IS PICKED UP BY TESTS FOR OTHER PROBLEMS patients who have x–rays, ultrasound, CT or MRI scans of the abdomen may have their AAA diagnosed as an additional finding.

 

SCREENING PROGRAMME Men in England are now invited to attend a screening programme on their 65th birthday. This involves patients attending a screening centre where they have an ultrasound scan to look for a AAA.

 

SYMPTOMS – AAAs can occasionally cause symptoms including: Abdominal pain (that may be constant or come and go). Pain in the lower back that may radiate to the buttocks, groin or legs.  The feeling of a "heartbeat" or noticing a prominent “pulse” in the abdomen.

 

RUPTURE – As the size of the AAA increases the risk of it bursting escalates. Rupture is very serious and is accompanied by the following symptoms:    Sudden onset severe back or abdominal pain. Rapid heart rate and dizzyness. Loss of consciousness. Nausea and vomiting.

 

 

What is an Abdominal Aortic Aneurysm (AAA)?

An aneurysm is an abnormal widening of a blood vessel by more than 50% of its diameter. They can occur in any blood vessel in the body, however the most common location is the aorta. This is the largest artery in the body carrying blood directly from the heart to all organs and limbs. The aorta must have a width of over 3cm in men and 2.5 cm in women to be considered an aneurysm

Currently in the UK, aneurysms are present in about 1.4% of the population, which increases to 5% in those aged over 60 years. Risk factors for developing and aneurysm include:

 

Being male.

Old age.

High blood pressure.

Poorly controlled diabetes.

High cholesterol.

Genetic conditions (e.g Marfans disease)

 

How is an abdominal aortic aneurysm diagnosed?

If this condition is suspected your Vascular Alliance consultant will obtain a history from you. They will ask you about possible symptoms, other medical conditions and establish if you have any risk factors. You abdomen, groins and legs will be examined to test the pulses and feel for an aneurysm. It is routine for you to undergo an ultrasound of the abdomen. This painless non–invasive test takes 10 minutes to complete and a result can be given to you at the time.

 

What happens if a AAA is found?

Most abdominal aortic aneurysms do not require immediate treatment. The majority of patients enter what is known as a “surveillance programme”. This means that you will attend at 6 monthly intervals for repeat ultrasound scans to assess whether the aneurysm has increased in size.

As the width of an aneurysm increases the wall of the artery becomes thinner with a consequent increased risk of rupture. Abdominal aortic aneurysms require treatment when their risk of rupture becomes higher than the risk that a curative operation or procedure poses. In most cases this point comes when the AAA has a 5.5cm diameter. As a result most patients have repeated “surveillance scans” until the aneurysm reaches this size at which point treatment options will be considered.

 

When a therapeutic intervention is being considered a CT scan will be organised for you to more accurately map the size, shape and nature of the aneurysm. This non–invasive scan takes 10–15 minutes to complete that will help determine which method of treatment is best for you.

 

When does an Abdominal Aortic Aneurysm (AAA) require Intervention?

The following are indications for treatment of your aneurysm:

 

An aneurysm greater than 5.5cm in size.

A symptomatic aneurysm with back pain or tenderness.

Aneurysms which grow at a rate of more than 1cm per year.

When small clots that form within the aneurysm break away and cause a blockage in smaller arteries of the leg, feet or toes. This can result in small areas of dead tissue.

 

Treatment Options

Once your AAA has been assessed and it has been decided that treatment is required, your consultant will discuss treatment options with you. There are 2 main forms of treatment that are offered:

           

Open Surgery.

EVAR EndoVascular Aneurysm Repair.

 

Open Surgery

 

What is it?

This is the traditional treatment for an abdominal aortic aneurysm. It is performed under a general anaesthetic and requires a large abdominal cut (incision). You will be admitted to hospital the day before your surgery and will spend a small period of time on the intensive care unit afterwards. Most patients spend a total of a week to ten days in hospital before they are discharged. The operation takes 90 minutes to 3 hours and the diseased part of the aorta is removed and replaced by an artificial vessel called a “graft” which is stitched onto healthier parts of the artery.

 

Before the Operation

You will be seen several weeks before your treatment for a pre-operative assessment. A number of blood tests will be taken and you will have a chest x–ray and an ECG (tracing of the heart rhythm).

 

An anaesthetist may consult with you to optimise medications you may be taking for diabetes, heart and lung disease.

 

As you will have a general anaesthetic, you should not eat for 6 hours prior to treatment. However, you may drink “clear fluids” like water up to 2 hours before.

