The following hypothetical consultation about surgery for an abdominal aortic aneurysm is presented for purposes of general information. Please see your doctor to discuss your individual case and the exams and treatments that are best for you.
An aneurysm is a bulge in a blood vessel wall. Although aneurysms can occur anywhere in the body, the most common location for an aneurysm is in the aorta, the largest artery in the body. In most cases, an aortic aneurysm causes no symptoms. If an aortic aneurysm ruptures, life-threatening bleeding can result, and approximately 15,000 people in the United States die from aortic aneurysms each year. When an aneurysm is found before it has ruptured, surgery can be performed to remove the aneurysm or to prevent blood from flowing into it. In our example, the patient is a 63-year-old man whose doctor referred him to UC San Diego Health System for evaluation for an aortic aneurysm that was found during a routine physical exam.
Doctor: Good afternoon. Nice to meet you.
Patient: How do you do?
Doctor: I am very well. Thank you.
Patient: My doctor was doing my annual physical exam and when he felt my stomach he was concerned that I had something he called an aneurysm. So he sent me to you to have this investigated.
Doctor: I see. That was observant of him; most people are not attentive enough to find an aneurysm early on physical exam. Has he had you get an ultrasound or CT scan yet to see if there is indeed an aneurysm there?
Patient: He sent me for an ultrasound and it did show a 9 centimeter aneurysm.
Doctor: That is something that we need to take care of. How old are you?
Patient: I am 63 years old.
Doctor: Has anyone in your family had a history of aneurysms that you know about?
Patient: No, I don’t believe so. My father died of a heart attack when he was 65 years old, but he didn’t have an aneurysm.
Doctor: Are you a smoker?
Patient: Between you and me, yes.
Doctor: The reason I ask is because the fact that you are a man and a smoker automatically puts you in a higher risk category for developing aneurysms, along with a history of heart disease in a parent. To your knowledge, have you had any kind of pain or problems with your abdomen or belly that you couldn’t quite put together?
Patient: Do you mean when I eat the wrong foods?
Doctor: No, just generally speaking. Do you have back pain or abdominal pain on a chronic basis?
Doctor: Well, most people with aneurysms like you are asymptomatic, meaning they do not have any signs or symptoms. The aneurysms are usually discovered by a good physical exam or by getting a scan. It is fortunate that your doctor picked this up because it is a large aneurysm and I recommend that it be fixed.
Patient: What would happen if I don’t get it fixed?
Doctor: Well, the risk of dying from an aneurysm this size is high -- probably around 30-40 percent per year. So if you don’t fix it, this aneurysm will most likely rupture sometime in the next 3 to 4 years. If the aneurysm ruptures outside of a hospital setting, you will have life-threatening internal bleeding.
Patient: All right, but how safe is the surgery to fix it?
Doctor: If you have this aneurysm fixed in an elective way, the risk is much less. The risk of dying from the operation is about 1-2 percent.
Patient: What exactly is involved in fixing it?
Doctor: We have a couple of different ways of fixing an aortic aneurysm. One is what we call an “open” operation -- and I actually do it a little differently than others do. I make an incision along the flank, or your side, and go behind your bowels. We replace that part of the aorta that contains the aneurysm with a synthetic graft made of polyester and we sew the graft into the aorta.
Patient: How long does the operation take?
Doctor: The operation typically takes about 3-4 hours and you will be in the hospital for about 5 days. Once that aneurysm is fixed, most of the time you are done with it -- you don’t have to worry about it in the future.
Patient: Are there complications to this method?
Doctor: Yes, there are complications that can occur. The most common complications are anesthetic related. Anytime you go under general anesthesia you have a risk of having a heart attack, abnormal heart rhythms, and so on, depending on your overall heart condition before surgery. The number two risk is that you could have bleeding that requires you to get a blood transfusion, so we always prepare for that possibility and have blood available. The third risk is that this operation can result, even though we are very careful, in sexual dysfunction afterwards, because the area that we have to work around is an area where there are nerves that are involved in sexual function. So if those are damaged then you can get retrograde ejaculation. So, those are the three major risks.
Patient: What is “retrograde ejaculation?”
Doctor: Retrograde ejaculation is where you are able to get an erection and have an orgasm but the ejaculate, instead of coming out your penis, goes back into the bladder. So, it doesn’t affect your ability to perform but it would be an issue if you wanted to have any more children, plus it always seems a little peculiar.
Patient: Would it still feel like an orgasm?
Doctor: Yes, it would.
