1. What is an Aneurysm?
An aneurysm is a stretching of a weakened artery, which balloons out rather like a worn motor car tyre. The wall of the artery becomes thinned by loss of its elastic tissue and the artery then inflates making it likely to burst. The most common artery to be affected is the aorta, which is the main artery in the abdomen (tummy).
Many thousands of people each year suffer from rupture of an abdominal aortic aneurysm. Most of these patients are men over the age of 60 years. Smoking and high blood pressure are known to increase the risk.
2. How is Abdominal Aortic Aneurysm detected?
Ultrasound scan of AAA
Some patients have the aneurysm diagnosed coincidentally when they are examined for another problem, or if they have a scan for a different reason (kidney trouble, or gallstones, for example). Occasionally, the patient may become aware of a feeling of pulsation in the abdomen. As the aneurysm stretches, it can also cause pain in the back or abdomen. If an aneurysm is suspected, your GP will refer you to a specialist Vascular Surgeon for advice; either your GP or specialist will order an ultrasound scan. Ultrasound scanning of the abdomen is a painless outpatient test that only takes a few minutes to do. It is used to decide whether an aneurysm is present and to measure its exact size.
3. Who is at risk?
It is known that men over the age of 60, younger men with a brother or father who has had an aneurysm, or men with other arterial disease (angina, hardening of the arteries or high blood pressure) are at risk. In some areas, people at increased risk of having an abdominal aortic aneurysm are being offered screening by ultrasound scan.
4. Do I need surgery?
Not all aneurysms need an operation. The risk of rupture and therefore the need for repair depends on the size of the aneurysm. If the aneurysm is large (more than 5.0cms in diameter), it is probably safer to have an operation to repair it than to leave it alone. This protects the aorta from rupture. Smaller aneurysms are usually observed by repeat scanning at 6 to 12 monthly intervals, in case they enlarge and become dangerous. Average enlargement is about 0.5cm per year, so surgery may be required at a later stage. Your specialist Vascular Surgeon will give you a clear explanation of the options in your case.
5. What does surgery involve?
Current surgical treatment involves the insertion of a new lining into the aorta (like the inner tube of a tyre) made of a very strong plastic material called Polyester. This will last up to 20 years, or more. The operation is done through an incision in the abdomen.
6. Is surgery successful?
If aneurysms are repaired before they rupture, there is a high overall chance of successful repair and a return to normal life expectancy. However, you should discuss the risks of surgery in your particular case with your surgeon.
7. How can I help myself?
There is nothing you can do about the aneurysm. However, improving your general health by taking regular exercise, losing weight and stopping smoking is helpful even if you do not need an operation at present.
8. Why do I need the operation?
Because the main artery (aorta) in your abdomen has stretched and weakened (aneurysm). This operation is to repair the stretched section so that it will not rupture (burst).
9. Before your operation
You will usually be admitted to hospital one or two days before your operation or you will be asked to attend a pre-admission clinic about a week earlier in order to allow time for tests required. This is to ensure that you are fit for your operation. These tests may include scans of the abdomen or x-rays of the arteries (arteriogram) if these have not already been done. Special scans of your heart to check that it is working properly may also be needed.
10. Coming into hospital
Please bring with you all the medications that you are currently taking. You will be admitted to your bed by one of the nurses who will also note down your personal details in your nursing records. Prior to surgery, you will undergo a number of investigations, if these have not been performed previously, including a heart tracing, a chest x-ray and blood tests. You will be visited by the Surgeon who will be performing your operation and also the doctor who will give you the anaesthetic. If you have any questions regarding the operation please ask the doctors.
11. The operation
You will initially be taken to a reception area in the theatre suite, then to the anaesthetic room where you will be given your anaesthetic, and then into the theatre. While asleep, you may have a small tube placed in your back (epidural) to help with pain relief following surgery. Also, tubes will also be inserted into your bladder to drain your urine, into your stomach (via your nose) to stop you feeling sick, and into a vein in your neck for blood pressure measurements and administration of fluid following surgery. You will have a cut either down or across your abdomen and occasionally it is necessary to make a smaller cut in one or both groins (see figure 3).
The aorta, and particularly the swollen area, will be replaced by an artificial blood vessel made of polyester as shown in figures 4-6.
More extensive disease can result in the aneurysm extending into the iliac arteries as shown over.
In these circumstances a bifurcated graft is used to replace the damaged areas as opposed to a straight graft (see fig 8).
12. After the operation
You will usually be taken to an intensive care unit following your operation in order to monitor your progress closely. It is sometimes necessary for you to remain on a breathing machine for a period after the operation but you will be taken off this as soon as possible. Following this sort of surgery, the bowel stops working for a while and you will be given all the fluids you require in a drip until your bowel will cope with fluids by mouth. A blood transfusion may also be required. The nurses and doctors will try and keep you free of pain by giving painkillers by injection, via a small tube in your back (epidural), or by a machine that you are able to control yourself by pressing a button. As the days pass and you improve, the various tubes will be removed and you will be returned to the normal ward until you are fit enough to go home. A pulmonary therapist will visit you before and after your operation. This is to help you with your breathing, which will reduce the risk of you developing a chest infection. A physical therapist will assist you with your walking, ambulation and help you to regain your physical strength.
13. Going home
If dissolvable stitches have been used, these do not need to be removed. If your stitches or clips are the type that need to be removed, and this is not done whilst you are still in hospital, the practice or district nurse will remove them and check your wound. You will feel tired for many weeks after the operation but this should gradually improve as time goes by. Regular exercise, such as a short walk combined with rest, is recommended for the first few weeks following surgery, followed by a gradual return to your normal activity.
Driving: You will be safe to drive when you are able to perform an emergency stop. This will normally be at least 4 weeks after surgery, but if in doubt check with your own doctor.
Bathing: Once your wound is dry, you may bathe or shower as normal.
Work: You should be able to return to work within 1-3 months following your operation. If in doubt please ask your doctor.
Lifting: You should avoid heavy lifting or straining for 6 weeks after the operation. You will usually be sent home on a small dose of aspirin if you were not already taking it. This is to make the blood less sticky. If you are unable to tolerate aspirin an alternative drug may be prescribed.
Chest infections can occur following this type of surgery, particularly in smokers, and may require treatment with antibiotics and physiotherapy. Slight discomfort and twinges of pain in your wound are normal for several weeks following surgery, but wounds sometimes become infected and these can usually be successfully treated with antibiotics. Also the wound in your groin can fill with a fluid called lymph that may leak between the stitches but this usually settles down with time. As with any major operation such as this, there is a very small risk of you having a medical complication such as a heart attack. The doctors and nurses will try to prevent these complications and deal with them rapidly if they occur. Occasionally, the bowel is slow to start working again but this requires patience and fluids will be provided in a drip until your bowels get back to normal. Sexual activity may be affected due to nerves in your abdomen being cut during the operation.
15. What can I do to help myself?
If you were previously a smoker, you must make a sincere and determined effort to stop completely. Continued smoking will cause further damage to your arteries and your graft is more likely to stop working. General health measures such as reducing weight, a low fat diet and regular exercise are also important.