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Open surgery remains the standard treatment for abdominal aortic
aneurysms. Endovascular repair of aortic aneurysms is a promising
technique that is much better tolerated than open surgery. This
technique, however, remains experimental and with current devices, only a minority of
patients will have aneurysms that are morphologically suitable for this
technique.
Open aneurysm surgery requires careful and comprehensive preparation.
Patients will undergo a series of blood and radiological investigations.
Cardiac and respiratory functions will be specifically assessed and
expert opinion is sought if necessary. In some cases, patients with
significant coronary artery disease may require interventional treatment
for this prior to their aneurysm surgery.
Once
anaesthetised, preparation for surgery will continue by
creating a sterile field for the operation. The procedure will then begin
and depending on the shape
and extent of the aneurysm, the incision may be vertical or
horizontal. The procedure principally involves exposing the
arteries above and below the aneurysm. A blood thinning drug is given
(heparin) and special clamps are applied to these arteries. These clamps
stop the blood from flowing through the aneurysm which is now safe to
open. After opening, the aneurysm is cleared of blood clots and any
small bleeding vessels are dealt with. A suitably sized
Dacron graft is
then sutured to the arteries above and below the aneurysm using a
special non-absorbable suture. The suture line must be fluid
tight to prevent bleeding. After testing the suture lines, the clamps
are removed sequentially thus allowing the blood to flow through the
graft to the pelvis and legs. The redundant aneurysm tissue is closed
over the graft to isolate it from the bowel. The abdomen is then closed.
Following completion of surgery,
the anaesthetic is reversed and patients are
gradually woken up. At this stage, patients may start remembering the
surrounding events. This can be an uncomfortable period especially if
the breathing tube is still in place and is about to be removed. Apart
from this, pain is usually quite well controlled.
From theatre, patients are transferred either to the intensive care unit or
to the high dependency unit. The duration of stay in these units will depend
largely on the complexity of the procedure and the individual patient's
speed of recovery. Family visit is usually allowed at this stage, but
patients may not be
able to properly communicate due to the various medications they are
taking. We encourage patients to drink on the same day of surgery, and if
this is tolerated, to have a light breakfast the following morning.
Over the following few days, and if all is going well, the level of
monitoring is scaled down and patients usually return to their original
ward after two to three days. Most of the lines and tubes
will be out by now and patients are encouraged to mobilise with the help
of the physiotherapy team. If all goes well, most patients will recover
well enough to be discharged after 7-10 days. Complete recovery, however,
can take up to three months. For the first few weeks following discharge,
patients will continue to feel rather weak and less energetic than usual. This feeling gradually
resolves.
Although much safer than in the past, open abdominal aortic aneurysm
surgery remains a major procedure with potentially serious complications.
The most significant of these complications is
Mortality. The average mortality rate for this type of surgery in the UK
ranges between 5 to 7%.
It is important to note that the pre-operative state of health
determines to a great extent the chances of a quick and full recovery.
As heart problems are the main cause of mortality following aneurysm
surgery, patients with pre-existing heart disease are particularly at
risk.
Transient Organ Failure such as respiratory or renal failure
may follow aneurysm surgery. The incidence of such complications is in
the region of 10%. Smoking, diabetes, hypertension and pre-existing
respiratory or renal impairment increase the risk of these complications.
Although prophylactic antibiotics are given immediately before surgery,
Infection remains
a risk. The commonest form of this complication is wound infection. This will affect
approximately 3-5% of patients. Less commonly, the inserted graft may
become infected. This is a much more serious complication which affects
approximately 1% of patients. Graft infection can be almost impossible
to eradicate and a second procedure may be required to
remove the infected graft. Aortic graft infection carries a very high incidence
of mortality.
Other possible complications related to this procedure include
limb ischaemia, bowel ischaemia and retrograde ejaculation.
The overall complication rate for open abdominal aortic aneurysm repair is around 15%.
Admission: Day before surgery
Anaesthetic: General-Epidural
Stay in
hospital: 6-11 days
Removal
of sutures: 10-14 days
Time off
work: 6-12 weeks
First
follow-up appointment: 6 weeks
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