Patient: So, given that I’m not going to have any more children, this shouldn’t be a big deal? I will still be able to get an erection?
Doctor: That is correct. And once again, this complication doesn’t occur in most people that have the operation but it is something to be aware of.
Patient: What other complications are there?
Doctor: The other complication that can happen occasionally is that the blood supply to the bowel or the colon can be affected by replacing that area of the aorta. If that happens, then the worst-case scenario is that you might have a colostomy temporarily. It is rare in elective operations; it is more common when a ruptured aneurysm is repaired. It is still something that can occur and you need to be aware of all the risks even though they are not likely.
Patient: That sounds like a major undertaking. Are there other options for treating this?
Doctor: Yes, there are. You may have heard that there is an option called an endovascular stent graft. That particular operation involves two small incisions in your groin rather than a big incision on your abdomen. Through the arteries in your groin we introduce the graft within the aneurysm and we open it up so that the graft actually fits inside and excludes blood flow into the aneurysm. It is still an operation under general anesthesia or occasionally an epidural.
Patient: That sounds simpler.
Doctor: It is simpler, but it is more complicated in another sense. Not everybody who has an aneurysm is a candidate for this kind of approach because it depends very much on the measurements of the aorta and the anatomy as we see it on CT scan. So the first step, whether we fix the aneurysm by open repair or endovascular repair, is to get a CT scan to see exactly what the shape of your aorta and aneurysm is. Now, let’s assume that your anatomy is favorable and we can fix it endovascularly. It is usually an operation that takes about 2-4 hours and you go home the next day, as opposed to five days with the open repair. The downside is that this procedure is not as definitive.
Patient: What do you mean?
Doctor: Even though we place these grafts as securely as we can, they are not sewn in because they are placed from within the artery and then the graft may move. A lot of changes can happen with the aneurysm as time goes on, so if you commit to that type of operation it is important that you get CT scans on a regular basis, probably for the rest of your life.
Patient: How often would I need to get a CT scan?
Doctor: For the first couple of years you would have to have a CT scan every six months. Then, if things remain stable, we might go to once a year, but it does require long-term surveillance because you can develop changes within the aneurysm that make it necessary to do something to repair those changes.
Patient: But this doesn’t happen with the other operation, the one you call the open surgery.
Doctor: Right. The open repair is a bigger operation, but once the aneurysm is fixed, that’s it. If you have an endovascular graft procedure, the aneurysm is fixed but it is not always permanently fixed because things can still change down the road.
Patient: So where do we go from here?
Doctor: Well, I think that because of the size of the aneurysm we should get a CT scan right away. Then I would like you to return so that we can discuss the results and decide which option is best for you.
Several days later patient has his abdominal CT scan and returns to see the doctor.
Doctor: Hello again. I’ve had the chance to look over your CT scan and you indeed have a large aneurysm. Not quite 9 cm, but about 7.5 cm, still big enough to be a really important concern. And I do think by looking at it that you would be a good candidate for an endovascular approach to the surgery if you so choose.
Patient: When would I choose an endovascular approach versus an open approach?
Doctor: Well, remember what we spoke about with regard to the long-term surveillance we would need to do if you had the endovascular surgery. My recommendation, and most of the vascular surgery community agrees, that if you are a young person, we recommend that you go ahead and have the aneurysm fixed by the traditional open approach, because it is more durable and we don’t want to subject you to twenty years of CT scans and watch to see what might happen to it.
Patient: Are you talking about me? I don’t think of myself as a young person.
Doctor: We define “young” as being around 65 years old or younger, and I would certainly put you in that category because you will probably live at least another twenty years. If you were older and more frail, then I would recommend an endovascular approach.
Patient: Let me ask you a question. If I had come in sooner and the aneurysm had been smaller, would that have been better?
Doctor: It would have been better in that a 5 cm aneurysm, for instance, has a lower risk of rupture than a 9 cm aneurysm. It terms of the technical aspects of doing the operation, I don’t think the size of the aneurysm makes a big difference. When an aneurysm reaches 5 cm in size, we want to repair it. So once it reaches about 5 cm or higher, then it is just a matter of timing, but we still recommend some form of repair.
Patient: Well, the rest of my life is still in good shape - I am working and enjoying that so I would like to get this fixed. How do I go about arranging that?
Doctor: My office will get you to see the anesthesiologist, have some blood tests done, and get it scheduled for you.
Patient: Thank you.
Doctor: My pleasure.
Learn more about aortic aneurysm at Vascular and Endovascular Surgery and the Sulpizio Cardivascular Center at UC San Diego Health System.