The best method to repair an aneurysm depends upon several factors, including the location and shape of the aneurysm as well as the physical condition of the patient.

Open repair

Surgery for Thoracic Aortic Aneurysm

A thoracic aortic aneurysm, an abnormal bulge in a weakened wall of the aorta in the chest area, can cause a variety of symptoms and often life-threatening complications. Due to the serious risks it presents, timely diagnosis and treatment of a thoracic aneurysm are critical.

Is a thoracic aortic aneurysm serious?

Thoracic aortic aneurysms affect about 15,000 people in the United States each year, and are the 13th leading cause of death. Research has shown that patients with untreated large thoracic aneurysms of the aorta are more likely to die of complications associated with their aneurysms than from any other cause.

What is the best treatment for a thoracic aortic aneurysm?

The decision on how to best treat a thoracic aneurysm or the aorta depends on its size and rate of its growth, location and your overall health. The risk of rupture increases when the aneurysm is larger than about twice the normal diameter of a healthy aorta blood vessel.

Medical Management

If a thoracic aneurysm is small and causes no symptoms, your physician may recommend “watchful waiting,” which includes:

  • Close monitoring of the aneurysm with CT or MRI scans every 6 months
  • Blood pressure medication to control high blood pressure, and decrease pressure on the weakened area of the aneurysm
  • Restriction of some physical activities. Heavy lifting should be avoided due to increased pressure on the aorta, which may put an aneurysm at risk of rupture

Surgery

The decision to treat a thoracic aneurysm with surgery is determined by many factors, including:

  • The presence of symptoms, including chest and back pain, and pain in the jaw, neck and upper back
  • If the aneurysm is growing more than 1 centimeter (cm) per year
  • Signs of an aortic dissection, including sudden, severe sharp tearing pain in the chest or back
  • The age of the patient and the patient’s overall medical condition

New evidence has shown that the size of the aneurysm in addition to a patient’s height plays an important role in the decision for surgery. While 5 centimeters is the size most aneurysms are considered for surgery, AHI surgeons have compiled years of experience and published studies to find that a patient’s height and their aneurysm’s size strongly correlates with the need for surgery. For instance, a patient who is over 180cm tall with a 5cm aneurysm would be recommended for surgery. Yet, a patient who is 173cm with a thoracic aneurysm of 4.7cm is a candidate for surgery due to their individual risk of rupture.

Due to highly individualized characteristics guiding the decision for surgery, it is best that a physician closely monitor your thoracic aneurysm on a regular basis.

The aorta

To understand how surgery is used to treat a thoracic aneurysm, it is best to know where the aorta is located and how it functions. The aorta is shaped like an old-fashioned walking cane with the stem of the curved handle coming out of the heart and curling through the aortic arch, which supplies branches of vessels to the head and arms. Once the aorta descends through the chest cavity into the abdomen, it separates off to provide blood to the abdominal organs and both legs.

aneurysms1

 

How is a thoracic aortic aneurysm treated with surgery?

The current standard surgical treatment of a thoracic aortic aneurysm is the open-chest approach. The main purpose of open-chest surgery to treat a thoracic aneurysm is to replace the weakened portion of the aorta with a fabric tube, called a graft. Repairing a thoracic aneurysm is surgically complicated and requires an experienced thoracic surgical team. However, neglecting the aneurysm presents a higher risk.

Athens Heart Institute surgeons have considerable experience in complex aortic operations, performing over 300 aortic procedures in 2005. Procedures include ascending aorta, aortic arch, descending aorta, thoracoabdominal repairs, and thoracic aorta endovascular stent graft procedures.

Preoperative evaluation

To help ensure the best outcome of thoracic aneurysm surgery, you will undergo a thorough preoperative evaluation to check for atherosclerosis (a hardening of the arteries that damages the artery’s walls) in the body’s blood vessels.

Preoperative evaluation may also include:

  • Screening of left ventricular (the heart’s left side) function and an assessment for the presence of coronary artery disease
  • Ultrasound examination
  • Pulmonary function testing with a spirometer to measure lung function

How is surgery for a thoracic aortic aneurysm completed?

