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Aortic aneursym - endovascular repair

Endovascular repair (EVAR) re-lines the part of the blood vessel where you have an aortic aneurysm, to prevent it from bursting (rupturing). It's also known as stent grafting, as it involves inserting a graft mounted on metal stents.

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 - the largest blood vessel in the body. It happens when part of the wall of the aorta weakens and expands.

Aortic aneurysms most often occur in the section 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)

You may be given the option of having endovascular repair rather than open surgery, as endovascular repair is minimally invasive (avoids having to cut into your abdomen/chest).

What are the alternatives?

Endovascular repair isn't suitable for everyone. It will depend on a number of factors, including the shape of your aneurysm, how near it is to other blood vessels and whether the arteries in your groin are large enough for the stent graft and the delivery device to be inserted. Open surgery has been the standard procedure for aortic aneurysm for many years. You may be advised to have this, rather than endovascular repair, which is a relatively new procedure.

Your surgeon will advise you 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 that you are fit and suitable for surgery, or these 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 stent graft can be inserted under a local or general anaesthesia. With a general anaesthetic, you will be asleep during the operation and feel no pain. Alternatively, you may prefer to have the surgery under local anaesthesia. This completely blocks feeling from your groin (where the stent is inserted) but you will stay awake during the operation.

Your surgeon will advise which type of anaesthesia is most suitable for you.

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.

About the operation

A stent graft consists of synthetic fabric tubes (the graft) mounted onto metal skeletons (stents). It comes pre-loaded on a delivery system, which is used to position the stent graft correctly.

Small cuts will be made in your groin and wires passed up the arteries in your legs until they reach the aorta. The surgeon will use X-rays to guide the wires, confirm the position of your aneurysm and put the stent graft in place. After the stent graft has been inserted, you will normally have a CT angiogram, which uses a dye to show up the aorta. This is to check that your blood is no longer flowing through the aneurysm.

The arteries and small cuts in the groin will be closed.

What to expect afterwards

After the operation, you will be returned to your ward, where you will normally stay for up to three days until you can return home. While you are on the ward, nurses will assess your operation site and monitor your blood pressure and heart rate. You may need pain relief to help with any discomfort in the groin as the anaesthetic wears off.

When you are ready to go home, you will need to arrange for someone to drive you home. You may be given a date for a follow-up appointment.

Recovering from surgery

If you need them, 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.

It can take up to two weeks to make a full recovery, but this varies between individuals, so it's important to follow your surgeon's advice.

What are the risks?

Endovascular repair 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 the general anaesthetic. The area where you had the stent inserted may feel sore for 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 or dye, excessive bleeding or developing a blood clot in a leg (deep vein thrombosis). The blood vessels may also be damaged during this procedure, which may lead to the aneurysm bursting.

The following complications can also occur after your procedure:

  • The graft may move from the position where it was positioned (called migration)
  • The wires or fabric of the stent graft may break (wire fracture or fabric tear)
  • One of the limbs of the stent graft may kink or block (limb thrombosis)
  • Blood may leak outside the stent graft (called endovascular leak or endoleak). This can increase pressure in the aorta where the aneurysm used to be. You may need further treatment if this happens

You will need to have regular check-ups for the rest of your life after having endovascular repair.

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
  • Greenhalgh RM, Powell JT. Endovascular repair of abdominal aortic aneurysm. N Engl J Med 2008; 358:494-501
  • Crane J, Cheshire N, Recent developments in vascular surgery. BMJ 2003; 327:911-915
  • Stent-graft placement in abdominal aortic aneurysm. National Institute for Health and Clinical Excellence (NICE), March 2006. www.nice.org.uk
  • Endovascular stent-graft placement in thoracic aortic aneurysms and dissections. National Institute for Health and Clinical Excellence (NICE), June 2005. www.nice.org.uk
  • Abdominal aortic aneurysms. Society of interventional radiology. www.sirweb.org, accessed 17 December 2007
  • The EVAR Trial Participants. Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR Trial 1): randomised controlled trial. Lancet 2005; 365(9478):2179-2186

Related topics

Abdominal aortic aneurysm

Open surgery for aortic aneurysm

Thoracic aortic aneurysm