ABDOMINAL AORTIC ANEURYSM
Patient information leaflet
What is an aortic aneurysm ?
The main blood vessel that comes from the heart is the aorta. It is the artery that takes blood to the body. Because of weakness caused by atherosclerosis it may balloon out - this is called an 'aneurysm'. The main risk factors are age, smoking, high blood pressure, high cholesterol level and a family history. Any part of the aorta may be affected (the part in the chest or in the abdomen). Most aortic aneurysms occur in that part of the aorta beyond where the blood supply to the kidneys is given off (called an 'infrarenal aortic aneurysm'). The aorta finishes by dividing into 2 arteries called the 'common iliac arteries'. These may also become aneurysmal.
What problems can they cause ?
Aortic aneurysms usually cause no symptoms. They may cause abdominal or back pain - this means that the aneurysm is about to rupture and requires an urgent operation to repair it. The aneurysm may rupture and cause severe abdominal pain and collapse. This is an emergency situation requiring immediate surgery. Unfortunately, the majority of patients with a ruptured aortic aneurysm die.
Because the aneurysm is full of clot, some of this may dislodge and travel to the legs. This debris gets stuck in the smallest arteries depriving the tissue beyond of its blood (ischaemia). This usually presents with a blue/black toe or part of the toe.
Will I need an operation ?
The decision to operate on an aneurysm, that is not causing symptoms, depends on its size and the risks involved. Recent trials have shown that aneurysms smaller than 5.5 cm can simply be observed. Once they are bigger than this an operation is considered if the risk of the aneurysm rupturing is greater than the risk of operating on it. The risk of the operation depends on your age, whether you have heart, chest or kidney problems or whether you have any other serious illness. Your consultant will discuss all of the risks with you before considering an operation.
What investigations will I need ?
Most aneurysms are diagnosed on an ultrasound scan (similar to that used in pregnant women). At Good Hope Hospital it may have been picked up as part of a screening programme. As the aneurysm grows its size is checked with regular ultrasound scans. Once it reaches a size where it needs an operation you will also have a CT scan - this gives information about the exact position of the aneurysm and can sometimes pick up other problems.
To assess your heart you may need an ECG (heart tracing), exercise tolerance test (heart tracing is done whilst you exercise on a treadmill), an echocardiogram (an ultrasound scan of the heart to tell us how well it is working) or a coronary angiogram ( an x-ray to look at the coronary arteries that supply the heart muscle - this is only done if the cardiologist, heart doctor, feels it is necessary).
What will happen before the operation ?
About a week before your operation, you will be requested to attend the hospital for a pre-admission clinic. Here you will be seen by a juniour doctor who will take a history from you and examine you. Please remember to bring all your tablets to this clinic. Blood tests, a heart tracing (ECG) and a chest x-ray, if necessary, will be taken.
On your admission date you will have to telephone the hospital to ensure that a bed is available for you. When a bed has been confirmed you can make arrangements to come to the hospital. You will need to bring with you soap, flannel, tooth brush and paste, comb/brush, shaving equipment if used, towel, night wear, dressing gown and slippers. Do not wear make up or nail polish. Do not bring valuables or too much money - only bring sufficient for a few telephone calls.
On the ward
You will usually be admitted the day before your operation. When you are admitted to the ward, the nurses will show you around the ward and again confirm all of your details.
You will be seen by the consultant surgeon on the evening before your operation when all details will be explained to you and you will be requested to sign a consent form. The anaesthetist will also see you before the operation. You will be required to starve form mid-night.
Because you will be undergoing a major operation we will need an ITU (Intensive Treatment Unit) bed for you to go to afterwards. We will not know until the morning of the operation whether this is available. If it is not, your operation may be cancelled until a bed becomes available. If an ITU bed is available, you will be taken to the operating theatre by a nurse and porter at the appropriate time.
