Open repair of
`Abdominal Aortic
`Aneurysms (AAA)
`
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`MEDTRONIC 1014
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`Ask 3 Questions
`Preparation for your Appointments
`
`We want you to be active in your healthcare. By telling us what
`is important to you and asking questions you can help with this.
`The three questions below may be useful:
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`OPEN REPAIR OF AAA
`The traditional operation involves
`cutting open your abdomen to replace
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`artery (a graft).
`
`In the UK under one third of planned
`AAA repairs are done using “open”
`AAA repair.
`
`The procedure
`Anaesthetic
`The operation is performed under general anaesthetic.
`
`As the surgery requires an incision in the tummy and can be
`quite painful the anaesthetic team will discuss whether to put in
`an epidural at the time of surgery. This is done to provide pain
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`tube in the back alongside the nerves of the spinal cord; local
`anaesthetic drugs can then be given down the tube to numb
`the nerves and block pain sensation. The alternative is to use
`“patient controlled analgesia” or “PCA” for short; this gives
`a small dose of strong painkiller through a drip every time you
`push a button.
`
`Your anaesthetic specialist will discuss the pros and cons of each
`approach with you.
`
`The anaesthetic team will place a “drip” in the artery in your
`arm (usually at the wrist) to monitor your blood pressure during
`the operation. This is called an “arterial line”. Once you are
`asleep the team will also insert a drip in a large vein in the neck;
`this is called a “central line” and is used for giving certain drugs
`(cid:65)(cid:78)(cid:68)(cid:210)(cid:77)(cid:79)(cid:78)(cid:73)(cid:84)(cid:79)(cid:82)(cid:73)(cid:78)(cid:71)(cid:210)(cid:89)(cid:79)(cid:85)(cid:82)(cid:210)(cid:185)(cid:85)(cid:73)(cid:68)(cid:83)(cid:210)(cid:68)(cid:85)(cid:82)(cid:73)(cid:78)(cid:71)(cid:210)(cid:65)(cid:78)(cid:68)(cid:210)(cid:65)(cid:70)(cid:84)(cid:69)(cid:82)(cid:210)(cid:84)(cid:72)(cid:69)(cid:210)(cid:79)(cid:80)(cid:69)(cid:82)(cid:65)(cid:84)(cid:73)(cid:79)(cid:78)(cid:14)(cid:210)(cid:57)(cid:79)(cid:85)(cid:210)
`will also have a urinary catheter inserted to monitor the amount
`of urine you make during and after the operation.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`Incision
`The aorta sits behind the intestines just in front of the spine. To
`get to the aorta the surgeon can either make an incision up and
`down in the middle from just below the rib cage to the top of
`the pubic bone or an incision from side to side above the belly
`button.
`
`Your specialist will discuss with you, which technique they will
`use. There are no clear overall advantages with one way or the
`other.
`
`Repairing the AAA
`This is a major operation. The risk of death in hospital in the UK
`with open AAA repair is currently 3%.
`
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`In order to repair the AAA the specialist must stop the blood
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`aneurysm.
`
`The aneurysm is then
`cut open and the
`graft sewn into place.
`
`The sac of the
`aneurysm is then
`wrapped around the
`graft, to help reduce
`bleeding and the risk
`of other structures
`sticking to the repair.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`After the operation
`If your recovery is straightforward, you will be in hospital
`between 7 and 11 days. It is usual for patients to spend one
`or two nights on the high dependency or intensive care unit.
`You will be allowed to eat and drink once you are fully awake
`following surgery. You may not feel like eating immediately,
`but usually you will be eating normally within 3 days of your
`operation. The nurses will aim to getting you sitting up and
`walking as soon as possible.
`
`Once you are well enough to return home, you will be
`discharged. At this stage, you may still need painkilling tablets.
`You may also notice that you tire easily. It is usual for it to take 3
`to 6 months, and sometimes longer, to get back to your normal
`level of activity. During this phase of recovery, you should plan
`periods of rest into your day, gradually reducing them as you get
`stronger. The best way to recover is to gradually increase your
`level of physical activity over three months. You may resume
`normal sexual relations as soon as you as you feel comfortable.
`
`Your wound should be dry and healed within 10 days. If you
`develop redness or swelling in the wound, you should see your
`doctor about this. You will be referred back to your surgeon if
`your doctor has any concerns.
`
`There is no set time for returning to work but you may need
`to wait 6-12 weeks before you are able to work. You should
`ask your surgeon about this. If you drive for a living, especially
`HGVs, you will need to be fully recovered before returning to
`work.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`Advantages of open repair
`Open repair has a number of advantages over stent graft repair
`(EVAR).
`
`In particular:
`
`(cid:3)(cid:131) Much more adaptable technique to complicated anatomy.
`More complex shapes of aneurysm can be treated than
`with standard stents.
`(cid:3)(cid:131) It is very durable. There is a very low rate of people ever
`needing further procedures on the aorta. Once the surgery
`is done the AAA is “fixed”. There is rarely need for long
`term x-ray follow-up
`(cid:3)(cid:131) Studies suggest that in the longer term (>8 years) patients
`who have open repair live longer than those who have
`stent grafts.
