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Questions every patient should ask their doctor
prior to signing a consent for vascular intervention.
Sponsored by the SCVS Ad Hoc Committee on Patient Advocacy.
- What is an aneurysm and what causes them?
An aneurysm is an area where the blood vessel (artery or vein) is enlarged or dilated. Where a normal artery may be an inch in diameter, in the area where the aneurysm is, the diameter is greater. Although the blood pressure within the aneurysm itself is the same as the rest of the body, the tension in the wall of the aneurysm is much greater and thus a tear with eventual rupture will cause internal bleeding. The larger the aneurysm, the higher the risk of rupture.
It is not known exactly what causes aneurysms. Several theories have been proposed including defects in the structural elements that provide strength to the wall of the blood vessel, damage caused by smoking and or high blood pressure and genetic defects which also affect the structural elements the blood vessel. Risk factors that are most commonly associated with aneurysms include cigarette smoking and high blood pressure. The most common aortic aneurysm occurs in the abdomen below the kidney arteries (infra-renal). These are frequently associated with aneurysms in the iliac arteries (the blood vessels that travel through the pelvis to each leg) and occasionally the popliteal artery (the blood vessel behind the knee). Aortic aneurysms can run in families particularly if more than one family member has had an aneurysm or the aneurysm you have is not associated with the usual risk factors such as smoking and high blood pressure. If so, an ultrasound examination of the abdominal aorta in first degree relatives over the age of 50 is advisable.
- I have no symptoms, so why should I consider repair?
Most aneurysms including aortic aneurysms do not cause symptoms. The first symptom may be a sign of rupture and internal bleeding often manifested as severe abdominal pain. Aortic aneurysms are frequently discovered on physical examination or imaging studies done for another reason in patients without symptoms. In the absence of rupture, aneurysms may cause abdominal discomfort, the feeling of pulsation in the abdomen, new or increased back pain, lower extremity swelling from compression of nearby structures, abdominal fullness after eating small amounts of food, and sudden loss of circulation to the legs.
Elective repair of aortic aneurysms is performed to eliminate the risk of rupture. Rupture most often results in death and patients who survived a rupture with emergency repair frequently will have major complications. The risk of rupture is increased with larger aneurysms. Thus repair is recommended taking into consideration the size of the aneurysm, overall risk of the intervention, and the life expectancy of the patient. As a general rule, aneurysms greater than 5 cm (2 inches) in acceptable risk patients should be considered for repair. Smaller aneurysms in patients with symptoms may also be considered for repair.
- What are my options for treatment of my abdominal aortic aneurysm?
Options for treatment of an aortic aneurysm include continued observation and intervention. Continued observation is recommended for smaller aneurysms that are asymptomatic. Imaging studies (ultrasound or CT scan) are repeated at timed intervals (6 to 12 months) to monitor the size of the aneurysm. If the aneurysm enlarges by more than .5 cm per year or reaches 5.5 cm or greater, intervention is usually recommended. During observation, patients should monitor and maintain normal blood pressure, refrain from cigarette smoking, and avoid strenuous activity.
The options for intervention include open surgical repair, or a minimally invasive endovascular repair with stent grafts. Open surgical repair involves an incision in the front or side of the abdomen with replacement of the aneurysmal segment with an artificial graft. Ar minimally invasive repair usually involves insertion of stent grafts to exclude the aneurysm from circulation through incisions or punctures in the groin.
- What are the risks of continued observation?
The risk of rupture of small (less than 5 cm) aortic aneurysms is very small but not zero. Continued monitoring is necessary to detect the aneurysms that are growing in size. Control of blood pressure is essential to reduce the risk of rupture during observation. In general, the risk of rupture of an aneurysm less than 5 cm is less than 5% per year. Development of symptoms is another indication to consider intervention. Continued cigarette smoking is associated with an increase in the risk of rupture.
- How long do I stay in the hospital after intervention and how long is the recovery?
The hospital stay after intervention will depend on the type of repair performed (open surgical or endovascular) and whether or not any complications have occurred. In the absence of complications, most patients will be in the hospital from 5 to 8 days after open surgical repair. Hospital stay after a minimally invasive, endovascular repair is usually one to two days. After open surgical repair, patients will spend one or two days in the intensive care unit whereas after endovascular repair, intensive care unit monitoring is usually not necessary. Significant complications can extend the hospital stay.
Most patients feel fully recovered after open surgical repair 6 to 8 weeks after surgery. During that recovery period, they are ambulatory and performing modest activities. After endovascular repair, most patients feel fully recovered within one to two weeks after intervention resuming normal activities usually within a few days after discharge.
- What restrictions in activities do I have now that I know I have an aneurysm?
There are no specific restrictions in activity, but it is important that your blood pressure is well controlled if you have high blood pressure. So if it is decided to observe your aneurysm consistent medical management of your blood pressure is very important. Exercise in moderation is acceptable; lifting and carrying objects is also not restricted.
- Are there any medications that I can take to treat my aneurysm instead of an operation?
Although there is much interest in finding a medical treatment for aortic aneurysms, none has been discovered at this time. Good control of your blood pressure and the use of beta blockers (a medication which slows the heart rate and force of heart contraction) are helpful in slowing aneurysm growth. No medication is available that stops aneurysm growth or causes the aneurysm to decrease in size.
- Do the minimally invasive (endovascular) aneurysm repairs last? Will I need to have more operations in the future?
Over the past decade thousands of minimally invasive (endovascular) aneurysm repairs have been performed. This has provided us with a good idea of the durability of the repair. Following a minimally invasive repair, approximately 15% of patients will require additional procedures to maintain the repair. Most of these procedures are minimally invasive where additional stents are placed to repair leaks that may develop over time. In 1-2% of patients, the leaks that develop are so severe that removal of the device with open repair of the aneurysm is required. These procedures when necessary require an abdominal incision and the use of a graft to replace the area of the aorta that has the aneurysm.
- What is the chance that I have another aneurysm somewhere else? Should I have additional studies to find the other aneurysms?
The location of your aneurysm is the most common site for aneurysm formation. Aneurysms can involve any vessel in the body, but these aneurysms are very uncommon. A CT scan is the best way to screen for additional aneurysms. This will reveal aortic aneurysms in other locations and other aneurysms that might be present in branch vessels of the aorta. Aneurysms of the arteries of the lower extremity can be detected in most instances by a simple physical exam. Brain aneurysms are a completely different from aortic aneurysms. Consequently studies to detect brain aneurysms are not necessary.
- What to ask your surgeon.
It is important to ask your surgeon his/her experience with aneurysm repairs and what the results have been including how long you will be in the hospital and the potential complications. Depending on a variety of factors, your surgeon may recommend a minimally invasive repair or open surgical repair. These repairs are very different so it is important for you to ask your surgeon his/her experience with each type of repair.
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