Ascending aortic aneurysm repair

Overview

Traditional open surgery is used to treat an ascending aortic aneurysm. Their weakened part of ascending aorta is cut out by the surgeon, and it is then replaced with a graft (a tube made of synthetic fabric). This graft serves as a fresh lining for their artery, allowing blood to flow through.

If aortic aneurysm surgery is carried done before a rupture or dissection, the results are good. 95% to 98% of patients who undergo elective surgery recover. However, thoracic aortic aneurysm dissections and ruptures frequently result in death. About 1 in 5 patients who experience a rupture or dissection pass away before undergoing surgery. Emergency surgery patients are less likely to survive than elective surgery patients.

The survival rate after elective thoracic aortic aneurysm repair is about 85% for at least five years. When emergency surgery is performed following a rupture or dissection, that percentage lowers to 37%.

Reasons for undergoing the procedure

People who have Type A dissection, also known as a ruptured or dissected ascending aortic aneurysm, require surgery. It’s an urgent procedure that might just save their lives.

If the patient has an aneurysm that is susceptible to rupture or dissection, surgery may also be necessary. Using imaging tests, a healthcare provider will check the patient’s aneurysm once or twice a year. A small or stable aneurysm may not require immediate medical attention. However, surgery will be required if the aneurysm is large or exhibits signs of rapid expansion in order to prevent rupture or dissection.

Six out of ten thoracic aortic aneurysms happen in the ascending aorta. They happen less frequently in the aortic arch or descending aorta.

Multiple factors determine the ideal time to repair an ascending aortic aneurysm. The patient’s symptoms are the most crucial factor. Others include the size and rate of growth of the aneurysm. Their physical factors, such as their body size and current health, also matter.

Risk

Undergoing a repair for ascending aortic aneurysm is a major surgical procedure. Similar to any major surgery, it involves potential risks and complications. Among them are the following:

• Bleeding.
• Blood clots.
• Graft infection
• Infection in the lungs, urinary tract or belly.
• Nerve damage
• Stroke or heart attack
• Difficulty of breathing.
• Kidney failure.
• Spinal cord injury.

People with additional major medical conditions, such as heart disease, kidney failure, lung illness, and a history of stroke, are more at risk for any open surgery.

Additionally, problems are more likely to occur in people over 65. Depending on the person, risks can change. Discuss the various dangers and how to manage them with the healthcare provider.

Procedure

Is it possible to employ endovascular techniques for the repair of an ascending aortic aneurysm?

Aneurysms in the descending thoracic aorta are treated with thoracic endovascular aortic repair (TEVAR). The section of the aorta that runs from the aortic arch to the diaphragm is that one. However, the ascending aorta is rarely treated with TEVAR. The ascending and descending aortas have different anatomical structures and blood pressures. TEVAR was specifically developed for the descending aorta.

TEVAR has been applied to the ascending aorta in a few uncommon situations of emergency. It can save persons with dissections who are too weak to recover from standard surgery.

New technology is being developed especially for the ascending aorta. This interesting study has a lot of potential. In the future, ascending aortic aneurysms might be treated with endovascular techniques. Open surgery as it is now practiced is recommended procedure.

Before the procedure

Patient and healthcare professional will discuss:

• Medication intake: The prescription, dietary supplements, and herbal products they are using must be disclosed to the healthcare provider. Medication falls under this category, both prescription and over-the-counter. As the patient gets ready for surgery, the healthcare provider can advise stopping some medications.
• Medical conditions: Prior to surgery, the patient will need to control issues including excessive blood pressure. If a patient has chronic bronchitis, they might need to take antibiotics.
• Current status: Inform the healthcare provider if the patient has a cold, the flu, a herpes outbreak, or any other ailment. If they are ill, it can affect the surgical outcome.
• Smoking or tobacco use: Prior to surgery, the patient should quit smoking for at least one month. The medical professional may provide them with resources to aid in quitting.