 

Your surgeon will visit you before the operation and ask you to sign a consent form once he has explained the procedure to you.

 

Once you are asleep, various tubes will be inserted into your bladder, wrist artery and arm veins. This will allow you to be accurately monitored and fluid to be administered. Most patients also have a tube placed into the back called an “epidural” for pain relief.

 

You may require a blood transfusion either during or after the operation. In most cases your own blood lost during the operation can be given back to you but blood from donors may also be needed. (Please make your consultant aware as early as possible if you have personal or religious concerns regarding this issue.)

 

How is Open Surgery performed?

Once you are asleep, a central vertical incision will be made in your abdomen from just below the ribs to below the belly button. The surgeon will then expose the aorta and apply a clamp above and below the aneurysm so that a repair can be performed without substantial blood loss. The aneurysm is then opened and an artificial tube called a “graft” is stitched to healthy artery identified at either end. The graft can be a straight tube or an upside down “Y” shape depending on the size and shape of the aneurysm.

Once in place the clamps are taken off one at a time to ensure the joins do not leak. The old wall of the aneurysm is loosely closed with stitches around the new stent. It is common for 1 or 2 tubes called “drains” to pierce the skin and enter the abdomen where they drain fluid or blood in the days after the operation. The wall of the abdomen is closed with strong stitches and the skin with metal staples. A dressing is applied and you will wake up in the recovery area or intensive care unit (ITU).

 

After the Operation

 

After your operation you will be given fluids by a drip in one of your veins until you are well enough to sit up and take fluids and food by mouth.

 

When you are stable and require no additional breathing or heart support you will be transferred from ITU back to the ward.

 

The nurses and doctors will try and keep you free of pain by giving pain killers by injection, via the epidural tube in your back, or by a machine that you are able to control yourself by pressing a button.

 

You will be given a daily injection of heparin under the skin to reduce the risk of clotting in your veins (known as “deep vein thrombosis”).

 

Within 2 to 5 days, the drip (intravenous fluids), epidural, abdominal drains and bladder catheter will be removed.

 

You will become gradually more mobile until you are fit enough to go home.

 

The physiotherapists may visit you after your operation. They will help you with your breathing to prevent you developing a chest infection and with your mobilisation to get you walking again.

 

The nurses will remove your stitches (if necessary) or metal skin clips 7 – 10 days after your operation. They will also check your wound and should continue to change dressings until the wound is healing nicely.

You may feel tired for many months after the operation but this should gradually improve as time goes by until you are back to normal by 6 months.

 

Most people that require aneurysm repair are retired but if you are still working you will need a minimum of 4 to 6 weeks recuperation.

 

You should refrain from driving for at least for 6 weeks after open repair or until you can competently perform an emergency stop under controlled conditions.

 

You should avoid heavy lifting for at least 6 weeks after the operation. This is to protect your scars and avoid hernias.

 

You should be able to bathe and shower lightly whilst your wounds are healing, although it is not advised to fully immerse non healed wounds in a bath.

 

Sexual Activity: You should be able to resume normal sexual activity as soon as you feel comfortable to do so. If you have any problems in this area you should seek advice from your GP or at follow up consultation with the surgeon. Impotence is a recognised problem of open aneurysm repair and you should ask more about this if you are concerned.

 

Your consultant will organise a follow–up appointment with you after 6 weeks to discuss your treatment and assess your recovery.

 

Success rates with Open Surgery

 

Surgery is definitive because the diseased artery is disconnected and consequently it cannot recur. However, it is a major operation with a 2-5% risk of death in the post–operative period mostly due to heart, kidney or lung problems. Consequently, open aneurysm repair is only performed when the risk of death from aneurysm rupture is higher than that from surgical repair.

 

Risks of Open Surgery

Surgery is a proven treatment option for abdominal aortic aneurysms however, there are risks associated with the procedure that can be split into 2 groups:

 

General Complications:

 

Medical Complications As with any major operation there is a small risk of you having a medical complication such as a heart attack, stroke, kidney failure, or chest problems post–operatively. Each of these is rare, but a small number of patients have fatal complications after their operation. For most patients this risk is about 5%. You will be monitored closely after the operation for any of these and appropriate treatment started promptly.

Chest infections – These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.

Blood clots in the legs (DVT) and lungs (PE) After any large operation there is a risk of DVT or PE. You will be given injections under the skin to reduce the risk, but this cannot be completely negated.

