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Surgery

Minimally invasive surgery repairs potentially fatal aortic aneurysms

09/01/2006

Endovascular Surgery

About 15,000 people die each year as the result of a ruptured aortic aneurysm – the “silent killer” that is the 13th leading cause of death in the United States. These deaths are preventable if the aortic aneurysm is diagnosed and repaired before it ruptures. Some 40,000 patients undergo such repair each year.

The advent of endovascular aneurysm repair (EVAR) has made such procedures safer and more comfortable
for many patients. EVAR offers the advantage of a minimally invasive technique, a hospital stay of one to two days (compared with seven to 10 days for the conventional open surgical procedure), a rapid return to normal physical activity (one week versus up to eight weeks), and a reduction in the mortality and complication rate associated with major invasive surgery. EVAR may be preferred in high-risk patients, such as those who are older and/or with increased risk factors such as heart disease, kidney disease, lung disease, or other conditions or circumstances.

Recently, the U.S. Preventive Services Task Force – an independent panel of medical experts that advises the federal Agency for Healthcare Research and Quality – recommended that all men ages 65 to 75 who have ever smoked have an ultrasound screening test to see if they are developing an aortic aneurysm. (Annals of Internal Medicine, Feb 2005, Volume 142 Issue 3, Pages 198-202.) The screening was not recommended for women because they are at lower risk for developing aortic aneurysms.

Symptomatology of an aortic aneurysm

Thoracic or abdominal aortic aneurysm can be quickly, painlessly and inexpensively diagnosed with ultrasound examination. Unfortunately, most patients are diagnosed almost accidentally. Aortic aneurysms are often discovered during an imaging study done for some other reason.

While an aortic aneurysm may be asymptomatic, some indicators may suggest its presence. About half of patients with a thoracic aortic aneurysm experience symptoms that, depending on the location of the defect, may include pain in the jaw, neck or lower back; chest or back pain; coughing, hoarseness or difficulty breathing. Symptoms of an abdominal aortic aneurysm may include a pulsing feeling similar to a heartbeat in the abdomen; severe, sudden pain in the abdomen or lower back; pain, soreness or discoloration of the feet.

Who is a candidate for endovascular repair?

Because of the dangers associated with treating the body’s largest blood vessel, intervention generally is not recommended until an aortic aneurysm grows to 5 or 6 centimeters in diameter and the risk of rupture exceeds surgical risks.

About 50 percent of patients with aortic aneurysm meet the anatomical criteria to be viable candidates for EVAR. Arteries need to be of a certain size to accommodate the catheter and graft, and there must be sufficient viable vessel above and below the site of the aneurysm for the graft to attach without leakage.

New and innovative procedures that combine endograft with a less invasive open surgery also are being developed. Endovascular surgeons are working with colleagues in vascular surgery to develop techniques of combined procedures that can render the aorta amenable to endovascular repair. If a thoracic aneurysm comes close to the origin of the iliac artery, for example, a smaller open procedure can be done through the abdomen to move the artery, and then endovascular repair of the aneurysm can be accomplished.

About the procedure

The endovascular approach is currently used to treat abdominal and descending thoracic aneurysms, and is being evaluated as a treatment for thoracoabdominal and arch aneurysms. Unlike open repair of an aortic aneurysm, which involves a lengthy incision to access the thoracic or abdominal cavity, endovascular repair requires only two small incisions and can be done under regional anesthesia. Catheters are introduced through the incisions in the groin and, guided by fluoroscopy or other imaging technology, are threaded through the femoral artery to deliver a woven polyester and titanium, self-expanding endograft to the site of the diseased segment of the aorta to reline the vessel, removing the aneurysm from the pathway of the blood flow and eliminating the risk of rupture.

The procedure generally takes two to three hours, which is about half as long as a traditional open repair. The endovascular procedure results in essentially the same reconstruction as is achieved with conventional open repair while avoiding a major incision.

Contact information

Ramin Beygui, M.D.
Assistant Professor of Surgery
Division of Cardiothoracic Surgery
(310) 267-4385

William J. Quinones-Baldrich, M.D.
Professor of Surgery
Division of Vascular Surgery
(310) 825-7032

Peter F. Lawrence, M.D.
Professor of Surgery, Chief of Vascular Surgery
Division of Vascular Surgery
(310) 267-0182





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