Abdominal Aortic Aneurysm

An Abdominal Aortic Aneurysm (AAA) is a weak area in the aorta where blood pools as the weak area expands. The aorta is the main blood vessel that supplies blood to the rest of the body from the heart. As the blood is pumped through the vessel, it beats against the weakened wall and bulges, similar to a balloon, which may burst (rupture). When the aneurysm measures less than 5cm. the risk of it rupturing is low, but treatment is usually necessary once it reaches 5cm or more. The goal of treatment is to keep it from rupturing, because if it does, chances of survival are low (10%-20%).

Prevalence

- AAA causes more than 15,000 deaths per year, which makes it the 17th leading cause of death in the United States

- Approximately 8% of people over the age of 65 are affected by AAA.

- Males are 4 times more prone to AAA than females

- At least 50% of people with AAA who do not treat it will die of a rupture

Risk Factors

- Family history of AAA

- Smoking (Smokers are 4 times more likely to die from ruptured aneurysms than non-smokers)

- High blood pressure

Symptoms

AAA often has no obvious symptoms, but some symptoms that may be present include the following:

- Abdominal pain that may be constant or come and go

- The feeling of a “heartbeat” or pulse in the abdomen

- Pain in the lower back, which may radiate to the buttocks, groin or legs

Symptoms of an aneurysm burst include the following:

- Sudden severe back or abdominal pain

- Paleness

- Excessive thirst and dry mouth/skin

- Nausea and vomiting

- Signs of shock (shaking, dizziness, fainting, sweating, rapid heartbeat, sudden weakness)

Diagnosis

Sometimes a physician is able to diagnose AAA by a physical examination, in which the physician feels a soft mass in the abdomen which pulses with the heartbeat. An ultrasound is the most common form of diagnosis, but other medical imaging may be used, such as CT or MRI. Another form of diagnosis is an Arteriogram, which provides the best, real-time imaging.

Arteriogram

An Arteriogram (also called an Angiogram or Angiography) is a procedure is a diagnostic test to provide an accurate diagnosis through real-time x-ray imaging. This procedure will allow the physician to get a good image of the aneurysm in order to decide the best treatment option for you.

How to Prepare for an Arteriogram

Prior to your procedure, you will receive specific instructions for how to properly prepare for your procedure. The following information is a general guideline for what you might expect, but always follow the instructions given to you by your physician.

- Be sure to tell your doctor about all medications you are taking and any allergies you may have, especially if you have an allergy to contrast dye or latex.

- You may be advised to stop taking blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs) for a specified period of time prior to your treatment.

- You may be asked to fast (not eating or drinking anything) for several hours prior to your procedure.

- Female patients should always inform their physician if they are or if there is a possibility that they are pregnant.

- Blood tests may be ordered to determine how well your liver and kidneys are functioning and to see how your blood clots.

- Shower or bathe the night before your procedure.

- Remove jewelry, nail polish/artificial nails and hairpins, but please wear the following items to the procedure if you use them:

- Eye Glasses

- Dentures

- Hearing Aid(s)

- You should plan to have a relative or friend drive you home following your procedure.

What to Expect During & After an Arteriogram

- You will be positioned on the examining table and be connected to monitors that track your heart rate, blood pressure and pulse during the procedure, and a nurse or technologist may insert an intravenous (IV) line into a vein in your hand to deliver sedation medication.

- The physician will discuss the procedure with you and answer questions you may have. You will also read and sign a consent form.

- The area where the catheter is to be inserted will be sterilized and draped with a surgical drape before the physician numbs the area with a local anesthetic.

- A very small nick in the skin is made where the physician inserts a catheter into the femoral artery near the groin.

- Contrast material, a clear fluid that is visible on x-ray imaging, is injected through the catheter to produce an image of the blood vessels. This fluid may cause a warm sensation for a moment.

- X-rays are taken and you may be asked to hold very still so that the images come out clearly.

- After the procedure, the catheter is removed and pressure is applied to stop any bleeding. The small opening is covered with a dressing (no stitches are needed).

- The procedure lasts about 1-2 hours.

