OPEN AORTIC ANEURYSM REPAIR

Open repair is the conventional treatment option for patients with an abdominal aortic aneurysm (AAA). The operation is performed via an abdominal incision and involves sewing a prosthetic (synthetic) graft in to the aorta to replace the aneurysm sac.

Open repair may be chosen over endovascular (minimally-invasive) repair for young fit patients, or for those with anatomy which is not suitable for an endovascular approach.

Preparing for the Procedure:

Prior to open AAA repair, all patients need a high-resolution CT scan, a baseline set of blood tests and an echocardiogram (ultrasound of the heart). Some patients require respiratory (lung) function tests. You will be seen by an anaesthetist before the operation for assessment and review of all test results.

Unless otherwise specified, all regular medications are continued prior to the procedure. Mr Milne will give you specific instructions regarding anti-platelet medications (e.g. aspirin and clopidogrel), anti-coagulant medications (e.g. warfarin and Rivaroxaban), and any medications taken for diabetes.

Bring a small suitcase with you to the hospital in preparation for a five to seven night stay.

 

Description of the Procedure:

The procedure is performed under general anaesthetic.

An incision is made along the midline of the entire abdomen. The small bowel is mobilised and moved to the side to allow dissection of the aorta, which runs just in front of the spine. The aorta divides in to two iliac arteries at the level of the umbilicus. These arteries travel to the legs, and may be dissected also if they are aneurysmal.

A clamp is placed above the aneurysm sac and on each iliac artery to isolate the aneurysm. The aneurysm sac is opened and any back-bleeding blood vessels are oversewn. A prosthetic graft is then selected to sew in to place and replace the aneurysm. It may be a tube graft (straight) or a bifurcated graft (with trouser legs), depending on the anatomy of the aneurysm. The top of the graft is sewn to normal artery above and normal artery (or arteries) below.

The clamps are then released and the graft checked for haemostasis. The aneurysm sac is then closed over the prosthetic graft to act as an envelope around the graft. The bowel is checked and placed back in to its normal position.

The abdomen is then closed with very strong sutures and the skin is closed with a dissolvable stitch underneath the skin.

 

Following the Procedure:

You will be transferred to the intensive care unit for monitoring after the procedure.

On the first day after the procedure, you will be sore along the incision line in the abdomen. Pain relief will be given to minimise this and you will be encouraged to sit up and start with chest physiotherapy. If comfortable, you will be able to sit out of bed in a chair.

It is expected that the bowels will take several days to 'wake up' after being handled during the procedure. You will therefore only be allowed to sip on water for the first day.

Over the following days, you can expect to be transferred back to the vascular ward. You will progressively increase your oral intake to fluids, followed by solids if tolerated. You will also be encouraged to walk and continue chest exercises with the physiotherapist.

The aim for discharge from hospital is roughly five to seven days after the procedure. Occasionally, a longer stay is required if issues have arisen. 

You will be scheduled for a review appointment with Mr Milne 4 - 6 weeks after the procedure.

After this, you will be reviewed at 6 months and 12 months post-operatively.

 

Travel:

You may travel short distances, under 4 hours, 4 weeks following the procedure. It is ideal to avoid flights/train/car travel over 4 hours duration for 6 weeks following the procedure. It is important to stay hydrated and walk around the cabin regularly whenever flying.

 

I acknowledge the travel restrictions following this procedure       Signed:___________________________ Date:____________________

 

Possible Complications of the Procedure:

- Pain/bruising:

• It is normal to experience some pain and bruising along the abdominal wound
• You will receive pain-relief medications through the drip initially, then orally. You will be sent home with medications for ongoing pain relief if required.

- Bleeding:

• Even when there is no bleeding at the time of operation, major bleeding can occur (usually in the first 24 hours) from the site of aneurysm repair. This is uncommon (~1 - 2%).
• If it occurs, it requires an urgent trip to theatre to fix.

- Infection:

• Antibiotics are given at the time of surgery to minimize the risk of infection.
• The risk of an infection involving the abdominal wound is ~1 - 2%. This type of infection usually resolves with a course of antibiotics.
• More serious infection involving the aortic endograft is rare (~1%)

- Bowel ischaemia:

• During an open AAA repair, one of the arteries which supply the bowel is most often oversewn without any adverse consequence
• The bowel is examined at the end of repair to ensure that it looks well perfused. If there is any doubt, the artery is sewn in to the graft to maintain perfusion to the bowel.
• The risk of having problems with poor blood flow to the bowel in the immediate post-operative period is ~3%.
• If it occurs, it may require a trip to theatre to inspect the bowel formally. The damaged bowel may also need to be excised to prevent further problems.

- General Complications:

• These are complications that occur away from the site of the procedure. They are a risk to all patients undergoing major surgery of any kind under general anaesthetic.
• They include heart attack, stroke, kidney dysfunction, chest infection, clot in the legs (deep vein thrombosis - DVT) and clot in the lungs (pulmonary embolus - PE).
• If any of these occur, the majority of patients are successfully treated whilst an inpatient, although the length of hospital stay would likely be increased.

- Mortality:

• The largest trials conducted to date internationally indicate a risk of dying from complications associated with open AAA repair of between 2 - 5%.
• This should be put in to context by remembering that the overall risk of dying from a ruptured AAA is ~80%.

Return to the Treatment Options for Aortic Aneurysms page.