Aortic aneurysm is a condition where a part of the aortic lumen is permanently expanded, characterized by the weakening of the aortic wall — which loses its flexibility, thereby reducing blood flow.
The main problem with this condition is that it usually doesn’t produce any symptoms until it’s potentially too late, resulting in complications, such as aortic rupture. Keeping in mind that the aorta is the main blood vessel in your body, with the role of carrying oxygen-rich blood directly from the heart to almost every other part of your body, the consequences of this internal bleeding can be fatal, with almost half of people with aortic rupture dying on their way to the hospital.
Currently, there are two main types of surgery dealing with aortic aneurysm repair, the first being classic open type surgery, and the relatively newer, minimally invasive approach, called endovascular aortic repair (EVAR). Although both of these types of surgery show satisfying results, open repair is being favored because of its low price and the possibility to treat more complicated cases, whereas EVAR is generally more convenient for patients because of shorter recovery period.
How is open surgical procedure performed?
Open surgical repair (OSR) involves the process of replacing the aneurysmatic part of the aorta with a synthetic one, called a graft. Because of the extent of this type of procedure, it is done under total anesthesia.
Depending on the location on the aneurysm, which can happen anywhere along the aorta, there are two main methods of surgery – open chest repair (in case of thoracic aortic aneurysms) and open abdominal repair (in abdominal aortic aneurysms).
1. Open chest repair
This type of surgery involves an approach called thoracotomy, meaning that the aorta is approachable through an incision made either on your chest or upper back. The aorta then needs to be clamped down in order to stop the blood flowing through it. This is mainly done in descending aortic surgery.
In ascending aortic and aortic arch aneurysms, the next step involves rerouting the blood from the heart to other vital organs, which is done via special tubes called cannulas, with the help of a technique which utilizes cardiopulmonary bypass pumps (CPB), also called a heart-lung machine, which serves to pump and oxygenate blood, finally delivering it to those organs.
This type of surgery may include the process of artificially stopping the heart from beating, using low temperatures to put the patient in a carefully managed clinical death, because it’s easier to work on a still heart, especially when operating on the ascending aorta, if the aortic valve needs to be replaced too. The brain is treated in a similar fashion, since low temperatures reduce the need for oxygen, which is useful because the aortic arch, which needs replacement, gives away branches that supply the brain.
Finally, when the blood flow is taken care of, the surgeon can start replacing the damaged part of the aorta by removing it and placing the artificial graft instead, reattaching it with the previously disconnected arteries. When the repair is finished, blood flow will resume as normal. The incision may now be closed, and you are then taken in the intensive care unit to recover.
2. Open abdominal repair
This procedure is done in a similar fashion, with the exception that the CPB pump Is not needed. The surgeon will enter through the abdomen, clamp the aorta, and replace the aneurysmatic part with a graft, then reattach the arteries previously branching out from the abdominal aorta.
Depending on the part of the aorta the operation is taking place and the extent of the surgery, there are several types of grafts, ranging from simple tubular ones, “Y” shaped ones, to the ones with predefined “outlets” for small arteries.
How to prepare for this type of surgery?
Preoperative evaluation consists of procedures measuring the aorta (such as an ultrasound or a CT scan), testing your heart and lungs function, and blood tests, to make sure you’re in stable condition. Your doctor will give you precise information on how to prepare for the surgery itself. Usually, you are told to stop smoking immediately (if you still smoke), don’t eat or drink anything for about 12 hours before the procedure, and to sign a consent form. Make sure that your doctor is familiar with your everyday medical therapy, so you could know what medications are you allowed to take.
What risks do open repair surgeries involve?
Because these procedures present massive surgeries, the first risk presented is the total anesthesia, which comes with its own hazards. Since the operation involves large blood vessels, bleeding and potential blood clot formation may always present problems. Also, organ failure due to lack of blood, as well as infections (especially in the lungs) are also things which must not be overseen.
What to expect after an open repair surgery?
After a few days spent on recovery in the intensive care unit, you will probably be transferred to another hospital department, where you will slowly start the rehabilitation process, while your wounds heal. Usually painkiller and anti-nausea medications are prescribed. If your progress shows satisfying results, you are free to go home. Your doctor will talk to you and give you a list of things you must and mustn’t do. Usually it involves gradually resuming your normal activities, some exercise, diet regulation, and of course, medications. Unhealthy food, smoking, and heavy lifting are strictly forbidden, because they may cause major problems with blood vessels, which can be life threatening.