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Treatment of Abdominal Aortic Aneurysm (AAA)

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Updated November 13, 2011

If you have been diagnosed with abdominal aortic aneurysm (AAA), the big question for you and your doctor will be deciding on the best treatment. If your AAA is large, if it is expanding relatively rapidly, or if it is causing abdominal or back pain (which would strongly indicate that it is expanding), it is likely that your doctor will recommend surgical repair.

What Is Surgery for AAA Like?

Surgery for AAA repair is a major procedure, performed under general anesthesia. The surgery requires a long incision, from the bottom of the breastbone to the pubic area. After locating the aneurysm, the surgeon clamps the aorta to shut off the blood flow, and resects the aneurysm. The aorta is repaired by inserting a synthetic graft to replace the part of the artery that has been removed.

The post-operative period is often fairly difficult, and generally requires a stay in the hospital of at least a week. Complete recovery often takes up to two months. Depending on your other medical conditions, and the specific location of your aneurysm, serious complications are possible that involve the kidneys, intestines, legs, heart and lungs.

Is There a Less Invasive Form of AAA Repair?

Because the standard surgery to repair AAA is so daunting, major efforts have been made to perfect a less invasive type of surgical treatment. The approach that has been developed is called endograft repair.

An endograft is a graft that is inserted into the femoral artery, and advanced into the aorta to the site of the AAA. With endograft repair, the AAA itself is not resected. Instead, the endograft is inserted inside the AAA, and deployed in such a way as to isolate the aneurysm itself from the blood flow within the aorta. Because the aneurysm is no longer exposed to blood flow, rupture is theoretically no longer a risk.

Several endograft products have been developed, using different materials and different deployment techniques, and so far they all appear to work about equally well.

Is Endograft Repair Better Than Standard Surgery?

In general, there is good news and bad news about endograft repair for AAAs. The surgical procedure with endograft repair is far less traumatic than with standard surgical repair, so the post-operative mortality is much lower, and the recovery time is much shorter and much less difficult. However, while the complications of standard surgery tend to occur very early after the operation, complications with endograft repair tend to occur later.

These complications can include:

  • "Endoleak," in which the flow of blood into the AAA itself is not completely cut off by the endograft, so the AAA can continue to expand, and can rupture.
  • "Postimplantation syndrome," a poorly-understood acute inflammatory syndrome which can cause fever and a generalized, sometimes rather severe, illness.
  • "Device migration," in which the endograft shifts its position within the aorta at some point in time after the surgical procedure. Device migration, which has been seen in more than 10% of patients after endograft repair in some studies, can cause serious problems, including rupture of the AAA.

So, while endograft repair yields better short-term results than the standard open surgical repair, the long-term complications of endografts soon "catch up," so that the likelihood of dying within a year of the procedure is almost exactly the same for both approaches.

In general, endograft repair of AAA is done in patients who are judged to have a very high post-operative risk with the standard surgical approach. If the risk of post-operative complications is not judged to be unusually high, most surgeons still prefer the open surgical approach.

The bottom line with AAA repair is that there is no free lunch. This is is why it is so important to have a frank discussion with your doctors regarding your own individual risks before agreeing to the surgery. This is also why surgical repair of an AAA should be considered only when the possibility of AAA rupture is judged to be substantially more dangerous to you than the possibility of post-surgical complications.

Isn't There Medical Treatment for AAA?

There is no medical treatment that will make an AAA go away, or shrink it. However, there are important non-surgical steps that anyone with an AAA should take. These include all the things you can do to reduce your cardiac risk, including maintaining a healthy weight, eating a healthy diet, getting regular exercise, controlling hypertension and cholesterol, and, especially, quitting smoking. Smoking is the strongest risk factor for AAA, and people who already have an AAA have a much higher risk of rupture if they continue to smoke.

Summary

Once you have been diagnosed with AAA, the "next steps" are not straightforward or easy. Making the right choice for yourself will require you to learn all you can about all your options, and excellent communication with a knowledgeable doctor whose opinion you trust.

Sources:

Brewster, DC, Cronenwett, JL, Hallett, JW Jr, et al. Guidelines for the treatment of abdominal aortic aneurysms. Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery. J Vasc Surg 2003; 37:1106.

Lederle, FA, Kane, RL, MacDonald, R, Wilt, TJ. Systematic review: repair of unruptured abdominal aortic aneurysm. Ann Intern Med 2007; 146:735.

Bolke, E, Jehle, PM, Storck, M, et al. Endovascular stent-graft placement versus conventional open surgery in infrarenal aortic aneurysm: a prospective study on acute phase response and clinical outcome. Clin Chim Acta 2001; 314:203.

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