 

Operation related Complications

 

Bleeding – Less than 1% of patients have significant bleeding from the graft after the operation. This may require an urgent further surgery to repair the problem.

Wound infection – Wounds sometimes become infected particularly those in the groin. This may need treatment with antibiotics.

Graft infection – Very rarely (about 1 in 500), the artificial graft may become infected. This is a serious complication, and requires long term intravenous antibiotic therapy.

Bowel problems Occasionally the bowel is slow to start working again after the operation. During this time (usually 3 – 5 days) you may feel nauseous or even vomit. Fluids will be provided in a drip until your bowels get back to normal and no other treatment is required. In a very small percentage of cases the blood supply to parts of the bowel can be lost. This may require further surgery to remove any dead bowel.

Sexual dysfunction – Rarely the nerves that are important in obtaining an erection are damaged during the procedure.

Hernias – The abdominal muscles are cut to gain access to the abdomen. Though they are rejoined with stitches a residual weakness is left and in some cases a hernia can develop. That is why it is important not to perform any heavy lifting for 6 weeks after the operation.

Limb loss Very rarely when clots form within the graft they break off and block arteries within the legs. This may require a further procedure to treat the blockage. Rarely circulation cannot be restored and blood supply to the foot is so badly affected that amputation is required.

 

2. EndoVascular Aneurysm Repair (EVAR)

 

What is it?

EVAR is a newer form of treatment for AAAs that began in the 1990s. Its advantage is that it is much less invasive than open surgery which means that patients have fewer complications and make a faster recovery. It does not require an admission to the intensive care unit and most patients are home within 3 – 5 days of their procedure.

EVAR is a joint procedure between a consultant vascular surgeon and a radiologist. 2 small cuts are made in the groin in order to access the artery. A special tube called a “stent” is then fed up the artery until it sits along the length of the aneurysm. The stent ensures that blood can only flow down the tube and no longer through the AAA. Consequently the AAA is prevented from enlarging further or bursting.

EVAR is usually performed with patients that are awake but numb from the waist down thanks to an anaesthetic tube in the back. However, it can also be completed under a general anaesthetic.

 

Before the Procedure

After your AAA is diagnosed you will undergo a CT scan (a test involving  x–rays) that will accurately map the anatomy of your aorta and the arteries arising from it. Only 50 – 60% of AAAs are suitable for treatment with EVAR based on the shape and angulation of the aneurysm seen on the CT scan.  Patients in the remaining 40% will only be suitable for open surgical treatment. Your consultant will discuss your CT scan result with you and advise you on which treatment is appropriate for you.

Those undergoing an EVAR procedure will be seen several weeks before treatment for a pre–operative assessment. A number of blood tests will be taken and you will have a chest x–ray and an ECG (tracing of the heart rhythm). An anaesthetist may consult with you to optimise medications you may be taking for diabetes, heart and lung disease.

You should not eat for 6 hours prior to treatment. However, you may drink “clear fluids” like water up to 2 hours before.

Your surgeon will visit you before the procedure and ask you to sign a consent form once he has explained the treatment to you.

 

How is EVAR performed?

You will first be taken to an anaesthetic room in the operating theatre department. Once there an anaesthetist will place a tube into your back that will make you numb from the waist down or if you are having a general anaesthetic put you to sleep. Other tubes will be inserted into your bladder and arm veins. This will allow you to be given fluids and monitored during the procedure.

You will then be moved into the operating theatre. 2 cuts will be made in the groin, one on each side and you surgeon will then expose the femoral (leg) artery. A needle will then be inserted into the artery. This allows x–ray dye called “contrast” to be administered which will give you a warm feeling each time it is given and may make you feel the need to pass water. This is entirely normal.

Guide wires will then be directed up the artery into the pelvis and then the abdomen using x–rays. The stent is fed over this wire and placed so that it runs from healthy artery above, down the full length of the aneurysm to healthy artery below. Once positioned appropriately the stent is “deployed” so that it forms a tight seal and is held in place. X–rays are used throughout the procedure to confirm placement.

Once completed, the wires and needles are removed from the groin arteries. Stitches will be used to close the wound and those in the skin will be dissolvable so you do not have to have these taken out at any point. The wound will be covered with a dressing and you will return to the ward where you will be monitored closely overnight.

 

After the Procedure

 

You will need to stay in bed overnight for monitoring and to protect the groin wounds.

 

You will be given food and water when you get back to the ward. Drinking is encouraged to flush the x–ray contrast out of your kidneys.

