Aortic aneurysm repair at Brighton Hospital

What is aortic aneurysm repair?

Aortic aneurysm repair is surgery to fix a bulge that has formed in the wall of your aorta, the main artery carrying blood from your heart to the rest of your body. The weakened section is either removed and replaced with a synthetic tube called a graft, or reinforced from inside using a stent, to stop it bursting.

What conditions does it treat?

Treating aneurysms, which can can either be:

• an abdominal aortic aneurysm, a bulge in the section of the aorta that runs through your tummy
• a thoracic aortic aneurysm, a bulge in the section of the aorta that runs through your chest

You might need aortic aneurysm repair if you have:

• an aneurysm that is 5.5cm or larger in diameter, or one that is growing quickly
• an aneurysm causing symptoms, such as pain in your belly, back, chest, groin or inner thigh, or a pulsing feeling in your abdomen
• a ruptured or dissected aneurysm, needing emergency surgery to save your life.

What are the benefits of having aortic aneurysm repair?

Aortic aneurysm repair can be life-saving. It significantly lowers your risk of the aneurysm bursting or tearing, both of which are life-threatening emergencies, and your surgeon will usually only recommend surgery once this risk outweighs the risk of the operation itself.

If you've already had a rupture or dissection, emergency surgery gives you the best chance of survival. Without any treatment, a rupture is almost always fatal.

Are there different types or surgical approaches?

There are two main approaches to repairing an aortic aneurysm. Open surgery involves a long incision in your chest or tummy, so your surgeon can remove the weakened section of the aorta and sew in a synthetic graft to replace it.

The other option is a keyhole procedure, known as endovascular aneurysm repair (EVAR) for aneurysms in your tummy, or thoracic endovascular aortic repair (TEVAR) for aneurysms in your chest. Your surgeon makes a small cut, usually in your groin, and guides a stent graft, a tube covered in fabric, up to the aneurysm, where it opens out and seals against the artery wall from the inside.

Open surgery tends to mean you're less likely to need further procedures in future, while keyhole repair usually means a smaller cut and a shorter recovery. For some complex aneurysms near where the aorta branches off to supply your head and arms, specialist centres are also developing keyhole techniques that avoid the need for any incision in your neck. Which approach suits you depends on your fitness and the size, shape and position of your aneurysm, and your surgeon will talk you through the options.

What happens before the operation?

Preparation usually begins weeks before your operation, with a pre-assessment appointment to check you're well enough for surgery. In general, you'll need to:

• have a physical examination and some tests, and let your team review any medicines, supplements or herbal remedies you take
• stop smoking at least a month beforehand if you smoke, since this protects your arteries and lowers your risk of complications
• get conditions like high blood pressure, high cholesterol and diabetes well controlled before you go ahead
• keep gently active, such as by walking or cycling, to help your fitness beforehand
• stop eating and drinking, including water, from midnight the night before your operation
• arrange for someone to drive you home when you're discharged

What happens during the procedure?

You'll be given a general anaesthetic for either type of surgery, so you'll be asleep throughout. What happens next depends on which approach you're having.

If you have open surgery:

1. Your surgeon makes a long incision in your chest or tummy, depending on where your aneurysm is.
2. Clamps are used to stop blood flow through the affected section of your aorta; you may be connected to a heart-lung machine to keep blood moving around the rest of your body.
3. The weakened section of your aorta is removed and a synthetic graft is sewn in its place.
4. The incision is closed with stitches or metal clips

If you have a keyhole procedure (EVAR or TEVAR):

1. A small cut is made, usually in your groin.
2. A catheter is guided through your blood vessels up to the aneurysm, using X-ray images and dye to check its position.
3. A stent graft is passed through the catheter and released so it expands and seals against the wall of the aorta from the inside.
4. The catheter is removed, and the cut in your groin is closed and covered with a dressing

What does recovery look like?

After open surgery, you'll spend some time in intensive care before moving to a regular ward, with a total hospital stay of around five to ten days. A physiotherapist will help you get moving again, and your care team will manage your pain and monitor your wound closely. After a keyhole procedure, your hospital stay is usually much shorter, often around three days, with just mild bruising and discomfort at the cut in your groin.

Full recovery from open surgery typically takes four to six weeks, though some people need two to three months, while recovery from a keyhole procedure is often quicker, with a return to daily activities within a couple of weeks. Either way, avoid heavy lifting, driving and strenuous exercise until your team confirms it's safe, and keep your wound clean and dry as it heals. It's normal to feel more tired than usual and to have a reduced appetite for a few weeks after open surgery, as your body focuses on healing.

What are the risks and complications?

As with any major operation, aortic aneurysm repair carries some risk, though your surgical team will do everything possible to keep you safe. Possible risks include:

• bleeding, which occasionally needs a blood transfusion
• a blood clot, which may need blood-thinning tablets for 3 to 6 months
• infection in the wound, the chest or the graft itself
• a heart attack or stroke
• kidney problems
• reduced blood flow to your legs, bowel or other organs during surgery
• nerve damage, which can affect sensation or, in men, cause erection problems
• a leak around a stent graft (called an endoleak), which needs monitoring or further treatment
• rarely, weakness or paralysis affecting your spinal cord or legs