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home : columns : ask the doctors December 11, 2018

4/9/2018 7:47:00 AM
Surgical techniques for aneurysm have greatly improved over time

Dear Doctor: I was recently diagnosed with an aortic thoracic aneurysm and scheduled for surgery. What are the risks, and can I expect to live a normal life afterward?

Dear Reader: As difficult as it is to hear the diagnosis of an aortic aneurysm, you're fortunate that your surgery could be scheduled. (More on that later.) Now an explainer for other readers: An aortic aneurysm is a bulging area within the aorta -- the body's main artery -- through which the heart pumps blood to the rest of the body. The aorta starts in the chest, called the thoracic region, and then runs down into the abdomen.

The problem with these bulges is that they can lead to rupture of the aorta, causing major blood loss and possible death. The majority of ruptures -- accounting for two-thirds of aneurysm-related hospital visits -- occur in the abdominal aorta; thoracic aneurysms account for the other third, and the rate is increasing.

People with thoracic aneurysms are usually unaware of the aneurysm until it is about to rupture; most are found through imaging studies looking for something else. The decision on whether to have surgery is based on the size of the aneurysm, whether the aneurysm is growing rapidly and whether it's causing symptoms. Survival rates are much higher for aneurysms that don't cause symptoms; the five-year survival rate in those needing urgent surgery is 37 percent, and 85 percent among people choosing to have the surgery. So you can see why the ability to schedule surgery is a positive.

The type of surgery depends on the location of the aneurysm. Those closer to the heart are more likely to require an open surgical procedure -- specifically, a median sternotomy. In this surgery, the sternum (breast bone) is cut up the middle to open up the chest, and blood must be bypassed away from the heart and into a machine that pushes it through the body. The diseased section of the aorta is then removed and replaced with an artificial graft.  

For aneurysms farther from the heart, an endovascular repair can suffice. With this operation, there is no need to open up the chest. A doctor inserts a graft through an artery in the upper thigh and places it inside the vessel. The graft works like a stent, allowing blood to flow through it without putting pressure on the aneurysm.

The risks of an open procedure, because of the amount of surgery involved, are greater than those of endovascular repair. Complications include pneumonia, stroke and heart attacks during the procedure, although newer surgical techniques have dramatically lowered the complication rate.  

One problem with the endovascular repair, however, is that over time -- in about 7 percent of cases -- the graft/stent within the blood vessel can move away from the area of the aneurysm, exposing the aneurysm again to rupture. Also, in 25 percent of cases, blood can leak around the stent (an endoleak), leading to increased risk of rupture.  

Although the open procedure has a greater risk of complications, the overall survival rate is similar for both procedures. But surgical techniques for both procedures are improving all the time, increasing the likelihood of a return to normal life. I don't have the specifics of your case, but it's safe to say you should follow your doctor's advice to get back on your feet as quickly as possible.

Robert Ashley, M.D., is an internist and assistant professor of medicine at the University of California, Los Angeles. Send your questions to askthedoctors@mednet.ucla.edu, or write: Ask the Doctors, c/o Media Relations, UCLA Health, 924 Westwood Blvd., Suite 350, Los Angeles, CA, 90095. Owing to the volume of mail, personal replies cannot be provided.





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