At NYU Langone, cardiovascular and vascular surgeons treat some people who have aortic aneurysms with surgery that is designed to repair or replace damaged tissue. The type of surgery doctors choose to perform depends on many factors, including the location of the aneurysm and its size. Your health is also a factor in the decision.
Endovascular surgery, sometimes called EVAR, is a minimally invasive procedure that involves relining the aneurysm from within. The process would be like repairing a damaged bicycle tire by inserting a new inner tube into the tire through a valve without removing or opening the tire.
When first introduced in the 1990s, endovascular aneurysm repair was performed in people who were not otherwise healthy enough for open surgery. Now, however, this procedure is the standard of care at NYU Langone for many people with aortic aneurysms.
In endovascular aneurysm repair, a surgeon makes a small incision in the leg—or, sometimes, a puncture in the skin of the leg—to reach the femoral artery. The surgeon then feeds a flexible, compressed fabric tube reinforced with metal mesh, called a stent graft or endograft, through the femoral artery and into the aorta. X-rays are used to guide the doctor to the aneurysm.
When the stent graft reaches the inside of the aneurysm, it is expanded to its full diameter and seals against the artery’s wall. This allows blood to flow through the aorta without putting pressure on the damaged walls, preventing the aneurysm from growing and protecting the aorta from rupture. Over time, the aneurysm may shrink.
Sometimes, doctors cannot use a traditional stent graft to repair an aneurysm, because the aneurysm occurs in an area where a stent could block blood flow to the arteries that branch from the aorta. Surgeons at NYU Langone are skilled in the use of devices called fenestrated stent grafts, which enable them to perform endovascular repairs of aneurysms located in these areas of the aorta.
Fenestrated stent grafts have customized holes that allow blood to flow through the arterial branches to vital organs, and they can be tailor-made to fit each person’s arterial anatomy. NYU Langone doctors have the expertise to use fenestrated stent grafts for complicated repairs—for example, of juxtarenal aortic aneurysms, which occur in the portion of the aorta where smaller arteries branch off to supply the kidneys with blood.
Endovascular aneurysm repair can be performed with local, regional, or general anesthesia and doesn’t require large incisions or sutures. Complications include leaking blood, blockage of blood flow, or movement of the stent. You can expect to spend one or two days in the hospital after an endovascular repair, so that doctors can monitor you for any complications. You may then need one to two weeks to recuperate at home, during which time your doctor may limit your activity.
After surgery, your doctor may recommend CT scans or aortic duplex ultrasounds, or both, annually to make sure the stent is working properly.
Depending on the location of the aneurysm, your NYU Langone surgeon may decide to perform open surgery when the aneurysm is a certain size—usually larger than 5 centimeters, or larger than 5.5 centimeters if it is a thoracic aortic aneurysm—or has an abnormal shape. Sometimes, open surgery is used when a stent graft may block arterial branches to major organs, though advances in fenestrated stent grafts continue to make less invasive techniques possible.
Open surgery is appropriate only for people who are healthy enough for it. This type of surgery requires general anesthesia.
Your NYU Langone cardiothoracic or vascular surgeon makes an incision near the aneurysm. For a thoracic aortic aneurysm, the incision may be made along the breastbone, which is then opened, or between the ribs. For an abdominal aortic aneurysm, this incision is made below the ribs.
The surgeon places clamps above and below the bulging aneurysm, which is cut open during surgery. Typically, the surgeon places a polyester tube in the aneurysm, sutures it to the healthy sections of the aortic wall above and below the aneurysm, and stitches the opening closed. The tube serves as a new, stronger part of the aorta wall.
You can expect to remain in the hospital for up to five days after surgery, so your doctor can monitor you for complications. These may include internal bleeding, heart attack, or ischemia, which is when the heart doesn’t pump enough blood to the organs.
Before you go home, your doctor may advise not driving for 1 to 2 weeks and avoiding lifting anything heavier than 10 pounds for 4 to 6 weeks. You may have a CT scan or MRI scan several months after surgery to ensure the aorta is healing properly.
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