Aortic Aneurysm Repair (Ascending Aorta)
If an aortic aneurysm—a bulge in the wall of your body's main artery—is larger than 2 inches (or 5.0 to 5.5 centimeters) in diameter, is growing fast, or is causing serious symptoms (such as pain or trouble breathing), it is advisable to consider the possibility of surgical repair.
If you are diagnosed with an aneurysm, your surgeon will evaluate the specifics of your situation and help you weigh the risks of cardiac surgery against the risks of continuing to manage the disorder with medication and other nonsurgical treatments. If your aneurysm and its symptoms have not yet reached a point where surgery is indicated, you can enroll in Dartmouth-Hitchcock's comprehensive, multidisciplinary aneurysm follow-up clinic; this will provide you with regular imaging of your aneurysm and assessment of your health status.
Should you and your surgeon decide the time is right for surgical repair, keep in mind that the cardiac surgeons at Dartmouth-Hitchcock have considerable expertise in all the proven options for the surgical repair of aneurysms.
There are a number of ways to repair or replace the portion of an aorta damaged by an aneurysm. Which option is used will depend on such factors as where your aneurysm is located (whether it's in your ascending aorta or aortic arch, for example, or in your descending aorta), how big it is, and the overall state of your health. Your surgeon will determine which of the following procedures is most appropriate in your particular situation:
- Open-heart surgery to repair an aortic aneurysm involves making a 7" to 10" incision over the middle of the sternum, or breastbone, then dividing the sternum to allow access to the heart. In some cases a less invasive option, involving a slightly smaller sternal incision, is possible. In either case, the actual repair involves replacing the damaged portion of your aorta with a graft—a tube the same size as your aorta, made of a durable artificial material such as Dacron, which is sutured, or sewn, into place. It will be necessary to stop your heart from beating during the procedure, so the operation can be performed on a motionless and bloodless field; while your heart is stopped, a device known as a heart-lung bypass machine will take over your heart's function and maintain your circulation. Very occasionally, during complex operations involving replacement of a portion of the aorta, you may also be put into a state known as hypothermic circulatory arrest; this involves lowering your body temperature to significantly slow your body's cellular activity, permitting your blood flow to be temporarily stopped. (The term "hypothermic" comes from Greek words meaning "low heat," while "circulatory arrest" means your circulation is arrested, or stopped.) In other cases, a technique known as axillary cannulation (or the insertion of a drainage tube, known as a cannula, in an artery in your armpit, or axilla) can allow aortic replacement to be performed without hypothermic circulatory arrest; this advance may reduce the incidence of postoperative strokes and neurological deficits.
- Endovascular surgery may be an option for some patients. This minimally invasive procedure involves making a couple of tiny incisions (often just 1" to 2") in blood vessels in your groin; inserting long, thin tubes known as a catheters through the vessels to the point where your aneurysm is located; and then using X-ray guidance and long, thin instruments threaded through the catheters to place a little mesh tube known as a stent graft inside the affected portion of the vessel. (The term "endovascular" comes from Greek and Latin words meaning "within a vessel.") In circumstances when it is appropriate, endovascular surgery can sometimes be done with the patient under local rather than general anesthesia; in addition, it usually does not require hypothermic circulatory arrest or use of a heart-lung bypass machine. Since this approach avoids the need to open the chest at all, it usually results in much faster healing.
- Valve-sparing surgery can be considered for operations on the part of the aorta closest to the heart, the aortic root. This procedure involves replacement just of the damaged portion of the vessel, not of the aortic valve as well; it is thus appropriate only for patients whose aortic valve is intact or repairable. The alternative is known as a composite graft, and it involves not only replacing the affected portion of the aorta but also replacing the aortic valve with a mechanical valve.
It is important to keep in mind that every medical choice involves a trade-off between risks and benefits—whether it is to undergo surgery, take medication, or even just carefully monitor a condition (an option known as "watchful waiting").
In the case of an aortic aneurysm, if you meet the criteria above (that is, your aneurysm is larger than 2 inches, growing fast or causing serious symptoms), deciding whether surgery is advisable involves balancing the risks involved in any heart surgery against the increasing likelihood that your aneurysm may rupture, or burst. Your risk of dying if you suffer a ruptured aortic aneurysm is between 50% and 75%.
The risks involved in surgery are far lower. A given patient's risk will vary, depending on such factors as age and overall health status, but the average mortality, or risk of death, from repair of an aortic aneurysm is about 5%. Surgery to repair an aneurysm is also associated with a 3% to 5% risk of a blood clot that causes a serious stroke. And any surgical procedure involves a very small risk of other complications, such as infection. Patients who smoke can reduce their risk of complications if they stop smoking at least two to four weeks before their surgery (it is best not to quit immediately before having heart surgery, however, because when people stop smoking they often have short-term bronchorrhea, or excess secretions in their respiratory tract, which makes them cough a lot—and coughing a lot when you have just had heart surgery is not a good idea).
The benefits of a successful repair are considerable. The overwhelming majority of patients who undergo repair of a major aortic aneurysm, once they recover, feel better than they did before the operation, are able to breathe far better, and are able to resume any activities they wish to engage in.
A typical open-heart procedure takes from four to six hours, in some cases up to eight hours; patients are then maintained under general anesthesia for an additional four to six hours. If their wound is healing well and there is no excess bleeding, they can emerge from anesthesia and have their breathing tube removed. Most patients stay in the ICU until midday of the day after their procedure; if they continue to do well, the drainage tubes in their chest can then be removed and they can be moved to a regular hospital bed later that day. The typical hospital stay ranges from 7 to 10 days, in some cases up to 14 days. At that point, the vast majority of patients are able to go home, with support from the visiting nurse service, though about 15% to 20% may need to spend some time in a rehab facility for more extensive rehabilitation. After discharge, patients are advised not to drive for about three weeks and not to lift anything heavier than 5 lbs. for about six weeks. Beyond that point, they can resume whatever activities they wish to.
Patients tend to be surprised at how easy it is to control their pain. By the second day after their operation, most patients are comfortable without intravenous pain medication, taking only oral painkillers, and the overwhelming majority are discharged home on just Tylenol or Motrin.
In cases when minimally invasive surgery is appropriate, both the length of the operation and the recovery period are typically shorter (and much shorter in the case of endovascular surgery).
Page reviewed on: Jun 26, 2018
Page reviewed by: Jock McCullough, MD
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