What is an aneurysm?

An aneurysm is a dilatation of a blood vessel by more than 50% of its diameter. When talking about aneurysms we mostly mean the widening in the arteries, although they can also occur in veins. As an aneurysm grows the vessel wall becomes thinner and may burst. Generally an aneurysm can occur in any blood vessel in the body. However the most commonest location is the aorta. The aorta is the main blood vessel in the body and runs from the heart through the thorax into the abdomen. Currently in the UK, aneurysms are present in about 1.4% of the population, this increases to around 5% in those aged over 60 years.

What does this mean for me and how is this diagnosed?

Aneurysms are a condition of the elderly. In young people they are very rare and usually associated with genetic disorders. Most aneurysms are asymptomatic. In fact many patients will never know that they have one. Usually they are found incidentally when patients have diagnostic tests for other conditions for example gallstones or kidney stones. Only in rare cases an aneurysm becomes symptomatic. Then the symptoms include back or epigastric pain. There may also be a feeling of tenderness in the abdomen. If an aneurysm becomes very big, the vessel may burst. That causes extreme pain and is a serious condition that would require immediate treatment.

There is currently a regional aneurysm screening program set up in the noth west at present. Men aged 65 years of age will get an invitation to attend an ultrasound scan of their aorta.

Should you be diagnosed with an aneurysm your GP or the diagnosing specialist will refer you on to a vascular specialist.

What are the risks factors for developing an aneurysm?

Aneurysms are more common in men. As with other arterial disease, factors such as smoking, high blood pressure, poorly controlled diabetes and having high levels of cholesterol increase the risks of developing an aneurysm. Some genetic factors also play a role, especially in the young. However, these are rather rare.

Will I require surgery?

Not necessarily, first of all you will need to be seen in a clinic. Then you will get more tests performed. Initially this may simply be another ultrasound scan by a specialist vascular technician. If the aneurysm is small it will be fine just to observe it and you will get regular follow-up scans to keep an eye on its size.

Only if the aneurysm reaches a threshold size of around 5.5cm or demonstrates signs of rapid growth, then intervention will be considered.  A CT scan will be arranged and you will be sent for a fitness assessment (don't worry, we will not ask you to run a marathon). Once all the information is to hand,l then you will be seen again in clinic to discuss the best way forward. The following are indications for intervention of your aneurysm:

• An aneurysm greater than 5.5cm in size
• A symptomatic aneurysm with back pain or tenderness
• Aneurysms which grow at a rate of more than 1cm per year
• Having had a blood clot due to the plaques of the disease around the aneurysm

How do you repair an aneurysm?

There are two methods for repairing an aneurysm. We will always recommend the option we think is the best for you. However, we certainly involve you in the decision making process, especially if both options are possible.

1. Open repair

This is the conventional technique. It requires a long incision in the abdomen. We then identify the aneurysm and clamp the aorta above and below it. Then we will replace the diseased part of the aorta by stitching an artificial vessel, called graft, onto both ends. The graft is made from a special textile and looks like a tube or upside-down Y.  Once this is stitched in place, the blood will flow through the graft. This is a major operation, so afterwards you will wake up on the high dependency unit for closer monitoring. Afterwards you will be transferred back to the vascular ward. Usually open repair requires a hospital stay between 7 to 10 days.

2. Endovascular repair (EVAR)

This is a much less invasive type of procedure often referred to as key hole surgery. Here the idea is not to resect the aneurysm, but to place a special tube, called a stent, inside the aneurysm. This stent seals tightly with the healthy vessel above and below the aneurysm, thus allowing the blood to flow through the stent and not into the sac. The procedure involves entering the arterial system through two small incisions in the groins. We can then pass the stent up the pelvic arteries into the aorta and place it into the right position there. Rather than opening up the abdomen it is visualised using a dye that is injected into the arteries and can then be observed on an x-ray. After this procedure you can come back straight to the ward, but still will need a monitor bed. You will be able to get up the next day and normally go home after 3-5 days.

What will happen to me after surgery?

After discharge you will then be seen in a follow up clinic usually after 6 weeks. At this point if you had the open repair and we are happy with your progress you will discharged.

If you have had the endovascular repair you will have to enter a long term surveillance programme where you will have scans at certain intervals: at 3, 6 and 12 month initially and then yearly after. This is to make sure that the stent remains in its position and excludes the aneurysm. Around 10% of patients who undergo a Stent graft treatment may need additional key hole procedures to maintain successful exclusion of the aneurysm.

How long before I can resume normal activities?

The recovery time varys between each individual and between the type of surgery you had. Generally speaking EVAR (Stent graft) patients recover quicker than the patients that underwent open repair. You need to be aware, that it can take up to 6 month until you are fully recovered and feel your old self again. However, in most activities you will be able to participate before that:

• Work: Most people that require aneurysm repair will be retired. You will have to look at 4 to 6 weeks minimum off work, depending on the job as well as the type of repair.
• Driving: You should refrain from driving for at least for 6 weeks after open repair or until you can competently perform an emergency stop under controlled conditions. Those undergoinf stent graft repair may be able to drive sooner. 
• Lifting: You should avoid heavy lifting for at least 6 weeks (open procedure) and 2 weeks (endovascular procedure) after the operation. This is to protect your scars and avoid hernias.
• Bathing: You should be able to bathe and shower lightly whilst your wounds are healing, although it is not advised to fully immerse non healed wounds in a bath.
• Sexual activity: You should be able to resume normal sexual activity as soon as you feel comfortable to do so. If you have any problems in this area you should seek advise from your GP or at follow up consultation with the surgeon. Impotence is a recognised problem of open aneurysm repair and you should ask more about this if you are concerned.

What are the complications of surgery?

As you know all surgical procedures have some risks. Aneurysm repair is certainly one of the bigger procedures performed. However, once an aneurysm needs treatment, the risks of not treating it are higher than those of operative complications. All possible complications will be discussed with you in detail when you are seen in the clinic and again when you are on the ward before the operation. There will be plenty of time for you to ask any question you are concerned about. You will also be offered a detailed information sheet.

EVAR specific risks may include: A problem with getting a good seal between stent and vessel, thus still allowing bloodflow into the aneurysm sac (endoleak) and the need for further procedures in the future if this happens. There is also a small risk to the kidneys from the dye and the blood supply to them.

Open repair specific risks may include: hernias, sexual dysfunction in men, injury to organs close to the aneurysm during the operation (i.e. bowel), pain.  The risk to a patients life from open repair is around 5% in fit individuals and around 1-2% for those undergoing a stent-graft repair.

For both procedures there are also medical risks including the recovery period such as heart attack or pneumonia. These are somewhat smaller for patients undergoing EVAR than for those with open repair.

What can I do to reduce the risk of any complications and ensure the best long term result?

The best way is to work on your risk factors. The general rule is: "The fitter you are, the less likely you are to develop complications."

Firstly you should quit smoking if thats a habit you entertain. This is the most important step you can take to further protect yourself and your repair from future damage and will be beneficial to all aspects of your health not just your arteries. If you are keen to quit smoking then there are options available for you to aid quitting and support should be available via your GP.

Also it will be to keep your blood pressure down and having good diabetic control over your blood sugars.