Christopher Imray - Aortic Aneurysm Surgery

Aortic Aneurysm Surgery (open/endovascular stenting)

An aneurysm is an abnormal dilation of the vessel wall. The abnormal swelling can cause symptoms when it grows, leaks or embolises (showering off debris from within the vessel). Whilst any vessel can dilate, most commonly aneurysms form in the abdominal aorta, the iliac, femoral and popliteal arteries. Occasionally aneurysms form in the thoracic aorta and carotid arteries.

Diagnosis

The diagnosis is usually made either by clinical examination or by ultra sound examination. CT or MR scanning will give more details about the anatomy of the AAA (Abdominal Aortic Aneurysm).

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Indication for Surgery

The risk of the aneurysm leaking/rupturing has to be weighed up against the risk of surgery itself. In small aneurysms (less than about 55mm) the risk of surgery is usually greater than the risk of observation alone. Repeat ultrasound examinations at 6 monthly or yearly intervals allow the rate of growth to be determined. Over 55mm the risk of rupture is probably greater than the risk of surgery so surgery is usually advocated.

Elective vs Emergency Surgery

The risk an elective surgical repair varies from individual to individual but is usually between 3-7% of a major complication or death. Emergency repair carries a 50% mortality.

Screening for abdominal aortic aneurysms

There is growing evidence that the introduction of a population screening programme (in particular for men) will save lives. Hopefully this will be introduced into the UK shortly.

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Open vs Endovascular Repair

Conventional open surgery on the abdominal aorta was first undertaken in the 1950s. The operation is a well tried and tested procedure with good long term results. Endovascular repair of AAA was first undertaken in the early 1990s. Its attraction is the small scars and rapid recovery from surgery. Unfortunately not all aneuryms are suitable for an endovascular repair and the long term results are less well understood. At C&W CVU we work in close collaboration with our interventional radiologists and aim to offer the most appropriate approach to each individual.

Factors Predisposing to Leak or Rupture of Aneurysm

Diameter of aneurysm
Smoking
Diastolic blood pressure
Expansion rate
Family history
Chronic lung disease

Open Surgery

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Dacron graft	Top end sewn into position


	Lower anastomosis complete

Thoracic Aneurysms

Thoracic aneurysms are relative rare. Treatment options are conservative (leave alone), open surgery or endovascular surgery. We work closely with our cardiothoracic colleagues to try to determine the safest approach.

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	8.5 cms thoracic aneurysm with stent in place

Popliteal Aneurysms

Aneurysmal dilatation can occur in any vessel, but more commonly occurs

in the femoral (groin) or popliteal (behind the knee) arteries. Repair is advised before it either leaks or embolizies (showers debris).

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	5cm popliteal aneurysm with reverse vein graft

Complex visceral artery reconstructions

Occasionally the renal (kidney) or mesenteric (gut) arteries narrow or block. Often the best approach is an endoluminal approach. There are situations when the endoluminal approach is not possible or an open approach is more appropriate. The long saphenous vein (upper thigh) is harvested, reversed and then used as the conduit.

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Right Renal Artery Bypass	Right renal artery bypass (2)


	Aorto-bifem with left renal artery bypass


	Bifurcating jump vein graft from supra coeliac to common hepatic and superior mesenteric artery for mesenteric angina

Managing an abdominal aortic aneurysm, C Imray, 2006 - Click here to view PDF

Screening for AAA: press release Jan 2008

http://news.bbc.co.uk/1/hi/health/7172094.stm

Abdominal aortic aneurysm (AAA), which can cause one of the body's main blood vessels to burst, is the third most common cause of death among older men. Over the next five years, ultrasound scan screening will be rolled out across 60 centres to cover all men aged 65 and over. The Department of Health says this will save 700 lives a year within 10 years. Doctors welcomed the announcement, but called for more details to be given on how the screening programme will be funded and organised. The announcement comes ahead of a speech on the NHS by Prime Minister Gordon Brown on Monday, in which he is expected to stress the importance of measures to prevent ill health.

So far about £3m has been set aside for pilot projects this year which will offer screening to 32,000 men in England. Eventually it is hoped 270,000 men a year will be screened. Men are six times more likely to have an aneurysm than women. If detected early enough, the condition can be corrected by surgery. The abdominal aorta carries blood to the intestines and other organs nearby and if an aneurysm occurs in this area it can be fatal, with most patients dying before they get to emergency care. Announcing the screening programme, Health Secretary Alan Johnson said: "We should be looking at how to stop disease taking hold in the first place."The programme is a very good example of the kind of measures we will have to make more widely available if we are going to expect clinicians and public to take more responsibility for early identification and lifestyle changes."

This is the NHS's first men-only screening programme. AAA kills over 3,000 men a year - roughly twice as many deaths as cervical cancer for women, which has its own screening programme. "Key to success will be funding to train technicians to undertake the scans and for the organisational infrastructure of the scheme. We await further information on this." Jonothan Earnshaw, honorary secretary of the Vascular Society, which represents specialists in this area, said: "We welcome the announcement of an abdominal aortic aneurysm screening programme and look forward to working with the government.