Overview

 

Aneurysmectomy is a surgical procedure in which a dilated, weakened section of an artery (aneurysm) is removed (resected). The artery is either replaced with a synthetic graft, as for an aneurysm in the chest (thoracic aneurysm), abdomen (abdominal aneurysm), or leg (femoral or popliteal aneurysm); or it is clipped, as for an aneurysm in the brain (cerebral aneurysm). The procedure may be elective or performed as an emergency surgery when an aneurysm leaks or ruptures.

In recent years, a nonsurgical approach to abdominal aneurysm repair using a stent-graft has become more common. This approach is less invasive and has fewer complications and a shorter recovery time. It is useful for individuals whose overall health makes them poor risks for surgery.

Risk factors for aneurysms are similar to those found in other cardiovascular disease, such as chronic obstructive pulmonary disease (COPD), high blood pressure (hypertension), atherosclerosis, connective tissue disorders (Marfan's syndrome and Ehlers-Danlos syndrome), inflammation of the blood vessels (vasculitis), and some congenital disorders.

Aftercare

After aneurysmectomy, the patient is monitored in an Intensive Care Unit for the first 24-48 hours. Follow-up tests include ECG, chest x ray, and ultrasound.

Risks

Elective aneurysmectomy has a 5-10% rate of complications, such as bleeding, kidney failure, respiratory complications, heart attack, stroke, infection, limb loss, bowel ischemia, and impotence. These complications are many times more common in emergency aneurysmectomy.


How Procedure is Performed ?

The specific surgical procedure varies according to the site of the aneurysm and the need for maintaining circulation to parts of the body beyond the aneurysm. All these procedures are performed in the operating room under general anesthesia br />
Aneurysms that involve the upper (ascending) or horizontal (transverse) portion of the large artery in the chest (aorta) are resected and repaired while the individual is on the heart-lung machine (cardiopulmonary bypass). The individual's body temperature is profoundly lowered while on the heart-lung machine to protect the brain and heart. An incision is made through the midline of the chest, and the sternum is split. The affected portion of the artery is then resected. Synthetic materials such as Dacron then replace the resected portion of the aorta. The sternum is held closed with wires and the skin stitched closed.

Aneurysms in the lower (descending) thoracic aorta are resected and replaced, and the individual's circulation is maintained by something less complicated than total cardiopulmonary bypass via a thoracotomy incision. The techniques fall under the general category of partial cardiopulmonary bypass or various shunts. The goal of these methods is to prevent damage to the spinal cord during the surgery.

Aneurysmectomy involving the lower abdominal aorta does not require that circulation be maintained to the lower portion of the body beyond the aneurysm since no vital organs (heart and brain) are in jeopardy and adequate natural pathways (collaterals) normally exist for the blood to reach the lower abdomen and legs via, in particular, the anterior spinal artery. The abdomen is opened with a midline incision and the aorta is clamped. The affected portion of the aorta is then resected and replaced with a synthetic graft. The abdomen is closed with stitches.

In some cases, an endovascular approach may be used to repair an abdominal aortic aneurysm instead of open surgery. This approach involves making two small incisions to reach the arteries in the right and left groin instead of making a long incision along the abdomen. This approach is less invasive and results in a faster recovery time. In some instances, this type of surgery may be performed under local anesthesia instead of general.

The stent-graft repair approach involves making an incision in the patient's groin, where a catheter is inserted into a blood vessel that leads to the aorta. A stent-graft (a tube inside a metal cylinder) is inserted through the catheter. The stent-graft is then threaded to the weak part of the aorta where the aneurysm is located. Once in place, the metal cylinder of the stent-graft is expanded like a spring to hold tightly against the wall of the blood vessel. Blood then flows through the stent-graph and avoids the aneurysm, eliminating the long-term risk of its bursting. This procedure is done with local anesthesia.

Aneurysms in the legs are treated in much the same way as abdominal aortic aneurysms. The aneurysm is exposed, clamped, resected, and replaced and the skin stitched closed.

Aneurysmectomy involving an artery in the brain is done through clipping rather than resecting the aneurysm. During this procedure, which is often done as microsurgery, with an operating microscope and tiny surgical instruments, the body is maintained at normal or somewhat lower temperatures. Under general anesthesia, the skull is opened and the brain exposed. The aneurysm is located and clipped. The skull is then closed, usually with a metal plate or plates and screws. The skin is then stitched closed.

Complications

Complications common to aneurysmectomy, irrespective of the procedure site, include bleeding, infection, and complications from anesthetic use. Additional complications related to upper and transverse aorta aneurysmectomy and the heart-lung machine include stroke, heart attack (myocardial infarction), excess fluid in lung (pulmonary edema), shock, kidney (renal) failure, liver (hepatic) failure, destruction of red blood cells (hemolytic anemia), and death. involving the lower thoracic aorta can result in paralysis of the lower half of the body. Major complications following aneurysmectomy involving the lower abdominal aorta are renal failure and vascular and neurological problems that affect the lower abdomen (i.e., impotence) and the legs (i.e., paralysis and loss of extremity). Stroke is the major complication of aneurysmectomy of aneurysms of the brain.

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