Thoracic aneurysms occur above the diaphragm, including in the ascending aorta, the aorta arch and the descending thoracic aorta. The location of a thoracic aneurysm determines many factors, including where the incision for surgery is made. If the aneurysm is close to the aortic valve, an incision in the front of the chest (median sternotomy) may be used. An aneurysm close to the aortic valve may also require the valve to be repaired or replaced. If surgery is needed on the aortic arch, the procedure is approached from the front chest area. A standard incision for an aneurysm in the descending thoracic aorta is made on the left side of the chest (left thoracotomy).

Repairing a thoracic aneurysm

After making an incision in the chest, your thoracic surgeon will replace the weakened portion of the aorta with a graft. The graft is made of a material that is stronger than the weakened aorta, allowing blood to pass through the vessel without causing a bulge.

Many patients who have a thoracic aneurysm may also have heart valve disease, disease of the aorta next to the heart, or extensive aorta disease, leading into the abdomen or other major arteries. For those thoracic aneurysms that are extensive or more complex, heart surgery is sometimes performed at the same time as an open-chest aneurysm repair. In addition, thoracic surgeons may work alongside vascular surgeons to complete a complex procedure involving the entire aorta or peripheral blood vessels.

The standard surgical treatment for thoracic aneurysms is open-chest aneurysm repair, but AHI surgeons are now able to treat some thoracic and thoracoabdominal aneurysms with a promising, newer procedure called an endovascular stent. Endovascular means that surgery is performed inside your body using thin, long tubes called catheters. By entering through small incisions in the groin, the catheters guide a stent graft through the blood vessels to the site of the aneurysm. While endovascular stents are only used in limited cases, this type of repair is being evaluated for optimal use.

What are the risks of thoracic aortic aneurysm surgery?

The risks involved with repairing a thoracic aneurysm depend on the extent of the repair required, the length of surgery and on your overall general health. Your surgeon will talk with you about the possible risks and benefits of the procedure.

In 2013, mortality for thoracic aortic procedures declined to 4.9% at AHI.

Complications after thoracic aneurysm surgery may include:

  • Heart attack
  • Irregular heartbeats
  • Bleeding
  • Stroke
  • Paralysis due to injury of the spinal cord
  • Graft infection
  • Kidney damage

How long will it take to recover from thoracic aortic aneurysm surgery?

Your length of hospital stay following thoracic aneurysm surgery depends on your condition and the operation performed, but it is typically 7-10 days. Most people need at least 4 to 6 weeks to recover from thoracic aneurysm surgery. If your aneurysm is extensive, involves intervention to repair other complications, or if you have other conditions such as heart, lung or kidney disease, recovery may take 2 to 3 months.

After you’ve had surgery to repair an aneurysm, it is recommended you adopt the same heart-healthy lifestyle led by other heart surgery patients. Your health care team can provide more information.

 

Endovascular Repair of Thoracic Aortic Aneurysms

The standard surgical treatment for thoracic aortic aneurysms is open-chest aneurysm repair, but the Athens Heart Institute surgeons are now able to treat many thoracic and thoracoabdominal (occurring in the lower part of the thoracic aorta and the upper part of the abdominal aorta) aneurysms with a minimally invasive procedure called an endovascular stent graft.

What is an endovascular stent graft?

Endovascular means that surgery is performed inside your aorta using thin, long tubes called catheters. Through small incisions in the groin, the catheters are used to guide and deliver a stent-graft through the blood vessels to the site of the aneurysm. The stent graft is then deployed in the diseased segment of the aorta and “relines” the aorta like a sleeve to divert blood flow away from the aneurysm. An endovascular stent graft is a fabric tube supported by metal wire stents (also called a scaffold) that reinforces the weak spot in the aorta. By sealing the area tightly with your artery above and below the aortic aneurysm, the graft allows blood to pass through it without pushing on the aneurysm.

What are the benefits of endovascular repair?

Endovascular repair of thoracic aneurysms is generally less painful and has a lower risk of complications than traditional surgery because the incisions are smaller. Endovascular aorta aneurysm procedures also allow you to leave the hospital sooner and recover more quickly after your aorta repair.

