The primary artery in your belly, the abdominal aorta, has a weak and enlarged portion, as your vascular surgeon has indicated to you (abdominal aortic aneurysm). You must have surgery to replace this section of the aorta with a graft in order to stop the aneurysm from rupturing (bursting).
Your aneurysm’s architectural characteristics, such as its form and location in respect to the renal arteries, make it a good candidate for endovascular repair (EVAR), which involves replacing the aorta with a stented graft. Because of your age and medical history, the newer approach was chosen for you as a better alternative (than open surgical repair). In this process, a liquid known as the “contrast” is injected in order to make the blood flowing within the blood arteries visible on an x-ray. Later, your kidneys and urine help your body get rid of the contrast.
You will usually be admitted to the hospital one or two days before surgery so that there is enough time for the necessary investigations (blood tests, chest x-ray, electrocardiography, echocardiography etc) to be done. Your physician will generally require that 2 units of blood are available for you.
You may need to discontinue any anticoagulant, like Warfarin or Sintrom, or antiplatelet drugs like Clopidogrel (Iscover, Plavix) or Aspirin, for a few days, (if you have been prescribed these before) in order to reduce the risk for bleeding during the operation.
When you are admitted, it will be quite useful to bring with you all medications you are on. Your medical history will be recorded. Later, your vascular surgeon and the anaesthetist who will put you to sleep will visit. They will explain certain aspects of the procedure and of the immediate postoperative care. You will be asked to sign a form confirming that you understand why the procedure needs to be performed, the risks of the procedure and that you agree to the surgery.
Your vascular surgeon will visit you immediately before the procedure to mark up your veins with a waterproof pen, agreeing with you which veins will be removed. You should ensure that all your varicose veins are marked.
When you are admitted, your medical history will be recorded. Later, your vascular surgeon and the anaesthetist will visit you to explain the procedural details and clarify any doubts you may have. You will need to sign a consent document attesting to your understanding of the necessity for and risks associated with the operation.
The first part of any operation is the administration of anaesthesia. Your operation will be performed either under general anaesthesia or under regional anaesthesia (insertion of an epidural catheter in your back to provide pain relief during and after the operation). A urinary catheter will be placed in your bladder to monitor your urine output.
Endovascular or endoluminal refers to a technique that uses long, thin tubes known as catheters to pass past the wall of your arteries and into their lumen.
Initially, a small incision is made in each groin area, where the arteries are punctured and wires followed by angiographic catheters are passed and guided to the desired location.
Using x-rays that are projected on a video screen, a process called fluoroscopy, the catheters are gradually exchanged to larger ones and finally a tube (typically made of a polyester or PTFE graft with a stent exoskeleton), called stent-graft or endograft, will be guided to the site of the aneurysm. This Endograft allows repair of the aneurysm from the inside while preventing increase in flow and pressure in the aneurysm. After confirmation that it is in the right position, all catheters will be removed and the wounds closed.
Following the operation you may need to stay for a while in the High Dependency Unit before coming back to your room. Occasionally you may be transferred to the Intensive Care Unit for closer observation (where you will usually stay for less than 24 hours). You ought to be able to eat lightly and move the next day. Your hospital stay may be cut down to 2-3 days following an EVAR, and your recovery period may be quicker than it would be with an open repair.
You will often feel tired but this will improve as time goes by.
- Your physician will advise you to regularly go for short walks and then rest for gradual return to normal activities
- You can have a bath and wet the wound(s) a few days after the operation
- Your physician will make arrangements for your stitches or clips to be removed unless absorbable sutures have been placed
- You will be able to drive when you can perform an emergency stop safely. This will be 3-4 weeks after the operation
- You should avoid lifting weights for 6 weeks
- If you work, you should be able to return to work in 6-12 weeks
- You will usually be recommended to take Aspirin or Clopidogrel (Iscover, Plavix) and a statin, as you probably did before the operation
- This procedure requires follow-up for a long time (probably through life) with imaging inestigations, currently CT Angiography (CTA), to confirm that it continues to function properly with the endograft in the right position. Lately, experience is gained from follow-up with special duplex ultrasonography
- You may occasionally develop fever and low-back pain immediately or soon after the procedure. These signs may last for several days and are managed with anti-inflammatory medications.
- The risk for heart or chest problems is present, especially if you have a previous history of similar problems.
- Complications related to the technical part of the operation may be:
- Leak of blood around the endograft. If the leak can be documented on imaging investigations it’s called “endoleak”; if not, it’s called “endotension”. A leak may happen even years after the procedure. The risk in case of a leak is that the aortic sac may continue to expand and the aneurysm size to increase, leading to its delayed rupture.
- Migration of the endograft away from the desired position
- “Fracture” of the endograft
- Clotting (thrombosis or obstruction) of one or both endograft limbs and arrest of blood flow through it. It occurs in around 5% of cases and usually requires an urgent corrective procedure to save the limbs.
- Following endovascular stent grafting for an abdominal aortic aneurysm, it is estimated that up to 10% of patients per year may require a corrective procedure, which is usually feasible with an endovascular technique again.
- Other rare, but serious, complications may be either early, like artery rupture, kidney failure, mesenteric ischaemia (reduction of blood flow to the bowels) and paraplegia, or late, like infection of the endograft and late rupture of the aneurysm.
These risks are higher if pateints are not on regular follow-up after EVAR.
- Your physician will advise you to regularly go for short walks and then rest for gradual return to normal activities
- You can have a bath and wet the wound(s) a few days after the operation
- Your physician will make arrangements for your stitches or clips to be removed unless absorbable sutures have been placed
- You will be able to drive when you can perform an emergency stop safely. This will be 3-4 weeks after the operation
- You should avoid lifting weights for 6 weeks
- If you work, you should be able to return to work in 6-12 weeks
- You will usually be recommended to take Aspirin or Clopidogrel (Iscover, Plavix) and a statin, as you probably did before the operation.
- This procedure requires follow-up for a long time (probably through life) with imaging investigations, currently CT Angiography (CTA) yearly, to confirm that it continues to function properly with the endograft in the right position.
To lessen the likelihood of causing future artery damage, you should adjust your way of living. If you don’t, you run a higher chance of having a heart attack, a stroke, or issues with your feet’s circulation.
These changes include:
- Giving up smoking for good
- Daily cardiovascular exercise for 25 to 30 minutes, such as brisk walking
- Preserving your optimal body weight
- Consuming meals low in calories, cholesterol, and animal fat
- Using medicine to manage diabetes, blood pressure, and cholesterol
Attend for follow-up CT scanning of the abdominal aorta & iliac arteries as your vascular surgeon has instructed you.
