The main goal of aortic aneurysm surgery is to prevent its most dangerous complication – aortic rupture. The decision to operate depends on the probability of aortic rupture, and the risk that the operation may present to each patient.
For example, in patients with manifesting symptoms (strong pain in the belly or back area, pulsating mass in the abdomen, low blood pressure, signs of bleeding), urgent surgery is required. However, because of the complexity of the operation, it is extremely important to create optimal conditions, which include stabilizing the state of the patient, having a sufficient blood supply, and assembling a team in the operating room.
Who is eligible for aortic aneurysm surgery?
When talking about patients with an already diagnosed aortic aneurysm, but without symptoms, the decision is based on the size of the aneurysm itself. For example, fusiform abdominal aortic aneurysms which measure less than four centimeters in diameter have a very small risk of rupture, unlike the ones measuring more than 5.4 cm in diameter, as well as all saccular aneurysms, which are all to be treated promptly. For those patients whose aneurysms measure between 4 and 5,4 cm, there are no explicit recommendations, so it is up to the surgeon to decide, based on available data of each patient.
What types of surgery are available for aortic aneurysm treatment?
Today, two main types of surgery are widely considered:
- Classic open surgery, which involves operating on a patient during a total anesthesia and replacing the whole aneurysmatic part of the aorta with a synthetic one.
- Endovascular aneurysm repair (EVAR) (or TEVAR, in thoracic aorta surgery), a minimally-invasive method, which uses stents placed inside of the problematic part of the aorta to strengthen its wall.
Other than these, new methods of aortic aneurysm treatment have emerged in the last 20 years, such as the “mini-laparotomy”, total laparoscopic surgery, and robotic surgery. Although they minimize the recovery time, the use of these methods is limited, especially in complicated cases.
Open-type surgery or open surgical repair (OSR)
Open surgical repair surgery means that the aorta is accessed through the abdomen, or chest, in case of thoracic aortic aneurysm.
Then, the parts of the aorta above and beneath the aneurysmatic part, as well as the branching arteries which supply other organs, need to be sutured for the blood to stay inside the vessels.
Other than that, in thoracic aortic aneurysm surgery, there is a potential problem with supplying brain with constant blood flow, which is solved by special external CBP (cardiopulmonary bypass) pumps.
After that, the problematic part of the aorta is replaced with a synthetic graft. The graft used in this type of surgery depends on the part of the aorta the procedure is taking place in, but most commonly it is a cylindric or a “Y” shaped tube, coated in biological materials, such as collagen, gelatin, and proteins.
Depending on where on the aorta the procedure takes place, other arteries branching from the aorta need to be re-implanted, so normal blood flow won’t be compromised. The advances in medical fields have made this method extremely safe, with excellent postoperative results.
Endovascular Aneurysm Repair (EVAR)
This minimally-invasive procedure involves implanting a special type of stent graft which is placed via a catheter that is pushed to the desired location through arteries located in the groin area. The entire procedure is extremely precise, mostly because it’s controlled with the help of fluoroscopy. Fluoroscopy is a method based on X-ray, and although the radiation is weaker compared to taking a chest X-ray, the flow of the rays needs to be constant to evaluate the position of the graft and the state of blood vessels in real time.
To plan this type of surgery, doctors need to precisely evaluate the condition of the blood vessels, which is done using multi-slice computed tomography (MSCT), another X-ray based method, which is also used to evaluate other possible issues that may ensue during the procedure.
Which of these procedures is better?
Patients treated via EVAR spend shorter time in intensive care units, and the length of their hospitalization is generally shorter, which makes it convenient for elderly patients. The amount of blood lost during EVAR is also significantly smaller than during OSR.
On the other hand, due to the rate of possible complications (such as leaks caused by an incomplete closing of the aneurysm, which can even cause rupture), EVAR often requires reinterventions during the first month. And let’s not forget the exposition to ionizing radiation because of fluoroscopy.
Furthermore, when comparing EVAR and OSR, EVAR shows less cardiac complication (such as arrhythmias or heart attacks), as well as significantly fewer digestive and urinary track issues, but shows frequent issues regarding blood vessel complications, such as blood clotting.
Sometimes, patients treated with EVAR show symptoms which are known as a “post-implantation syndrome”, characterized by high temperature, fatigue, back pain, and irregular blood cell count. This syndrome is usually treated by Aspirin, but nevertheless demands to be controlled regularly. Generally, patients treated with EVAR need to be checked on a regular basis for longer periods of time.
Quite unexpectedly, the possibility of infection in patients treated with EVAR and during OSR is more or less the same, as well as the patient’s quality of life. The thing is, although EVAR patients show better quality of life and longer survival rate during the initial post-operative period, both of these values tend to be the same when talking long-term recovery.
Finally, when talking about the price of the surgery itself, grafts used in OSR tend to be as 30 times as cheaper than endovascular grafts used in EVAR, meaning that some medical centers just can’t afford EVAR as a regular method.
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