 

If all is well the morning after the procedure, the various tubes (into bladder and veins etc) can be removed and you will be encouraged to start walking around.

 

You will be given a daily injection of heparin under the skin to reduce the risk of clotting in your veins (known as “deep vein thrombosis”).

 

You should start or continue to take a daily aspirin and statin tablet for life to reduce the risk of heart attacks and strokes.

 

Most patients go home 3 5 days after the treatment.

 

Most people that require aneurysm repair are retired but if you are still working you will need a minimum of 4 to 6 weeks recuperation.

 

You should refrain from driving for at least for 2 4 weeks after EVAR or until you can competently perform an emergency stop under controlled conditions.

 

You should avoid heavy lifting for at least 2 weeks after the operation. This is to protect your scars and avoid hernias.

 

You should be able to bathe and shower lightly whilst your wounds are healing, although it is not advised to fully immerse non healed wounds in a bath.

 

Your consultant will organise a follow–up appointment with you after 6 weeks to discuss your treatment and assess your recovery.

 

You will enter a long term surveillance programme where you will have scans (ultrasound and CT scans) at certain intervals: at 3, 6 and 12 month initially and then yearly after. This is to make sure that the stent remains in its position and excludes the aneurysm from any blood flow.

 

Success rates with EVAR

EVAR is an excellent treatment for abdominal aortic aneurysms with proven success rates of 92 95%. Its main advantages over open surgery are reduced mortality after treatment (1 2% vs 5 7%) and reduced length of hospital stay (3 5 days vs 7 10 days). Unfortunately, EVAR patients require lifelong surveillance to detect and treat a complication of the treatment known as “endoleak”. This is when blood leaks between the stent and the artery wall into the aneurysm, thereby putting it back at risk of rupture. Around 10% of EVAR patients will need additional keyhole procedures to treat an endoleak.

 

Risks of EVAR

Generally EVAR patients have fewer problems and a quicker recovery than patients undergoing open surgery. Complications can be split into 2 areas:

 

General Complications:

 

Medical Complications As with any major operation there is a small risk of you having a medical complication such as a heart attack, stroke, kidney failure, or chest problems post–operatively. Each of these is rare, but a small number of patients have fatal complications after their operation. For most patients this risk is about 5%. You will be monitored closely after the operation for any of these and appropriate treatment started promptly.

 

Chest infections These can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy.

 

Blood clots in the legs (DVT) and lungs (PE) After any large operation there is a risk of DVT or PE. You will be given injections under the skin to reduce the risk, but this cannot be completely negated.

 

Operation related Complications

 

Endoleak – When blood leaks between the stent and the artery wall into the aneurysm, thereby putting it back at risk of rupture. All patients enter a surveillance programme after EVAR treatment and 10% will need additional keyhole procedures to treat an endoleak.

 

Procedure Failure – Up to 5% of EVARs fail because of technical reasons or difficult anatomy. This may necessitate a future open operation or very rarely conversion to an open operation in the same sitting.

 

Bleeding – Less than 1% of patients have significant bleeding from the groin after the operation. This may require an urgent further surgery to repair the problem.

 

Wound infection – Wounds sometimes become infected and may need treatment with antibiotics.

 

Graft infection – Very rarely (about 1 in 500), the artificial graft may become infected. This is a serious complication, and requires long term intravenous antibiotic therapy.

 

Bowel problems Occasionally the bowel is slow to start working again after the operation. During this time (usually 3 – 5 days) you may feel nauseous or even vomit. Fluids will be provided in a drip until your bowels get back to normal and no other treatment is required. In a very small percentage of cases the blood supply to parts of the bowel can be lost. This may require further surgery to remove any dead bowel.

 

Limb loss Clots can form within the stent. Pieces can subsequently break off and block arteries within the legs. This may require a further procedure to treat the blockage. Rarely circulation cannot be restored and blood supply to the foot is so badly affected that amputation is required.

 

Contrast related Complications:

 

Allergic Reaction Some patients experience an allergic reaction to the X–ray contrast. In most cases this is minor but very rarely (1 in 3000) a reaction may be severe and require urgent treatment with medicines.

Kidney Injury – The x–ray contrast can affect the kidney function. If you are likely to be at risk of this, special precautions will be taken to reduce the chances of this problem occurring. If you are a diabetic on Metformin tablets, you should not take this on the day of the procedure and for 48 hours after the procedure.

How to contact us

Professor M Baguneid

Consultant Vascular Surgeon

Email: admin@vascularsurgery.org.uk

Web: www.vascularsurgery.org.uk

 

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