Therapy of the aortic aneurysm

Overview – Conservative

A conservative therapy of aortic aneurysm includes waiting with regular ultrasound scans. The therapy is indicated mainly for small aneurysms and those of type III. The aortic aneurysm must not increase in size by more than 0.4 cm per year.

Furthermore, the accompanying or causative diseases must be treated. It is essential to ensure that the blood pressure is adjusted. The blood pressure of aneurysm patients should not exceed 120:80 mmHg.

Overview – Interventions

In younger patients with small aneurysms or trauma to the descending aorta, radiological therapy may be indicated. A groin vessel is opened parallel to imaging, a plastic-coated tube (stent) is inserted into the vascular system by means of a catheter and advanced to the aneurysm site. An advantage of this therapy is the avoidance of a costly surgery, a disadvantage is the reduced sealing of the aneurysm site. Surgical therapy is necessary if the aneurysm is symptomatic or ruptured (emergency surgery). Non-symptomatic aneurysms may also require surgery under certain circumstances (see below).

Operation of an aortic aneurysm

First of all, during the operation the chest is opened and the vessels are displayed. It is necessary to separate the affected vessel from the rest of the bloodstream during the operation so that the operation can be performed without bleeding (cross-clamping of the aorta). The so-called heartlung machine is used to divert the blood that normally flows through the aorta.

In the case of bag-shaped aneurysms, the sacculation is removed and the rest sutured. In the case of short-stretched aneurysms, the exposed ends of the aorta are brought together again and sutured after the removal of the bulge. Aneurysms of dissecan type I and II are treated with a plastic prosthesis.

For this purpose, the prosthesis is pre-treated in a so-called blood bath shortly before surgery. This causes the blood to flow around and seal the plastic. During the operation, this so-called stent is then placed at the site of the aneurysm.

To do this, it must be opened, the stent inserted and then the aneurysm sutured over it. An indication for surgery is an increased risk of rupture, i.e. tearing of the aortic aneurysm. The risk of dying from a spontaneous rupture must be greater than the risks of surgery.

In principle, a diameter of the aneurysm of more than 5 cm is considered the limit for a relevant risk. The more risk factors are involved, the more likely surgery is advisable. Further factors are: Even non-symptomatic aneurysms are an indication for surgery, if the final decision for surgery should be made by an experienced vascular surgeon in consideration of all risk factors and other diseases of the patient.

  • Enlargement of the aneurysm by more than 1 cm per year
  • Irregular bagging of the wall
  • Still existing blood flow in the wrong lumen
  • High blood pressure
  • Chronic lung disease (COPD)
  • Inflammation of the aorta
  • Nicotine consumption
  • Family cluster.
  • Patients are younger than 70 years of age and have no risk factors for surgery.
  • These are elderly patients with aneurysm sizes of more than 5-6cm.
  • If Marfan syndrome patients have an aneurysm diameter of more than 4 cm.

Basically, a distinction can be made between an open surgical procedure and a so-called Endovascular Aneurysm Switching (EVAR). As a rule, minimally invasive EVAR is preferred because it is less stressful for the patient than a large open procedure. In the long run, however, the advantages and disadvantages of both procedures balance each other out.

With EVAR, a prosthesis (so-called stent graft) is advanced through the groin artery to the aneurysm via a catheter procedure, similar to the implantation of a stent after a heart attack, in order to bridge the aneurysm after the stent graft has been deployed. However, certain conditions must be met, such as a certain distance from the vessels leading from the aorta, low calcification of the arteries or good kidney function. CT scans must be performed at regular intervals to monitor the stent graft, but this is often an exclusion criterion for young patients.For more complicated aneurysms or young patients the open procedure can be chosen.

The abdominal cavity is opened either with an abdominal incision (median laparatomy) or a flank incision (retroperitoneal approach), the organs are carefully pushed to the side and the aorta is exposed, so that healthy vessel walls can be seen at the top and bottom of the abdomen. The aorta is then clamped and the aneurysm replaced by a vascular prosthesis. In the case of an aneurysm of the aorta near the heart in the thorax, a heart-lung machine must be used.

The duration of the operation depends largely on the selected procedure. Minimally invasive EVAR usually takes less time than open surgery because the access route via the groin to the aorta is more direct and faster. EVAR takes on average one and a half to two hours, open surgery at least three – or longer, depending on the complications.

Initially, a distinction is made between risks that are directly related to the operation and risks that may still occur years later. The direct perioperative risks are significantly higher with open surgery than with EVAR. General risks are, as with any surgery, With open surgery the risk of blood loss or reduced blood supply to the abdominal organs is more relevant than with EVAR.

There is also a higher probability of damaging the nerve plexus around the aorta, which can lead to disorders during ejaculation. With EVAR, on the other hand, there is a higher risk that the prosthesis will become loose over time and slip within the aorta (so-called dislocation). In addition, so-called endoleaks can occur more frequently than with open surgery, in which the aneurysm is supplied with blood again despite the stent graft.

In both procedures, new aneurysms can develop in the long term, preferably at the edges of the inserted prosthesis, and insufficiencies of the suture can lead to life-threatening bleeding into the abdomen. The risk of dying during open surgery is on average 5-7%, but it is lower in a specialized center and with fewer risk factors. The risk of dying directly with EVAR is slightly lower, but in the long run the mortality rates balance each other out due to the increased complication rate with EVAR compared to open surgery. After five years, about 60-75% of patients are still alive.

  • Bleeding,
  • Injury to nerves,
  • Scarring and
  • Infections.