Consent:Abdominal Aortic Aneurysm

Nature

Operation to repair the widened (aneurysmal) main arterial blood vessel in the tummy;

• General anaesthetic, patient is put to sleep
• Usually long incision in the middle of the tummy. Alternatives are a transverse incision, and a lateral incision curving from the left side down to the lower midline.
• Top and bottom of the aneurysm are located and dissected so that they may be clamped
• Usually the blood is thinned
• Blood vessels above and below the aneurysm are clamped
• Aneurysm is opened
• Clot is scooped out and discarded
• Any blood vessels bleeding into the aneurysm are stitched
• A new inner tube of plastic is stitched into the top and bottom of the aneurysm to carry the blood. Sometimes it is necessary to put in a plastic tube with two legs, one for each lower limb.
• Blood flow is restored to the lower limbs
• Aneurysm is not usually removed but is stitched over the new inner tube of plastic
• Abdomen is closed

After the operation;

• The patient is transferred from the operating room to the intensive care unit.
• The patient usually requires artificial ventilation with a special machine from several hours up to several days, most patients do not need the ventilator after 16 hours.
• Many tubes and apparatus for monitoring and supporting the patient are required.
  • Intra venous cannulae; plastic tube passed into a vein; to give fluids, blood and drugs

  • Central line; plastic tube passed into a large central vein; to give fluids, blood and drugs; to continuously monitor the filling pressure in the large veins

  • Arterial line; plastic tube passed into an artery; to continuously monitor blood pressure and to take blood samples

  • Naso gastric tube; plastic tube passed through the nose, back of the throat and swallowing tube into the stomach; to keep the stomach empty, to prevent vomiting and discomfort

  • Urinary catheter; soft plastic tube passed through the urethra into the urinary bladder; to drain urine from the urinary bladder and monitor urinary output

  • Endo tracheal tube; plastic tube passed through the mouth and voice box into the trachea (breathing tube); usually connected to a ventilator machine with special tubing; to ventilate the lungs and help in removal of secretions from the airways

  • Pulse oximetery; clip like apparatus applied to the finger, toe or earlobe; to continuously measure saturation of oxygen in the blood

  • Cardiograph; electrodes and wires attached to the patients skin; to continuously monitor the electrical activity in the heart

• Most patients are transferred from the intensive care to the ward area on the first day following the operation

• Most of the very bad pain following the operation is gone after two days. There is still alot of discomfort, which gradually lessens over the next ten to fourteen days

• Most patients are able to start drinking after four days and may eat when they tolerate fluids well

• Most patients can sit out of bed with help on the second day, and are able to stand the third or fourth days and walk, initially with help following that

• Most patients may leave the hospital for home or convalescence on the tenth day

• Recovery at home is not immediate, the after effects of the operation will persist for four to six months, this is manifest as poor appetite, poor energy and often poor sleep. These symptoms are improved by eating well, exercising and with time.

Alternatives

Do nothing

Risk of rupture of the aneurysm is dependent on the size, the larger the aneurysm the greater the risk of rupture. The surgeon usually recommends operation when the risk to the patient is greater without surgery than with it

Endovascular stent

A new experimental procedure to repair the aneurysm by placing a lined expandable cage into the aneurysm from the inside. The device is introduced from the groin and opened when in the correct location. There is a trade off between quicker recovery against increased problems in the longer term related to the device requiring re-interventions and close out patient follow up with repeated scans.

Risk factor reduction

At the moment there are no drugs in use that reduce the risk of expansion or rupture of aneurysms. However it has been shown that obstructive airways disease, smoking and high blood pressure increase the risk of aneurysmal rupture; it therefore makes sense that patients should stop smoking, have their blood pressure controlled and have their chest problems treated.

Attend hospital urgently when symptomatic

Some patients may not wish to have surgery until the aneurysm gives trouble. It is estimated that about 50% of people with a ruptured aneurysm survive to reach hospital. Of those that reach hospital survival is about 50%, overall about 20% of people who suffer a ruptured aneurysm will survive.

Benefits

• The risk of rupture is eliminated
• Psychological benefit of elimination of worry regarding the aneurysm

Risks

• Risk of the anaesthetic
• Mortality between 3% and 8% (In contrast to 80% for a ruptured aneurysm), in the main related to ischaemia cardiac events
• Bleeding, infection and ugly scar from any incision
• Low risk of requiring early re-operation for bleeding
• Risk of decreased circulation to the lower limbs which may require further surgery to correct, low risk of amputation of lower limb(s)
• Risk of stress ulceration of the stomach and duodenum
• Risk of chest problems, collapsed lung, chest infections
• Risk of infection of the urinary tract
• Risk of urinary retention in men
• Risk of Deep Venous Thrombosis and its sequelae
• Longer term risk of infection of the graft
• Longer term risk of further aneurysm formation, either adjacent to the graft or in other locations