Physicians:

Big Surgery, Small Incision, Home:
Endovascular Abdominal Aortic Aneurysm Repair
(published in the Wilmington Star-News - June 27, 2000)

Not all news from the world of medicine is negative these days. Research and technological advancement continue to provide exciting new approaches to treatment of many health problems. Consider for instance, abdominal aortic aneurysm (AAA) repair. Since the 1960s, AAA repair has required a large belly incision, direct stress to the heart, intensive care unit monitoring, four to ten days in the hospital, and four to six weeks to full recovery. Now there is a better way.

Two endovascular devices recently released by the FDA allow repair of an AAA with two small groin incisions, decreased anesthesia, no intensive care unit requirement, less than two days in the hospital and full recovery in a matter of days. These devices are being employed at New Hanover Regional Medical Center. The hospital was chosen as one of a small number of centers in North Carolina for initial use because of its physicians’ recognized expertise in vascular surgery.

The aorta is the largest blood vessel in the body. It runs from the heart through the chest and abdomen and branches into two major arteries that supply blood to the legs. Branches of the aorta supply blood to all the major organs of the body. AAA occurs in the part of the aorta between the branches to the kidneys and the branches to the legs. Patients with an AAA may notice a mass with a heartbeat located between the solar plexus and the belly button.

Normally, the diameter of the aorta ranges from 1.5 to 3 centimeters or about one inch. It is considered aneurismal when the diameter is twice its normal size. AAA occurs four times more frequently in men than in women and is more prevalent in the population over 50 years of age.

An AAA is a bulge in the aorta resulting from a weakness in the wall. The exact cause of the weakness is under investigation but it is related to atherosclerosis (hardening of the arteries), cigarette smoking, and high blood pressure. The bulge may continue to expand until the aorta ruptures causing massive bleeding. This occurs in approximately 15,000 patients each year in the United States making it the thirteenth leading cause of death. The larger the aneurysm becomes, the more likely it is to rupture. The goal of the physician caring for a patient with an aneurysm is to prevent rupture.

AAA rarely causes pain or problems and may not be diagnosed until rupture. Most aneurysms today are found during routine examination as a pulsatile abdominal mass or during x-rays for other problems. It is known that aneurysms tend to occur within families and smokers die four times more frequently with ruptured AAA than nonsmokers. Anyone with a family member who has an AAA should be examined by their physician and considered for an aortic ultrasound, a sound wave test that can rapidly detect the presence and size of an aneurysm.

The current standard for repair of AAA requires an open belly incision from the xiphoid process (solar plexus) to the symphysis pubis (pelvic bone). The aorta must be clamped to temporarily stop the flow of blood while a polyester or Dacron tube is sewn in place to replace the bulging blood vessel. This creates a significant resistance to the flow of blood from the heart and stresses the heart muscle. While very safe when performed by experienced surgeons, this operation may result in heart attack, kidney failure, incision pain, need for blood transfusion, intensive care monitoring, prolonged hospital stays and a four to six week recovery time.

The endovascular AAA repair devices released by the FDA in September of 1999 have enjoyed excellent track records in their initial deployment. A polyester tube is attached to a metal stent to form a device called a stent graft. This graft is housed in a tube comparable in diameter to a fountain pen and can be passed into the aorta from small openings in the leg arteries at the groin. Under x-ray guidance, the stent graft is then opened inside the aorta without the need to stop the flow of blood and seated inside the bulging vessel to provide a new channel of blood flow. The excluded blood in the aneurysm sac clots and the blood flow is channeled through the stent graft to the arteries branching to the legs. The blood pressure is transmitted to the stent graft walls rather than the thin wall of the aneurysm and the risk of rupture will be significantly reduced.

The advantages of endovascular AAA repair are minimal skin openings, the lack of the belly incision, and the minimal stress on the heart. This provides the patient with decreased pain, anesthesia, chance of blood transfusion, intensive care monitoring, number of days in the hospital, and recovery time at home.

Thanks to new technology and creative applications, the goal of preventing aneurysm rupture is achieved using a less painful and more “user friendly” method with endovascular AAA repair. Good news for our patients from the world of medicine.