Abdominal Aortic Aneurysm Repair

What is an abdominal aortic aneurysm repair?

Your doctor may recommend abdominal aortic aneurysm (AAA) repair to treat an aneurysm. An aneurysm is a bulging, weak spot in the aorta that may be at risk for rupturing. In this case, the aneurysm is in part of the aorta that 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 you.

Why might I need AAA repair done?

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 possible complications may include:

Open repair

• Heart attack
• Irregular heart rhythms
• Bleeding during or after surgery
• Injury to the bowel
• Loss of blood flow to legs or feet from a blood clot
• Blood clot
• Infection of the graft
• Lung problems
• Kidney damage
• Spinal cord injury

EVAR

• Damage to surrounding blood vessels, organs, or other structures
• Kidney damage
• Loss of blood flow to leg or feet from a blood clot
• Groin wound infection
• Groin hematoma (large blood-filled bruise)
• Bleeding
• Endoleak (continual leaking of blood out of 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. Be sure to discuss any concerns with your doctor before the procedure.

How do I get ready for AAA repair?

Ask your healthcare provider to tell you what you need to do before your procedure. 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 the AAA done?

How is AAA open repair done?

1. You will lie on your back on the operating table.
2. 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.
3. A healthcare provider will insert a catheter into your bladder to drain urine.
4. A healthcare provider will clean the skin over the surgical site with an antiseptic solution.
5. 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.
6. 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.
7. 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.
8. 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.
9. Your provider will apply a sterile bandage.
10. After an open procedure, your doctor may insert a tube through your mouth or nose into your stomach to drain stomach fluids.
11. 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?

1. You will be placed on your back on the operating table.
2. 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.
3. 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.
4. 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-like 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.
5. Your provider will inject contrast dye to see the position of the aneurysm and the blood vessels next to it.
6. 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.
7. He or she will expand the stent graft and attach it to the wall of the aorta.
8. Your provider will inject dye again to check for blood leaking out into the aneurysm area.
9. If your doctor sees no leaks, he or she will remove all of the instruments.
10. Your doctor will suture the incisions back together and apply a sterile bandage or dressing.

What happens after the AAA repair?

In the hospital after AAA open repair

After the procedure, a member of the surgical team will take you to the recovery room or the intensive care unit (ICU) to be closely watched. You will be connected to monitors that will display your heart activity, blood pressure, breathing rate, and your oxygen level.

You may have a tube in your throat to help you breathe until you can breathe on your own. As you continue to wake up from the anesthesia and start to breathe on your own, a healthcare provider will adjust the breathing machine to allow you to take over more of the breathing. When you are awake enough to breathe completely on your own and you are able to cough, the healthcare provider will remove the breathing tube.

After the breathing tube is out, your nurse will help you cough and take deep breaths every 2 hours. This may be uncomfortable due to soreness, but it is very important that you do this to keep mucus from collecting in your lungs. This can lead to pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

Your nurse may give you pain medicine as needed.

You may be on IV medicines to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, your doctor will gradually decrease then discontinue these medicines as your condition allows.

Once your provider removes the breathing tube and your condition has stabilizes, you may start liquids to drink. Your diet will move gradually to 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 drink or eat until the tube is removed. Your provider will remove the drainage tube when your intestines work again. This is usually a few days after the procedure.

When your doctor decides that you are ready, you will be moved from the ICU to a postsurgical nursing unit. Your recovery will continue here. Your activity will be gradually increased as you get out of bed and walk around for longer periods.

Arrangements will be made for discharge from the hospital. This will include prescriptions for new medicines and directions for a follow-up visit 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 monitors that will display your heart activity, blood pressure, breathing rate, and your oxygen level.

You will remain in either the ICU or PACU for a time and then moved to a regular 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 space that surrounds the spinal cord in the lower back. It causes numbness in the lower body, abdomen, and chest.

Your activity will be gradually increased as you get out of bed and walk around for longer periods. You will start solid foods as you can handle them.

Arrangements will be made discharge from the hospital. This may include prescriptions for new medicines and directions for a follow-up visit with your doctor.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. Your doctor will remove the sutures or surgical staples during a follow-up office visit, if they were not before leaving the hospital.

The surgical incision may be tender or sore for several days after an aneurysm repair procedure. Take a pain reliever for soreness as advised by your doctor.

You should not drive until your doctor tells you it's OK. Other activity restrictions 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, depending on your particular situation.

Next steps

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