- Following the procedure, you will spend about six hours in a recovery room to allow the puncture site to heal before you are allowed to move. You will not be allowed out of bed and will need to use a bedpan or urinal.

- In recovery, a nurse will regularly check your blood pressure, foot pulses, and the puncture site. You will be allowed to eat and drink unless you are going into surgery.

- Your physician’s staff will schedule a follow-up clinic appointment for you. The physician will review the imaging and discuss the results of the procedure with you at this appointment.

Treatment

There are three treatments for AAA, which include the following:

- Watchful Waiting

- Surgical Repair

- Interventional Repair (Endograft)

Watchful Waiting

This is suitable treatment for small AAA’s, which are not growing at a rapid rate. An AAA less than 5cm in size that is not symptomatic has a low risk of rupture. The aneurysm will be monitored by an Interventional Radiologist through regular ultrasound exams (or other medical imaging) to determine the rate of growth and risk of rupture.

Surgical Intervention

This treatment is for large, unruptured aneurysms and it is performed by a vascular surgeon. This requires an invasive surgery where a vascular surgeon makes an incision and places a plastic graft for the blood to flow through. This keeps the blood flow from pulsing on the weakened blood vessel wall and expanding the aneurysm. If an Interventional Radiologist determines that surgical intervention is needed, you will be referred to the proper physician.

Interventional Repair (Endograft)

This procedure is performed by an Interventional Radiologist for smaller aneurysms that require intervention. Endograft (also called Stent Graft) is a minimally invasive procedure which redirects blood flow through a stent to keep it from beating on the weakened blood vessel wall and expanding the aneurysm.

How to Prepare for Endograft

- Be sure to tell your doctor about all medications you are taking and any allergies you may have, especially if you have an allergy to contrast dye or latex.

- You may be advised to stop taking blood thinners or nonsteroidal anti-inflammatory drugs (NSAIDs) for a specified period of time prior to your treatment.

- You may be asked to fast (not eating or drinking anything) for several hours prior to your procedure.

- Female patients should always inform their physician if they are or if there is a possibility that they are pregnant.

- Blood tests may be ordered to determine how well your liver and kidneys are functioning and to see how your blood clots.

- Shower or bathe the night before your procedure.

- Remove jewelry, nail polish/artificial nails and hairpins, but please wear the following items to the procedure if you use them:

- Eye Glasses

- Dentures

- Hearing Aid(s)

- You should plan to have a relative or friend drive you home following your procedure.

What to Expect During & After Endograft

- The physician will discuss the procedure with you and answer questions you may have. You will also read and sign a consent form.

- The area where the catheter is to be inserted will be sterilized and draped with a surgical drape before the physician numbs the area with a local anesthetic.

- A very small nick in the skin is made where the physician inserts a catheter into the femoral artery near the groin.

- A small, compressed plastic or wire mesh stent will be guided to the site of the aneurysm using medical imaging guidance and once it is properly placed, the physician will allow it to expand to fit the blood vessel.

- After the procedure, the catheter is removed and pressure is applied to stop any bleeding. The small opening is covered with a dressing (no stitches are needed).

- In recovery, a nurse will regularly check your blood pressure, foot pulses, and the puncture site. You will be allowed to eat and drink unless you are going into surgery.

- This procedure may require a 1-3 night stay in the hospital.

- Your physician’s staff will schedule a follow up CT, PET or MRI and a clinic appointment. The physician will review the imaging and discuss the results of the procedure with you at this appointment.

- You will be required to have regular (annual) CT or MRI imaging to monitor the stent and the aneurysm.

Risks

Please discuss the potential risks with your physician before your procedure.

- Possible damage to the blood vessel, bruising or bleeding at the puncture site, and infection

- Possible movement of the graft after placement, which may result into resumption of blood flow to aneurysm and rupture

Benefits

- This minimally invasive procedure requires much less recovery time and pain compared to traditional open surgery.

- May be performed under conscious sedation or general anesthesia

- Only a small nick in the skin is made, which does not require sutures

- It is a very safe procedure with low complication rates