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Aortic aneursym - open surgery

Open surgery is the standard type of surgery carried out to repair an aneurysm in the aorta (the largest blood vessel in the body) to prevent it from bursting.

Your care will be adapted to meet your individual needs and may differ from what is described here. So it's important that you follow your surgeon's advice.

About aortic aneurysms

An aortic aneurysm is a widening or bulge of a portion of the aorta. It happens when part of the wall of the aorta weakens and expands.

Aortic aneurysms most often occur in the part of the aorta that passes through the abdomen (abdominal aortic aneurysms). They can also occur in the part of the aorta near the heart (thoracic aortic aneurysms).

If an aortic aneurysm becomes very large, it may rupture (burst). If this happens it is life threatening, with many people dying before they reach hospital.

Diagnosis of aortic aneurysms

Aortic aneurysms often don't produce any symptoms, unless they are large or are growing quickly. Your GP may only suspect you have an aortic aneurysm following a routine examination. You may also be invited to be screened for aortic aneurysm at your GP surgery or local hospital, if you are a man over 65 and live in an area that has a screening programme.

Tests to confirm an aortic aneurysm may include:

  • an X-ray - aortic aneurysms near the heart are often found on routine chest X-rays
  • an ultrasound - this uses sound waves to create images of the inside of your body; ultrasound scans usually give a clear picture of an aneurysm and can show how big it is
  • an MRI (magnetic resonance imaging) scan - this uses magnets and radiowaves to produce images of the inside of your body
  • a CT (computerised tomography) scan - this uses X-rays to make a three-dimensional picture of the body; it gives a clear picture of the arteries around your aneurysm

Your doctor will probably suggest you have surgery if:

  • you have symptoms
  • your aneurysm is growing rapidly
  • your aneurysm is more than 5.5cm wide (6cm for aneurysms near the heart)

What are the alternatives?

Your doctor may suggest a newer type of surgery called endovascular aneurysm repair (EVAR). This involves inserting a stent graft (synthetic fabric tubes mounted on metal stents) into your aorta. The procedure avoids having to make a cut into your abdomen or chest, but it isn't suitable for everyone.

Your surgeon will advise which procedure is best for you.

Preparing for your operation

Your surgeon will explain how to prepare for your operation. For example if you smoke you may be asked to stop several weeks beforehand, as smoking increases your risk of getting a wound infection and slows your recovery.

You may be asked to attend a pre-admission clinic for routine tests, to check you are fit and suitable for surgery, or the tests may be done on the day you are admitted. The tests may include:

  • blood tests
  • an electrocardiogram (ECG)
  • an ultrasound of the heart
  • breathing tests

The operation is done under general anaesthesia. This means you will be asleep during the operation. Typically, you must not eat or drink for about six hours before a general anaesthetic. However, some anaesthetists allow occasional sips of water until two hours beforehand.

Before the procedure your surgeon will talk to you about the operation and you will be asked to sign a consent form. This confirms that you understand the risks, benefits and possible alternatives to the procedure and have given your permission for it to go ahead.

You may be asked to wear compression stockings to help prevent blood clots forming in the veins in your legs.

About the operation

Your surgeon will make a cut in your chest or your abdomen, depending on where your aneurysm is. He or she will then open the aorta close to the aneurysm and insert a graft. A graft is a piece of tubing, made out of stretchable material, which resembles a normal, healthy aorta.

The graft fits into the portion of the aorta that is damaged. Your blood will then flow through the graft, which means there is less pressure on the damaged wall of the aorta.

The cut is closed with either dissolvable stitches or clips.


What to expect afterwards

After your operation, you will be taken to an intensive treatment unit (ITU) or a high dependency unit (HDU), where you will be closely monitored for around 24 hours.

You may have a tube in your mouth, which passes into your windpipe and is connected to a ventilator (a machine to help you breathe). This will be removed once you are alert and can breathe by yourself. A clip on your finger will measure the oxygen level in your blood.

