An aneurysm repair is a complicated surgical procedure to repair aneurysms that have grown to the extent where surgical intervention has greater benefits and risks.  The most common repairs done by our surgeons are of the thoracic aorta and abdominal aorta.  This procedure can be done "electively" (as described earlier) or emergently (if the aneurysm has ruptured/burst).  

Pre-Operative Details:

Your surgeon will give specific instructions before the surgery, including risks (i.e. bleeding, infection, adverse reaction to anesthesia, etc.).  Please make sure to contact your insurance company for coverage.  You will also meet with the anesthesiologist prior to the surgery to go over your medical history.  Please do not eat after midnight the night before your surgery.  On the day of surgery, you will arrive at the hospital, get registered, and get changed into a hospital gown.  A nurse will then review your chart to make sure there are no problems and then get all the paperwork in order for surgery.  The anesthesiologist will then start an IV and you will be taken to the operating room, where the surgeon will verify your name and procedure before any medication is given.  Once you are under anesthesia, surgery will begin.

Operative Details:

The surgeon can either do the procedure with open surgery (one large incision) or through an EVAR procedure (endovascular aneurysm repair; 1-2 small incisions using catheters inside the blood vessels, usually accessed through the femoral artery).  

In the EVAR procedure, the surgeon enters the femoral artery with a catheter through the groin and moves up the artery into the aorta to the site of the aneurysm.  He then places a stent graft in the area of the aorta that contains the aneurysm to create a new "sleeve" for which blood can flow through without further enlarging the aneurysm.  

In the open surgical procedure, the surgeon will determine the best approach based on the individual's aneurysm anatomy and location.  Below are the types of aneurysms our surgeons repair and the general technique:

• Ascending aortic aneurysm
  • Pre-operative - You will be assessed for coronary artery disease to see if there is need to do a coronary bypass procedure in addition to the repair.  Your aortic valve will also be evaluated to see if there is any need for repair/replacement.
  • Operation - The surgeon will make an incision in the chest to get to the heart and the aorta.  Once cardiopulmonary bypass is established (a method to allow blood to flow through the body without using the heart as the pump), the aorta is clamped off and then the heart is stopped temporarily with a drug.  
    • Ascending aortic replacement - The aneurysm is opened and a Dacron graft is placed within the inner walls and attached to the heart and aorta.  The heart is started back up then to ensure proper blood flow and the bypass is removed.  Finally, the surgeon closes up the chest with stitches.
    • Valve-sparing aortic root replacement - Similar as above, except the Dacron graft is chosen to allow the aortic valve leaflets to function normally within the graft itself.  
    • Aortic root replacement - In this procedure, the aortic valve is removed and replaced with either a mechanical/porcine/homograft valve in addition to the Dacron graft.
    • Open distal anastomosis - The graft is sewn to the aorta first with the patient's body tilted.  Once all the air bubbles are out, the graft is then sewn to the heart or valve.  
• Aortic arch aneurysm
  • Pre-operative - All patients will be evaluated for ventricular function and atherosclerosis of the aorta.  There is a major concern for neurological injury, so precautions will be taken before an during the operation to ensure this does not occur.  
  • Operation - As above, the surgeon will make an incision in the chest to access the aortic arch region.  The body is then cooled to minimize neurological injury and the patient is put on cardiopulmonary bypass.  The arch reconstruction varies depending on the surgeon.  Usually, the surgeon first attaches the graft distally (furthest from the heart) first and then the 3 head vessels are reattached to the graft directly or onto a separate graft which is then attached to the main graft.  Then the graft is attached proximally close to the heart and the surgeon closes up as explained above.  
• Descending throacic and thoracoabdominal aneurysm
  • Pre-operative - The concern with this repair is the possible spinal cord injury that can result, so the surgeons will take precautions before and during the operation to ensure that the spinal cord gets proper blood flow.  
  • Operation - This procedure requires a different incision location, usually on the left side between the ribs and then the ribs are spread to access the aorta.  The aorta is then clamped after the head vessels come off.  To ensure adequate blood flow to the body, an atrial-femoral bypass and the body is cooled.  The aorta is then clamped off at the level of T4-T7 to allow blood flow to the kidneys, spinal cord, and organs in the abdomen.  The graft is then sewn in, first closer to the head.  If the aneurysms involve the renal/kidney vessels or any of the abdominal vessels off the aorta, they are reattached next to the main graft.  The patient is then rewarmed and the bypass is discontinued.  Lastly, the graft is attached distally and the surgeon closes up afterwards.  

Post-Operative Details:

After the surgery, you will be taken to the intensive care unit and be monitored.  You will likely experience pain and will given pain medication appropriately.  It is important to keep the incision areas clean and dry.  You will be watched for any changes in your neurological status, stroke, breathing problems, and coronary ischemia (poor blood flow to the coronary arteries which supply the heart).  The length of your hospital stay depends on how quickly you are able to recover and perform some physical activity.  If you experience fevers, severe pain, redness/swelling/warmth where the incisions were made, or drainage from the incisions, please let your doctor know immediately.  Your surgeon will give specific instructions about recovery time.  In addition, it is important to change your lifestyle, including quitting smoking, exercising more, and eating foods low in fat/cholesterol/calories.