Wed. Apr 14th, 2021

Those who don’t Realize that they are living with an abdominal aortic aneurysm can withstand sudden aortic rupture or tear and massive, catastrophic bleeding. However, others know in advance that they have a small, stable AAA, which is the luxury of their time to consider Treatment options – From watchful waiting to minimally invasive procedures to all-out open surgery. Here’s how doctors and patients decide when and in what kind of elective surgery they will do.

The aorta is the large, central artery that carries blood from the heart to your body. The upper segment within the chest is the thoracic aorta, and the lower segment is the abdominal aorta. Because the aorta gains pressure with each beating, parts of the aortic wall can be gradually weakened in those at risk. aortic dissection A tear is included in the aortic wall, separating the layers. Aneurism, a bulge or balloon in the artery wall, is more common in the abdominal aorta. A broken abdominal aortic aneurysm is a medical emergency.

Grafts are used to fix the weak aorta.
(Timothy Phelps and James Black MD, Johns Hopkins Hospital)

By diagnosing an AAA early, while it is still small, doctors can carefully monitor patients while treating their risk factors – called watchful waiting.

“Diagnosis of aneurysms is made with imaging studies, which are done for some other reason,” Dr. Says Benjamin Starness, a professor and head of the vascular surgery division at the University of Washington. “The patients would usually come in because they had an X-ray or they did an ultrasound study for some other completely unrelated condition, and oh by the way, they found out that they had this aneurism.”

Some risk factors make you more vulnerable: Men, being 65 or older. A smoker And having high blood pressure Or hardening of the arteries. AAA family history also increases your risk. Medical management can keep AAA under control for years through watchful weighting, routine imaging studies, lifestyle changes and medication.

The risks of women are close to men at an early age, Drs. Says James Black, head of vascular surgery at Johns Hopkins Hospital. However, at 65 and beyond, AAA risk “clearly prevails” for men, he says. But “the problem is that when aneurism is more unsafe in women, they are at greater risk of rupture,” he says. “So we sometimes get more nervous about aneurism in women than men.”

For balance surgery

Elective surgery is far superior to emergency surgery, and most patients do well postoperatively. The question is when is it to happen.

Dr., vice chairman of Vascular Surgery at Boiler University Medical Center, Dallas. John Eidt says, “The most important predictor of aneurysm burst is the diameter of the aneurism.” “Just like the diameter of a balloon, if it reaches some critical point, it is likely to burst.” As for size, fusiform aneurism, which is somewhat of the shape of a football, is likely to be slightly less bursty than saccular-shaped aneurism, EDT says.

Doctors use serial imaging to see if an aneurism is growing and how soon. “We like to intervene if we see significant changes,” Edit says. “We will see patients every six months or every year to plot a curve, a growth curve, or an enlarged curve.”

The onset of symptoms is inauspicious. “Sometimes, aneurysms will actually start causing pain because they are growing fast or like pre-rupture,” Idit says. “We think, this is a very important discovery. It predicts the risk of breakdown and will almost always cause us to intervene.”

The patient’s unique history – including age, gender, and overall health – is an important piece of the puzzle. “If you’re young, you’re more likely to determine your aneurism if you’re older,” Edit says. “Your lifetime is more at risk of breakdown.”

Concomitant conditions such as heart, lung or kidney disease increase the odds of undergoing surgery, Eidt states: “If your natural history [aneurysm] Not too bad, and your risk of the procedure seems excessive due to comradeship, then we increase the size of the aneurysm that you will get appropriate treatment. “

Cardiovascular surgeon and vascular surgeonS Specialists in procedures involving the heart, major arteries and veins, and the entire vascular system that carries blood throughout the body. Board certification is a measure of a surgeon’s qualifications. You can check the status of a surgeon’s certification through American board of surgery Website.

Patients should feel free to ask questions about qualifications and experience. “I don’t think it’s unfair to say to a doctor, ‘Well, how many of these have you done?” “‘How many jobs do you do on an annual basis? And can you tell me how many of these are in your hospital?”

In addition, patients need to trust and feel comfortable communicating with their doctors, who need to be able to explain AAA conditions, treatment options, and risks in ways they can easily understand. .

“I almost always show a CT scan to the patient in real time,” Edit says. “We sit at the computer monitor and watch the CT scan together.” Current technology allows 3-D reconstruction, he says. “So I can show you an aneurysm like we were looking at the sea in Jamaica.”

Choosing your process

Surgical options for aneurysms include traditional open surgery and low-invasive endovascular repair.

Endovascular repair is performed under general or local anesthesia. A stent – a thin metal tube that forms the core of a “stent graft” – is directed through the femoral artery to the area of ​​the aneurysm.

“You don’t remove the aneurysm, but you put a liner – essentially a spring-loaded fabric sleeve – inside the aneurysm that essentially reinforces the inside,” Eidit says. “It prevents blood pressure from increasing or breaking the aneurysm.” Recovery is minimal and easy with this option. Patients can usually leave the hospital within the next one or two days.

Black, however, notes that fit correctly may be an issue with the stent, and not all patients are good candidates. Patients should be prepared to return regularly, usually annually, for CT scans to ensure that the device is functioning well.

Open surgery is always done under General anesthesia. A large incision is made perpendicular to the abdomen, across or beside the abdomen. The aneurysm is separated and opened between the surgical clamps, and a synthetic graft is sewn to replace the weakened part of the aorta. Surgical risks include bleeding, graft or wound infection, renal perforation and blood clots.

It is important to realize that open surgery is “a major operation,” EDT says, taking patients up to weeks or months to fully recover. The trade off is that the results can be long lasting. “When you complete the operation, patients almost never have procedure problems – it happens in a way and is done and you do well,” he says.

Depending on your age, aneurysm status, co-existing conditions, general health and personal preference, your medical team will help you decide the right treatment for you.

A study was published online in May. JAMA Surgery Compared to early mortality for alternative AAA repair procedures. “Overall, the hospital mortality was 0.7 percent. [endovascular repair] And for 3.8 percent [open AAA repair], “The researchers found. Other studies found fewer major complications with endograpts in the short term, but two years and, the survival rate is comparable.

“Endovascular repair, not yet a panacea,” A. With commentary notes. “Endovascular AAA repair has yet to rid itself of irritating endolics, requires re-intervention and is a persistent (albeit low) risk of AAA breakdown.”

Open repair of the abdominal aortic aneurysm was among a handful of high-risk therapies evaluated by the Lepfrog Group to determine factors important for proper, error-free hospital care. Leapfrog concluded that AAA surgery is safer in hospitals where Quantity performed There are 50 or more cases in a year. Most recent America’s News Best Hospital The rating for the first time includes repair of the abdominal aortic aneurysm which is one of nine common procedures and conditions in which hospital performance is evaluated.

Today, Eidt says, somewhere between 75 and 80 percent of all AAAs are treated with endografts as opposed to open repair.

One way to find hospitals with high volume and advanced expertise in both procedures is to look for aortic disease centers or aortic centers of excellence that focus on conditions such as AAA.

Most large hospitals, Eidat says, have endovascular operating rooms. He says, “There are specially designed hybrid spaces where people can combine open surgery and endovascular surgery, which is steadily growing in the management of these complex aortic cases.”

However, he says some smaller Community hospital “The aorta of the stomach provides a high standard of care with very good results in the treatment of patients with aneurysm. Therefore, per se hospital size is not a measure.”

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