You will usually have a drip in your arm to provide you with fluids until you are well enough to eat and drink. You will be given painkillers to help with any discomfort as the anaesthetic wears off. You may also have tubes running out of small holes in your abdomen or chest. These drain fluid into a bag beside your bed. You will also usually have a catheter (a fine tube) to drain urine from your bladder into another bag.

Once you are stable and the ITU/HDU team is satisfied with your progress, you will be sent back to a standard ward, where nurses will continue to monitor you until you are ready to return home. This is usually after about a week. When you are ready, you can begin to drink and eat, starting with clear fluids. You will continue to receive pain relief and may be asked to continue wearing compression stockings to help prevent blood clots forming in your legs.

A physiotherapist will visit you daily and encourage you to do gentle exercises. You will usually be asked to take deep breaths and cough up any fluid in your lungs. These exercises will help speed up your recovery and prevent chest infections.

Dissolvable stitches will disappear on their own in seven to 10 days. Clips are usually removed about 10 days after your surgery.

When you are ready to go home, you will need to arrange for someone to drive you. You should try to have a friend or relative stay with you for the first 24 hours. Your nurse will give you some advice about caring for your healing wounds before you go home. You may be given a date for a follow-up appointment.

Recovering from open surgery

If you need pain relief, you can take over-the-counter painkillers such as paracetamol or ibuprofen. Follow the instructions in the patient information leaflet that comes with the medicine and ask your pharmacist for advice.

You will probably feel tired for several weeks after the operation, but this will gradually improve. Regular, light exercise, such as a short walk, combined with plenty of rest is recommended for the first few weeks.

It usually takes a few months to make a full recovery from this operation. But this varies between individuals, so it's important to follow your surgeon's advice.

What are the risks?

Open surgery for aortic aneurysms is commonly performed and generally safe. However, in order to make an informed decision and give your consent, you need to be aware of the possible side-effects and the risk of complications of this procedure.


Side-effects

These are the unwanted, but mostly temporary effects of a successful treatment, for example feeling sick as a result of having a general anaesthetic. After surgery, the healing wound will feel sore and it may leak fluid. This usually clears after a few days.

Complications

This is when problems occur during or after the operation. Most people are not affected. The possible complications of any operation include an unexpected reaction to the anaesthetic, excessive bleeding or developing a blood clot, usually in a vein in the leg (deep vein thrombosis, DVT).

Other complications of open surgery for aortic aneurysm are uncommon but can include:

  • wound infection - you may need treatment with antibiotics if your wound becomes infected
  • impotence (loss of sexual activity) - this can affect some men if nerves in the abdomen are damaged during the operation
  • infection of the graft - this is very rare, but serious, and usually means that your graft will have to be removed

The exact risks are specific to you and will differ for every person, so we have not included statistics here. Ask your surgeon to explain how these risks apply to you.

Further information

The Circulation Foundation

Sources

  • Kumar P, Clark M. Clinical Medicine. 6th ed. London: Elsevier, 2005:868-869
  • Kasper DL, Fauci AS, Longo DL. Harrison's Principles of Internal Medicine. 16th ed. New York: McGraw-Hill, 2005:1481-1485
  • National Screening Committee. National screening committee policy - abdominal aortic aneurysm screening. National Library for Health, March 2007. www.library.nhs.uk, accessed 31 March 2008
  • Morris PJ, Malt RA. Oxford Textbook of Surgery. New York: Oxford University Press, 1994
  • Aortic aneurysm - the operation explained. The Circulation Foundation. www.circulationfoundation.org.uk, accessed 31 March 2008
  • McLatchie GR, Leaper DJ. Oxford Handbook of Operative Surgery. Oxford: Oxford University Press, 1998:448-451

Related topics

Abdominal aortic aneurysm

  • Endovascular repair for aortic aneurysm
  • Thoracic aortic aneurysm