How are AAAs treated?
Most aneurysms are related to atherosclerosis, or plaque in the arteries. In fact, the most common cause of death in people with AAAs is not aneurysm rupture but rather other cardiovascular events such as heart attack or stroke. Thus, medical treatment for cardiovascular disease is the cornerstone of the medical treatment of AAAs. The only treatment for the aneurysm itself is surgical intervention; there is no pill or medicine that has been shown to reverse aneurysms once they have started to form.
There are two different methods a surgeon or other vascular specialist might choose to treat an aneurysm:
| Open repair/traditional repair | Endovascular aneurysm repair (EVAR) |
|---|---|
| Diseased aorta removed | Stent graft relines diseased aorta |
| Synthetic graft sewn into place | Performed under continuous X-ray (fluoroscopy) |
| Hospital stay: 5-10 days | Hospital stay: 2-5 days |
| Recovery period: 1-2 months | Shorter recovery period than open repair |
| Periodic imaging studies required for follow-up |
Open repair/‘traditional repair’
An incision is made in the abdomen and the aorta is clamped above and below the diseased portion to stop blood flow. The aneurysm sac is opened and a synthetic graft (or tube) is sewn into place. The average length of hospital stay following open repair is 5-10 days with a period of observation in the intensive care unit (ICU) immediately following surgery. Potential risks and complications of open repair include bleeding, infection of the graft, surgical wound infection, heart attack, stroke, lung complications, death, and, rarely, nerve or spinal cord damage (paralysis). Another possible risk of open surgery is sexual dysfunction after surgery. Patients should discuss this issue with their physicians before surgery.
The prognosis for open repair of an AAA depends on the overall health of the patient prior to surgery. Generally, patients will return to their previous daily routine within 1 or 2 months after surgery.
Endovascular repair (EVAR)
A stent graft is introduced into the aorta through incisions made in the patient’s groin. A stent graft is a synthetic tube that also has a stainless-steel scaffold attached to it to reline the inside of the aorta. The stent graft is packed down into a delivery system and deployed between two healthy portions of aorta. This graft relines and strengthens the weakened walls of the aorta and seals off the aneurysm sac. The surgery is performed under continuous X-ray (fluoroscopy) to help the surgeon guide the stent graft to the correct location in the aorta. The average length of hospital stay is 2-5 days, and this may require a period of observation in the ICU.
Potential risks and complications of endovascular repair include bleeding, infection of the stent graft, surgical wound infection, leakage of blood from the graft into the aneurysm sac, graft movement or separation of components of the graft, kidney failure, death, and, rarely, nerve or spinal cord damage (paralysis). Because this is a minimally invasive approach to aneurysm repair, many patients find the recovery to be shorter than for open surgery.
Innovations in treating complex aortic aneurysms
Endovascular repair of AAAs allows for the treatment of high-risk patients who would not be good candidates for traditional open repair. High-risk patients with heart, lung, or kidney problems would typically not do well with open repair due to the high risk of the surgery. Over the past decade, advances in surgical techniques and graft construction, in addition to carrying a lower rate of perioperative complications and death, have made EVAR a preferred choice for elective aneurysm repair. Current clinical research trials aim to make EVAR available to patients with more complex aortic anatomy through the development of customized stent grafts, and to increase the range of aneurysms that can be treated with commercial ‘off-the-shelf’ grafts.