Who is a candidate for endovascular repair of a thoracic aneurysm?

You may be eligible for endovascular stent grafting if your thoracic aneurysm has not ruptured and the aneurysm is 5 centimeters or more in size. Your physician can determine if aortic aneurysm repair is the best treatment by performing one or a combination of imaging studies, which may include:

  • High resolution, computed tomography (CT) scan
  • Magnetic resonance imaging (MRI)
  • Angiography (an x-ray of the blood vessels)
  • Transesophageal echocardiography (TEE), to record ultrasound images of your heart from inside your esophagus, or food pipe
  • Intravascular ultrasound

Physical characteristics of the aorta and the aortic aneurysm itself are very important in determining if endovascular aorta repair is the best treatment.

What happens during endovascular stent grafting?

Your surgeon will make small incisions in the skin above the femoral artery (the large artery that supplies blood to each leg) in the groin. A guide wire is threaded through the artery beyond the area of the thoracic aneurysm. By using x-ray guidance, your surgeon inserts the device over the guide wire. The stent-graft device is constrained within a catheter to make it easier to deliver the stent-graft through your blood vessels. Once the graft is guided to the thoracic aneurysm site, the catheter is withdrawn, exposing the stent-graft in place. The stent-graft then expands like a spring to fit against the walls of the aorta on either side of the aneurysm, and delivers blood flow through the weakened section.

aneurysms2

 

Once the stent-graft is in place, the blood flows through the graft, avoiding the aneurysm. Over time, the aneurysm typically shrinks due to the blood pressure being diverted away from the aneurysm.

AHI surgeons are also using fenestrated and branched endografts to treat more complex thoracic aneurysms involving the aortic arch and thoracoabdominal aneurysms (those which involve the aorta both in the chest and the abdomen). Additionally, branched and fenestrated grafts are used to extend thoracic grafts to repair those aneurysms that involve the vessels leading to the intestines or the brain and arms.

aneurysms3

 

For those patients with extensive aortic or multiple aneurysms, the best approach may require a combination of open surgery and endovascular repair. This combined therapy is referred to as a hybrid approach and most often includes what is known as an elephant trunk procedure.

What are the risks of endovascular repair of thoracic aneurysms?

Although endovascular surgery reduces recovery time to a few days, there are still potential risks. The possible complications of endovascular repair include:

  • Leaking of blood around the graft, known as “endoleak”
  • Movement, or migration, of the graft away from its initial placement
  • Stent fracturing

Additional complications that are rare but serious include:

  • Paralysis
  • Delayed rupture of the aneurysm
  • Infection

Your surgeon will discuss the benefits and potential risks of the procedure with you.

The long-term durability of endovascular stent grafting to treat a thoracic aneurysm is yet unknown because this is a fairly new procedure. For this reason, patients who have endovascular repair of their thoracic aneurysms must be monitored closely on a regular basis with examinations and imaging studies.

How long will it take to recover from endovascular repair of a thoracic aneurysm?

Your hospital stay following endovascular stent grafting is usually 2 to 3 days. While your recovery will take less time than recovering from open-chest thoracic aneurysm surgery, the early restrictions are similar and include:

  • No driving until approved by your physician (usually within 1-2 weeks after the procedure, and no longer taking pain medication)
  • No baths until the groin incisions heal; showers and sponge baths around the incision are permitted
  • Avoid lifting more than 10 pounds for approximately 4 – 6 weeks after the procedure

You will return for a follow-up visit within one month of the procedure. Follow-up imaging tests will take place 1 and 6 months following the procedure to make certain the stent is still functioning and in the proper location. If you aneurysm is shrinking and no problems are found, your subsequent imaging tests will take place yearly.

After you’ve had an endovascular repair of an aneurysm, it is recommended you adopt the same heart-healthy lifestyle led by other heart surgery patients. Your health care team can provide more information.

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Participation in the Pulse and Cardioelectrics Conference, July 2014

Feb 06/02/2014

Dr. Avgerinos participated and spoke at the Pulse and Cardioelectrics Conference, which took place from July 13-15 in Hersonissos, Krete. His speech was about the modern methods for treating aortic …

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