Endovascular Aneurysm Repair - Advantages and Complication

Introduction

An aneurysm is an abnormal ballooning of an artery due to its weakening or stretching. Aneurysms usually occur in the aorta, which is the main and largest artery in the body. It supplies blood from the heart to other parts of the body. The aorta that passes through the chest is called the thoracic aorta, and when it passes through the abdomen, it is known as the abdominal aorta. Normally, the aorta has a diameter of about one inch, and when it weakens, the artery tries to expand and causes a bulge leading to the formation of an aneurysm. When left untreated, the aneurysm may sometimes rupture and can lead to the individual's death.

What Is an Endovascular Aneurysm Repair?

Endovascular aneurysm repair refers to the treatment of an aneurysm by a minimally invasive technique. It uses specialized instruments and a stent graft material to be placed within the dilated artery to resume the usual blood flow. This helps repair the aneurysm alone rather than perform surgery on the whole artery.

What Causes an Aortic Aneurysm?

The following are the probable causes or the risk factors that damage or weaken the artery:

• Habits like smoking.

• High blood pressure.

• Injury to the artery due to trauma.

• Atherosclerosis (narrowing of an artery due to plaque buildup).

• Persons with conditions like Marfan’s syndrome (a disease affecting the connective tissue and weakening the artery wall).

• Infections like syphilis (a sexually transmitted bacterial infection). It is a rare complication in untreated patients of syphilis that weakens the artery and causes an aneurysm.

• Older adults.

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When Is an Endovascular Aneurysm Repair Required?

An endovascular aneurysm is indicated when the size increases by more than 5.5 centimeters. When left untreated, the aneurysm is prone to burst and lead to unfavorable complications. Another indication is when the patient experiences pain or notices a sudden increase in the size of the aneurysm. These situations require immediate treatment to prevent unfavorable outcomes.

Who Requires an Endovascular Aneurysm Repair?

The repair by the method of stent grafting is not indicated for all patients. There are a few situations that make the patient suitable for this procedure. They are:

• An unruptured aneurysm.

• A large aneurysm of more than 5.5 centimeters.

• A sufficient area is available within the artery to secure the stent.

• When other conventional methods increase the risk of complications.

Hence, an endovascular aneurysm repair is done only in patients satisfying the above conditions and in those who are unsuitable for conventional surgery that uses large incisions or cuts. The doctor discusses all the factors related to the surgery and decides the right option that suits each patient.

How to Prepare a Patient for Endovascular Aneurysm Repair Surgery?

• The doctor records the patient's detailed history, including the underlying medical conditions, and performs a physical examination.

• The doctor may run a few imaging tests to look into the condition of the artery and plan the treatment accordingly. They include ECG (electrocardiogram) to check the electrical activity of the heart, a CT (computerized tomography) scan to get a detailed view of the heart, blood tests (to check the presence of an infection or anemia), echocardiography to view the size of the aneurysm, and angiography (a radiocontrast dye injected into the blood vessel and an x-ray is taken to detect any blocks).

• The doctor will discuss the surgical procedure, and the patient signs a consent form as a willingness to start the procedure.

• If the patient is an active smoker, the habit must be quit at least two weeks before the surgery for proper healing.

• If the patient is under any medication, such as a blood thinner (Aspirin), it is stopped for a few days with the physician’s consent. Medicines such as vitamin E are also stopped two weeks before the surgery.

• The doctor prescribes medications that the patient has to consume before the procedure.

• Any allergy to the medication or anesthesia is noted to prevent complications after the surgery.

How to Perform an Endovascular Aneurysm Repair?

• The whole procedure is done under general anesthesia to make the process painless. The area to be operated on is cleaned, and the hair is shaved off.

• An incision or a small cut is made near the groin, and the femoral artery is located. The doctor usually performs an aneurysm repair on the abdominal aorta. A catheter (thin, flexible tube) is introduced into the incision made. The stent (a tiny tube) and the synthetic graft material are inserted over the catheter. An x-ray with radiocontrast dye is injected along the path to have a detailed view of the aneurysm and position the stent accurately.

• The graft is introduced into the aneurysm in a compressed form with a surrounding protective sheath. After reaching the aneurysm, the sheath is removed, and the graft that remains in place expands and adapts to the shape of the aneurysm. The final position is again checked with the x-ray, the catheter is removed, and the incision is closed with sutures.

When the aneurysm in the thoracic region has to be treated, a thoracic endovascular aneurysm repair is performed. The thoracic aorta extends from the aorta in the heart to the abdomen. The procedural steps are the same as above, but the location alone is different.

What Are the Advantages of Endovascular Aneurysm Repair?

• It is of a shorter duration than conventional surgery.

• Faster recovery.

• Less discomfort postoperatively.

• Blood loss during the surgery is less.

• Discharged within a few days from the hospital.

• Decreased risk of complications.

What Are the Complications That Occur After Endovascular Aneurysm Repair?

• General complications like allergic reactions to anesthesia, bleeding, pain, and blood clot formation.

• The stent might get blocked or start to leak, which requires additional surgery.

• Decreased blood supply to the legs, kidneys, and other organs.

• Problems with erection.

• Damage to the adjacent nerves causes numbness or tingling sensation in the legs.

• Kidney failure can occur due to administering a radiocontrast dye that may dilate the renal arteries or lead to their blockage.

• Infection can develop due to contamination of the stent by the bacterial growth around it.

The surgeon must be ready to deal with the complications and manage them immediately. If a situation arises to perform additional surgery, the patient is informed about the complication, and the necessary arrangements are made.

What Are the Other Types of Aneurysm Repair Available?

Apart from endovascular aneurysm repair, there are other options available. They include:

1. Open Aneurysm Repair: It involves making a larger incision and placing the stent into the aneurysm. The procedure takes longer than the endovascular repair and requires at least one week of hospital stay since the recovery is slow.

2. Hybrid Repair: It combines the open and the endovascular technique to use the benefits of both procedures, like the smaller incisions, endovascular stent, and an open repair.

3. Fenestrated Endovascular Repair: It is used to repair aortic aneurysms near the heart or arteries with multiple branches. Fenestrated endovascular repair consists of small openings to place additional stent grafts into the branches. This allows to fill all the branches affected by an aneurysm and provides a good outcome.

Conclusion

Endovascular aneurysm repair is a relatively simple procedure to manage the aortic aneurysm. Whether to choose the endovascular or the open type of surgery depends on the condition of the aneurysm and the underlying medical illness of the patient. In the long term, the outcome of endovascular repair is good, but if any complications occur, it requires additional surgery to manage them. A regular follow-up with the surgeon is scheduled to check the treatment progress.