CONDITIONS

Aortic Aneurysm

What is it?

Arteries carry blood away from the heart. The aorta, the main artery leading away from the heart, can sometimes develop an aneurysm. An aneurysm is an abnormal enlargement or bulge of the artery. An aneurysm can occur if the wall of the aorta is damaged by arteriosclerosis. Arteriosclerosis begins with damage to the innermost lining of an artery. Proven insults are high cholesterol, triglycerides or blood sugar in the blood, high blood pressure and tobacco smoke. Arteriosclerosis can weaken the walls of the artery leading to aneurysm growth. Over time, aortic aneurysms can grow, and as they become larger, are at increasing risk of rupture. Rupture of the aneurysm requires emergency surgery, is very difficult to treat and the vast majority of these patients do not survive. Aortic aneurysms usually occur in the abdomen below the kidneys (abdominal aortic aneurysm), though some occur at the level of the renal arteries, or at times are found in the chest. Most aneurysms are asymptomatic, and found incidentally on ultrasound or CT scans done for other reasons.

Now what can I do?

If you minimize your risk factors you will aid in preventing further damage to your arteries. Risk factors that you can control and improve are: STOP SMOKING TOBACCO, keep your cholesterol low, control your diabetes, lose weight, and become more physically active.

What are my treatment options?

Abdominal Aortic Aneurysm (AAA)

Larger aortic aneurysms can be managed with either open surgery, or minimally invasive endovascular aortic aneurysm repair (EVAR) with placement of stent grafts. Each patient has unique anatomy, and no single solution can treat everyone, however, as the technology has advanced almost all of our patients can be treated using the minimally invasive endovascular approach. It is critical that the treatment plan is individualized and fits the patient’s needs and their anatomic configuration. The surgeons at San Francisco Vein and Vascular Institute are experienced in both open surgery and endovascular stenting for the management of abdominal aortic aneurysms.

The endovascular treatment can now be performed without any incisions, and usually require just an overnight stay in the hospital. New technology is allowing endovascular stenting to be used in more complex aneurysms, such as those involving the renal arteries, and those with otherwise challenging anatomic configurations. In particular, we have experience using the latest technology for the most complex abdominal aneurysms. We have used fenestrated grafts (FEVAR) to treat aneurysms involving the renal and visceral arteries. These devices are custom built for the individual patient with fenestrations (a window or reinforced, precisely positioned hole in the graft) that allow for uninterrupted flow of blood to the liver, kidneys, and intestines. Having experience with all major types of endovascular grafts rather than just one or two, the surgeons at San Francisco Vein and Vascular Institute can offer a solution that is best for each individual patient, rather than trying to fit a square peg in a round hole.

For a small number of patients, endovascular stent grafts are not suitable due to various anatomic constraints. For these patients, open surgery may still be a good option. Open surgery involves replacement of the aortic aneurysm with a synthetic graft, that is sewn into place. An abdominal incision is required, and patients usually stay in the hospital for 5-7 days. While the open approach results in a durable repair the recovery is quite lengthy and extensive.

Thoracic Aortic Aneurysm (TAA)

Another area of expertise is the treatment of thoracic aortic aneurysms. Thoracic aortic aneurysms are less common than abdominal aortic aneurysms. They present a unique set of challenges as the aneurysm is closer to many of the vessels responsible for blood flow to the brain and spinal cord. In the last 15 years the technology has developed such that we are now able to treat many of these aneurysms using endovascular techniques (TEVAR), in most cases through tiny puncture sites in each groin rather than the traditional open approach utilizing a large chest incision. While experience in endovascular techniques is an essential component of any thoracic aortic interventions program, close collaboration with cardiothoracic surgical service is critical as well. In the treatment of these patients the cardiac surgeons at CPMC and the vascular surgeons at the San Francisco Vein and Vascular institute develop a treatment plan as team. Many patients are still best suited to open surgical repair. A 3rd frequently utilized approach is the hybrid¬Ě repair in which elements of both the open and endovascular approaches are utilized, often as a staged repair.

Regardless of the type of aneurysm at issue, an aneurysm treatment plan requires careful planning, including a comprehensive understanding of the available options. Our surgeons have the relevant expertise to enable us to create the individualized treatment plan that will provide the best result for each of our patients

Differences Open Approach Endovascular Approach
Selection criteria Size and growth rate of aneurysm
  1. Neck of aneurysm straight and not too large.
  2. Outflow from aneurysm not too large or too blocked.
Incision size/location Larger: abdomen Smaller: both groin creases
Surgery length 3-5 hours 2-3 hours
Hospital stay 5-7 days 2-3 days
Recovery time 4-6 weeks 2-3 weeks
Follow-up tests No Imaging required Abdominal ultrasound at 1 month, 5 months and annually thereafter.

What happens at the hospital?

  • Surgery is done as an inpatient. The day of your surgery, you must check in 2 hours before your surgery time.
  • Your procedure will be under anesthesia. You will speak with an anesthesiologist before your procedure.
  • After surgery, you may be monitored in the Intensive Care Unit (ICU). You can go home after you can get in and out of bed & walk independently.
  • You will be given a prescription for pain medication before you leave the hospital.

What should I expect after I go home?

  • Each day you will see improvement around your incision site and lessening of soreness. Bruising is a normal development.
  • You should resume normal eating and exercise patterns as soon as possible.
  • You should resume normal sleep/wake cycles as soon as possible.
  • You should shower regularly. You need to wash the wound vigorously with soap and water to prevent infections.
  • You may drive after about three (3) weeks when you feel safe.
  • You will be seen in our office 10-14 days after being home.

Scheduling your Surgery

  1. You will be notified of the date and time of your surgery by our office.
  2. You need a Physical Exam by your primary care physician within a month of your surgery. Call to schedule this appointment with him/her after you have your surgery date.
  3. You will also need to Pre-register with the hospital within 14 days prior to your surgery. Please bring your insurance card and a list of your medications.
    • (See Pre-registration Packet)CPMC, Pre-registration and Learning Center (415) 600-25001825 Sacramento Street (@ Van Ness Avenue). Call for an appointment to pre-register.
  4. The location to check in the day of your surgery is:
    • Open Surgical repair of AAA
      CPMC, Ambulatory Care Unit (ACU)
      2351 Clay St @ Webster St., 6th floor
    • Endovascular Surgical repair of AAA
      CPMC, Ambulatory Care Unit
      2351 Clay St @ Webster St., 6th floor
  5. You are not to eat solid food for or drink milk products 8 hours prior to surgery. You may drink ONLY clear liquids up to 5 hours prior to surgery.
  6. Doctor will see you at the hospital the day of your surgery.