In the anaesthetic room
The anaesthetist will insert a needle into the back of your hand. Through this drugs can be given which will make you go to sleep - this is a general anaesthetic. A tube is inserted into your windpipe so that a machine (ventilator) can breathe for you. Once you are asleep, a needle will be inserted into the small artery at your wrist. This will allow us to keep a very close eye on your blood pressure throughout the operation. A fine plastic tube will be inserted into the jugular vein in your neck - this allows us to monitor your blood volume. A tube (catheter) will be inserted into your bladder so that we can monitor the amount of urine you produce - also you do not need to worry about passing urine after the operation as it will automatically drain into a bag.
To control pain after the operation a fine plastic tube is inserted near the nerves in your back (epidural). This may be done whilst you are awake.
In the operating room
The whole of the abdomen and the groins will be shaved and cleaned with anti-septic liquid. Sterile drapes will be positioned to create a clean operating field.
The incision in you abdomen will be either up and down or sideways (your surgeon will discuss this with you beforehand). The aorta and aneurysm are then identified and special clamps placed on the arteries to create a relatively bloodless operating area. The aneurysm is replaced by stitching a dacron (polyester) graft in its place with permanent stitches. At the end of the operation the aneurysm wall is stitched over this graft to stop the bowel sticking to it.
Occasionally it may be necessary to make a cut in the groin. This is either because of difficulties during the operation or because the arteries inside your abdomen were not suitable for stitching the graft onto.
The wounds are all closed and dressed at the end of the procedure.
After the operation
You will be transferred to the ITU. Here you will be monitored very closely and kept asleep until you are warmed up. Once the staff are happy with your progress you will be given drugs to wake you up and the ventilator tube will be removed. You will stay on ITU for a few hours longer for further careful monitoring before being transferred to the HDU (High Dependency Unit).
On HDU you will be monitored closely for 24 - 48 hours. Once the staff are happy with your progress arrangement will be made for transfer back to the ward. Before this, the needle in the artery at the wrist will be removed.
On the ward you will be encouraged to mobilise and receive attention from the physiotherapist. The remaining tubes and needles will be removed. You will be allowed to eat and drink.
Once you are eating, drinking, opening your bowels, passing urine and able to walk around independently arrangements will be made for your discharge (usually 5 - 10 days after your operation).
Complications of the operation
Aortic aneurysm repair is a major operation with risks attached to it - your consultant will have discussed these with you. The following is an outline of the possible ones:
 | Death - this may occur in 7 - 9% of cases. Most deaths are due to heart problems. Your consultant will discuss this with you as your risk depends on your general state of health. |
| Heart problems - these include heart attack, heart failure or odd rhythms. |
| Chest problems - essentially chest infection. |
| Kidney problems - kidney failure may occur requiring dialysis for a short time. It is more common if you already have mild kidney failure. |
| Bleeding - either at the time of operation or a few hours later. This would require going back to theatre. |
| Wound infection - more of a problem in groin cuts but can occur after any operation. |
| Graft infection - this occurs in around 2% of cases but usually takes years to manifest. |
| Deep vein thrombosis / pulmonary embolus - despite all effort this can still occur. If a large clot dislodges from the leg veins and moves to the lungs it can be fatal. |
| Impotence in men - is a fairly common problem. The reason is damage to nerves around the aneurysm that are responsible for producing erections. |
| Long-term complications - these really do not appear for 5 - 10 years after the operation. They may include another aneurysm in the remaining aorta, a join between the graft and the intestine (aorto-enteric fistula) or a false aneurysm (this is due to a small leak at the join between graft and aorta which is encased in scar tissue). |
At home
When you go home you will feel tired. You should rest as much as possible. Equally, however, you should try and do more each day with regular periods of walking (around the house and garden to start with). Common sense will tell you if you are doing too much.
You can resume normal activities as you feel able to do so. Avoid driving for the first couple of weeks. Do not attempt heavy lifting for the first 6 weeks. Do not expect to feel 'normal' for 4 - 6 months after the operation.
If you have any worries or concerns (e.g. about the wound) contact your practice nurse or GP. You will normally have an appointment to see your consultant in hospital 8 weeks after your discharge.
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