The patient will get a physical examination a few weeks before the procedure. In addition to doing tests, the healthcare provider will consult with the patient about their health. Preoperative tests could consist of:

• Blood work: This will check the kidney function.
• Imaging test: A CT scan or heart MRI to examine the whole aorta. The same operation may be used to treat their aortic issues, such as aortic valve disease. The patient and the healthcare provider will talk about this choice.
• Duplex ultrasound: A duplex ultrasound to examine the carotid arteries. Leaving untreated carotid artery issues can make having a stroke more likely while having surgery. This test is necessary for individuals over 65, those with peripheral artery disease, and those with other risk factors.
• Coronary angiography: Coronary angiography for the detection of atherosclerosis.

On the day of operation, the patient will receive thorough instructions from the healthcare professional. These may consist of:

• Avoiding drinking the night before the procedure after midnight. Water is included.
• Taking specific medications the morning of the procedure.
• Arranging for someone to pick them up after their recovery and drive them to the hospital.

Ask the healthcare provider if there are any questions or if anything is unclear for the patient. An effective surgery requires careful planning.

During the procedure

The weakened section of the aorta will be replaced by a graft (a tube made of synthetic fabric) by the surgeon. The surgeon can repair the aortic root and aortic arch at the same time if additional aorta segments are also injured. Additionally, if necessary, the surgeon may replace the aortic valve. The state of the aorta, as well as the patient’s medical history and family history, will all affect how much surgery is required.

The medical team will provide comfort and relaxation once the patient is in the operating room. During the procedure, they will be given general anesthetic, which will put them to sleep. They will be placed on a heart-lung machine (cardiopulmonary bypass) for some of their surgery. To stop their blood circulation, the medical staff may potentially apply deep hypothermic circulatory arrest (DHCA).

The following steps will be taken during the procedure:

• Incision: A median sternotomy, or incision at the front of the chest, will be made by the surgeon.
• Clamping: An aortic cross-clamp will be used by the surgeon to stop blood flow through the ascending aorta.
• Graft insertion: The surgeon will insert a tube known as a graft to replace the bulging portion of the ascending aorta. This graft serves as the artery’s new lining. The surgeon will use stitches to secure the graft.
• Closure: The chest incision will be stitched or stapled closed by the surgeon.

Typically, this procedure takes three to four hours. Depending on how many problems need to be resolved, the time may change.

After the procedure

The patient will be transferred to the ICU for critical care. For a few days, they will be closely monitored before being transferred to a regular hospital room. Four to ten days are expected to be spent in the hospital overall.

They will get the following while they are in the hospital:

• Urinary catheter will assist the patient to pee.
• A fluid-draining tube that passes through the nose and stomach.
• Anticoagulants, which thin the blood.
• Blood clots in the legs can be avoided by wearing compression socks.
• A breathing machine to support the lungs.
• Medication for pain relief to facilitate your recovery.

The patient will gradually move more as they build up their strength. But it’s crucial to proceed cautiously and in accordance with the advice of the healthcare provider.

Make sure to arrange for a ride from the hospital to their home. You should refrain from driving until your healthcare provider grants approval.

Outcome

Most patients spend up to 10 days in the hospital. However, based on how they are doing, they might need extra time. Following discharge from the hospital, patients can continue to derive advantages from cardiac rehabilitation, which aids in the recovery of strength and independence. It typically takes four to six weeks for a full recovery. Some individuals, however, take several months to completely return to normal.

As the patient recovers, pay attention to their body and how they are feeling. If any of the following issues arise, contact the healthcare provider immediately:

Surgical wound (incision site) problems:

• Pain, swelling, warmth, or redness.
• The bandage soaking through with blood or clear liquid.
• Drainage that is greening or yellow.
• The incision’s edges splitting apart.

Other problems:

• Fever or chills.
• Even when at rest, chest pain or breathing difficulties.
• Legs that are swollen or unable to move.
• Lightheadedness, fainting, or excessive exhaustion.
• Throwing up blood or green or yellow mucous when coughing.
• Blood in the stool.

These issues could indicate a surgical complication. The healthcare provider will guarantee the patient receives the care and consideration they require.