`
`Problems with open repair
`(cid:3)(cid:131) Higher risk of death around the time of operation
` – In the UK the in hospital risk of death following open
`AAA repair is 3 in 100 compared to 1 patient in every
`250 for endovascular repair (stent graft or “EVAR”)
`(cid:3)(cid:131) All patients need to go to the high dependency unit or
`intensive care unit. There is a risk the operation may be
`cancelled due to a lack of a bed on the day the operation
`is planned for.
`(cid:3)(cid:131) Higher risk of major complications as an in-patient after
`surgery
` – Just over 25% (1 in 4 patients) have a major
`complication*
` (cid:106) Heart problems 7%
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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` (cid:106) Chest infections or breathing problems 13%
` (cid:106) Bleeding 2%
` (cid:106) Reduced blood supply to the legs 3%
` (cid:106) Kidney failure 5%
` (cid:106) Return to theatre – 1 in 14 patients
`(cid:3)(cid:131) Longer hospital stay (national average 8 days) and long
`time to return to normal activity (variable, most 6-12
`weeks; some still not back to normal at 6 months)
`(cid:3)(cid:131) Risk of hernia or adhesions in the abdomen in the long
`term – up to 1 in 10 patients need a procedure in the long
`term.
`
`*Data from the UK National Vascular Registry Report 2016
`
`Problems after any AAA repair
`Any patient who has a AAA repaired can have the following
`problems.
`
`(cid:3)(cid:131) Reduced sexual function
`(cid:3)(cid:131) Reduced blood supply to legs. If this happens we often
`must perform emergency surgery to correct the problem.
`The risk of losing a leg (major lower limb amputation) after
`any AAA repair is less than 1/100.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`(cid:3)(cid:131) Reduced blood supply to the pelvis. This occurs if the
`main blood vessel (internal iliac) suppling the pelvic
`organs is blocked off during the repair of the AAA.
`This is sometimes done intentionally when we treat an
`aneurysm that extends down into the pelvis (common iliac
`aneurysm). Not everyone who has a blocked internal iliac
`artery gets a problem – it is quite unpredictable.
` – The most common problem seen is pain in the lower
`back or buttock on walking (buttock claudication).
`This may last for a few weeks or months or can be
`permanent.
` – Very rarely the blood supply to the skin around the
`buttock can be lost (skin necrosis).
` – Reduced blood supply to the bowel in the pelvis.
`This leads to inflammation in the bowel (“ischaemic
`colitis”) which can progress to the bowel muscle
`dying and the bowel bursting. It is very uncommon for
`patients to have problems with the bowel in planned
`operations (1 to 2/100). The symptoms can be mild
`with diarrhea for a short period, to much more severe
`problems resulting in the need for emergency bowel
`surgery and a colostomy because the bowel has died
`or in the longer term narrowed up completely.
`(cid:3)(cid:131) Reduced blood supply to the spinal cord or nerves. This is
`very rare in patients having standard AAA repair (2/1000).
`This can result in weakness in one or both legs (paraplegia)
`(cid:3)(cid:131) Kidney failure/Dialysis (short term or long term)
` – This can be due to the stress the repair puts on the
`body, together with other factors (low blood pressure,
`drugs, x-ray contrast). This type of “acute kidney
`injury” usually recovers fully
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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` – The repair can cause one or more of the main arteries
`supplying the kidney/s to block off. This will produce a
`permanent reduction in the function of the kidney/s.
`This can lead to dialysis permanently.
` – Significant kidney problems occur after 1/100 standard
`EVAR and 4/100 open repairs.
`(cid:3)(cid:131) Aorto-enteric fistulas – unknown rate much less than
`1/100
` – This is a very rare complication that typically occurs
`many years after repair. This occurs when the graft
`used to repair the AAA sticks to the intestine and
`erodes into the bowel. This can cause life threatening
`bleeding or infection. This is usually seen only after
`open AAA repair. It is much more common after
`repairing an aneurysm that has already ruptured rather
`than after a planned repair.
`(cid:3)(cid:131) Graft infection 2/1000
` – The grafts for stents and for open repair are man-
`made fibres. It is possible for these grafts to pick up
`some bugs usually from the skin at the time of your
`operation or for bugs to stick to the graft when you
`have an infection in the blood stream at some time
`(for example a bad chest infection). These bugs slowly
`multiply over time and can cause a weakening of the
`joins around the stents or a collection of fluid around
`the graft. Such infection can sometimes be difficult
`to diagnose, and symptoms can range from feeling
`tired with flu-like symptoms to being very unwell with
`bleeding problems.
`(cid:3)(cid:131) Damage to other adjacent structures during the repair.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`Balancing the benefits and risks
`
`Open surgery places more stress on the body than EVAR. Your
`specialist may recommend that the risks of open surgery are
`too great to contemplate. This is very much dependent on your
`general health and the shape of your aneurysm. If you have an
`aneurysm which extends above or around the kidney arteries,
`or an aneurysm that involves the arteries going to the legs (iliac
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`risk of a complication will be higher.
`There is no doubt that open repair carries more risk around the
`time of the operation and takes longer to get over, but in the
`long term you are rewarded by a repair that is much less likely to
`need further procedures.
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`you is important. To make a shared decision with your specialist
`it is important that you read through the information and ask
`questions. This will help you to get the plan that is best for you.
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`Open repair of Abdominal Aortic Aneurysms (AAA)
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`www.nbt.nhs.uk/vascularsurgery
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`If you or the individual you are caring for need support reading
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`© North Bristol NHS Trust. This edition published January 2018. Review due January 2020. NBT002488
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