Treatment of Abdominal Aortic Aneurysm (AAA)

Is the less invasive form of surgery better than open surgery?

Doctor analyses scan of aneurism
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For anyone who has an abdominal aortic aneurysm (AAA), the goal of treatment is to prevent rupture. A ruptured aortic aneurysm is a fatal event if not treated immediately; and even with the best treatment the mortality rate is exceedingly high. So the goal is to keep a rupture from occurring.

Essentially, this means that many people with AAA should have elective surgical repair. If the AAA is large, if it is expanding relatively rapidly, or if it is causing abdominal or back pain (which would strongly indicate that it is expanding), surgical repair is strongly recommended.

What Is Surgery for AAA Like?

Standard, open-incision AAA repair is a major surgical procedure, performed under general anesthesia. The surgery requires a long incision, from the bottom of the breastbone to the pubic area. After locating the aneurysm, the surgeon clamps the aorta to shut off the blood flow, and resects the aneurysm. The aorta is repaired by inserting a synthetic graft to replace the part of the artery that has been removed.

The post-operative period is often fairly difficult, and generally requires a stay in the hospital of at least a week.

Complete recovery often takes up to two months. Depending on your other medical conditions, and the specific location of your aneurysm, serious complications are possible that involve the kidneys, intestines, legs, heart and lungs.

Is There a Less Invasive Form of AAA Repair?

Because the standard surgery to repair AAA is so daunting, extensive efforts have been made to perfect a less invasive type of surgical treatment.

The approach that has been developed is called endograft repair.

An endograft is a fabric-covered stent that is inserted by a special catheter via the femoral artery. The endograft is advanced to the site of the aneurysm and deployed to provide a new conduit for blood flow. That is, the AAA is not surgically resected; rather, it is isolated from the blood flowing within the aorta.

Because the aneurysm is no longer exposed to blood flow, rupture is theoretically no longer a risk.

Several endograft products have been developed by several companies, all using different materials and different deployment techniques. So far, none appears to be particularly superior to any of the others.

Is Endograft Repair Better Than Standard Surgery?

In general, there is good news and bad news about endograft repair for AAAs.

The surgical procedure with endograft repair is far less traumatic than with standard surgical repair, so the post-operative mortality is much lower, and the recovery time is much shorter and much less difficult. However, while the complications of standard surgery tend to occur very early after the operation (that is, while the patient is still in the hospital), complications with endograft repair tend to occur later.

These complications can include:

  • "Endoleak," in which the flow of blood into the AAA itself is not completely cut off by the endograft, so the AAA can continue to expand, and can even rupture.
  • "Postimplantation syndrome," a poorly-understood acute inflammatory syndrome which can cause fever and a generalized, sometimes rather severe, illness.
  • "Device migration," in which the endograft shifts its position within the aorta at some point in time after the surgical procedure. Device migration, which has been seen in more than 10% of patients after endograft repair in some studies, can cause serious problems, including rupture of the AAA.

So, while endograft repair yields better short-term results than the standard open surgical repair, the long-term complications of endografts soon "catch up," so that the likelihood of dying within a year of the procedure is almost exactly the same for both approaches.

When Is Endograft Repair Recommended Over Open Surgery?

In general, endograft repair of AAA is recommended in patients who are judged to have a very high post-operative risk with the standard surgical approach. If the risk of post-operative complications is not judged to be unusually high, most surgeons still prefer the open surgical approach.

The bottom line with AAA repair is that there is no free lunch. This is is why it is so important for anyone with an AAA to have a frank discussion with their doctors about their own individual risks before deciding on the optimal approach.

Is There Medical Treatment for AAA?

There is no medical treatment that will make an AAA go away, or shrink it. However, there are important non-surgical steps that anyone with an AAA should take. These include all the things people can do to reduce their cardiac risk, including maintaining a healthy weight, eating a healthy diet, getting regular exercise, controlling hypertension and cholesterol, and, especially, quitting smoking. Smoking is the strongest risk factor for AAA, and people who already have an AAA have a much higher risk of rupture if they continue to smoke.


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