Aneurysm: Surgical Therapy

1st order in aneurysm of the vessels supplying the brain.

  • Clipping – open microsurgical operation in which, after opening the skull, the aneurysm is isolated at its neck with a titanium clip

1st order in thoracic aortic aneurysm.

Conventional surgery with opening of the thorax (chest) via sternotomy (longitudinal transection of the sternum) with use of the heart-lung machine (HLM); the following procedures are possible:

  • Aortic arch replacement – partial/complete aortic arch replacement.
  • Composite replacement – combined aortic valve and aortic vessel prosthesis.
  • David operation – use of a vascular prosthesis and reconstruction of the aortic valve.
  • Supracoronary replacement – insertion of a vascular prosthesis above the openings of the coronary arteries; aortic valve replacement if necessary.

1st order in abdominal aortic aneurysm (AAA).

  • Interventional procedure (see EVAR below) with insertion of a stent prosthesis (“vascular stent”) or conventional surgery with opening of the abdomen and suturing in of a vascular prosthesis:
    • Patients who have been denied open aneurysm repair (OAR) because of age and comorbidities (concomitant diseases) may be treated with endovascular aneurysm repair (EVAR), a minimally invasive procedure.
    • In patients with low-risk profiles, the two methods, EVAR and open surgery, compete.
    • After endovascular treatment, to detect complications (endoleaks or stent migration), regular monitoring of the stent prosthesis is recommended. Stent prosthesis open rates are 93-98%.
  • Indication in nonruptured AAA (= nrAAA): 5.0-5.5 cm (men); > 4.5 cm (women).

Operative measures for aortic dissection

Stanford A = DeBakey type I/II (80%) Stanford B = DeBakey type III (20 %)
Localization Ascending aorta (ascending aorta) or aortic arch Descending aorta (descending aorta)
Surgery indication >55 mmNote: More than half of thoracic aortic dissections occur at diameters less than 55 mm
Symptoms
  • Severe thoracic pain, wandering.
  • Radiation between shoulder blades, in back and abdomen.
Therapy
  • Absolute indication for surgery!
  • Blood pressure reduction
  • Type B dissection without complications:
    • Conservative (surgical lethality is higher than the risk of spontaneous rupture).
    • Consistent blood pressure reduction!
    • Treatment of cardiovascular risk factors.
  • Surgery (see above) if complications are imminent:
    • Malperfusion (reduced blood flow).
    • Neurological symptoms
    • Hematothorax (accumulation of blood in the thorax).
    • Increase in size false lumen > 6 cm
Lethality (mortality related to the total number of people suffering from the disease).
  • Without surgery: 30-80% within 24 h.
  • With OP: 15-20% after 1 month
  • Without surgery: 10% after 1 year
  • With OP: 20% after 1 month

More hints

  • Small nonruptured intracranial aneurysms (“inside the skull“) do not necessarily require treatment if the diameter does not exceed 7 mm. In such cases, the risk of rupture is very low, well below 1%. Patients with minianeurysms can still expect 19.40 years of life in full health (Quality Adjusted Life-Years, QALY) with the strategy that did not include therapy or preventive follow-up. The “coiling” treatment decision (neurosurgical angiography-assisted endovascular embolization procedure) resulted in 17.53 QALY.
  • Later surgery worsens survival: In England (men: 63.8 mm; women: 61.7 millimeters mm), abdominal aortic aneurysm is operated significantly later than in the United States (men: 58.2 mm; women: 56.3 millimeters mm) with the consequence of a mortality (death rate) three times higher than in the United States: odds ratio 3.60 (3.55-3.64).
  • Endovascular aneurysm elimination (EVAR; Endovascular aneurysm repair) using stent-graft (“vascular stent”) systems is known to be associated with significantly lower perioperative mortality (mortality in the time surrounding the surgical procedure) than open surgery. This survival advantage persisted for about three years, after which the survival rates in both groups equalized, as long-term results (observation period: max. 8 years) of a large study could prove.
  • Abdominal aortic aneurysm (AAA): comparison of endovascular aneurysm repair (EVAR) versus aneurysm repair (OAR):
    • 30-day mortality: EVAR approximately 1.5% versus OAR approximately 4.7%.
    • After 3 years: mortality rate for both procedures approximately 19.9%; re-interventions: EVAR 6.6% versus OAR 1.5%.
  • Abdominal aortic aneurysms: Open surgery (OAR) was superior to EVAR in the long term in a long-term study. This is attributed to the fact that vascular prostheses are more prone to complications in the long term. After six months, no mortality benefits (mortality advantages) of EVAR were detectable. In the further course, mortality (mortality) continued to increase in this collective and reached the significance level at about the eighth year. After a mean of 12.7 years, all-cause mortality was 25% higher after EVAR (adjusted hazard ratio 1.25; 1.00-1.56). Aneurysm-related mortality was even almost 6-fold higher (adjusted hazard ratio 5.82; 1.64-20.65).