Patient information on endovascular repair of thoracic aortic aneurysm– ‘key hole’ repair of a ballooned artery in your chest

Who is this leaflet for and what is its aim?

This leaflet is for patients who have been diagnosed with a thoracic aortic aneurysm (TAA) and have been recommended to have endovascular repair of the TAA.

This leaflet aims to explain the procedure and its risks.

Background information

A thoracic aortic aneurysm (TAA) is an abnormal dilatation (ballooning) of the aorta, which is the main artery in the body and carries blood away from the heart. The other arteries in the body are supplied by the aorta, for example those that supply blood to the head, limbs and body organs.

An arterial aneurysm is an abnormal dilatation (ballooning) of an artery caused by a weakness in the wall of the artery. Generally an artery is called aneurysmal when it increases to one and a half times its normal size. Any artery in the body can develop an aneurysm but some are more commonly affected than others. In particular, the aorta, which is the main artery in the chest and abdomen is commonly affected. The main risks of aneurysms are either that they burst (leading to life-threatening bleeding) or they block, therefore, cutting off the blood supply to the areas supported by them.

Aneurysms are more common in people aged over 60 years. They are also more common in people who have high blood pressure and/or those who smoke.

Aneurysms can also run in families, particularly between brothers, because, in general, men are more commonly affected than women.

Diagnosis of TAA

The majority of TAAs cause no symptoms and are discovered by chance. A routine chest X-ray, or a CT/MRI scan performed for some other reason, may pick up the presence of an aneurysm.

Investigation of TAA

Accurate diagnosis and sizing of the TAA is done by a CT scan with dye to show up the aorta. The risk of rupture (bursting) of TAA is related to the size: TAAs bigger than 6cms in diameter are at risk of rupture and require surgical repair to avoid this. Smaller aneurysms are monitored with CT scans every six to twelve months, and surgery is only considered if they increase in size, or start to cause pain or other symptoms. The CT is particularly important when considering and planning keyhole (endovascular) repair of a TAA. Other investigations may be needed to measure the function of the heart, lungs and kidneys might also be arranged, because this surgery tends to put an extra strain on these organs.

The procedure

At the start of the surgery, we make an incision in the groin to expose and control the artery. In the other groin a needle and catheter are placed in the artery without a full incision.

The aortic aneurysm will be fixed by passing the endovascular graft (a polyester or Gore-tex graft supported by metal struts) through the artery in your groin under x-ray control up to the thoracic aorta. The wound will be closed with dissolvable sutures.

Commonly patients recover from aneurysm surgery in the theatre recovery area for the first night, but you may return to the ward.

During surgery, you may lose blood. If you lose a considerable amount of blood your doctor may want to replace the loss with a blood transfusion as significant blood loss can cause you harm. The blood transfusion can involve giving you other blood components such as plasma and platelets which are necessary for blood clotting. Your doctor will only give you a transfusion of blood or blood components during surgery, or recommend for you to have a transfusion after surgery, if you need it.

Compared to other everyday risks the likelihood of getting a serious side effect from a transfusion of blood or blood component is very low. Your doctor can explain to you the benefits and risks from a blood transfusion. Your doctor can also give you information about whether there are suitable alternatives to blood transfusion for your treatment. There is a patient information leaflet for blood transfusion available for you to read.

After the procedure

Once your surgery is completed you will usually be transferred to the recovery ward where you will be looked after by specially trained nurses, under the direction of your anaesthetist.

The nurses will monitor you closely until the effects of any general anaesthetic have adequately worn off and you are conscious. They will monitor your heart rate, blood pressure and oxygen levels too.

You may be given oxygen via a facemask, fluids via your drip and appropriate pain relief until you are comfortable enough to return to your ward.

Some patients recover from aneurysm surgery in the theatre recovery area for the first night. However, you may go back to the ward on the day of surgery if there are no problems in recovery.

Sometimes, people feel sick after an operation, especially after a general anaesthetic, and might vomit. If you feel sick, please tell a nurse and you will be offered medicine to make you more comfortable.

At this time, you might find there is a urinary catheter inserted into your bladder, which allows your urine to drain into a bag. This is a temporary measure to prevent urine becoming retained which can cause your blood pressure to become unstable.

After certain major operations you may be transferred to the intensive care unit (ICU/ITU), high dependency unit (HDU), intermediate dependency area (IDA) or fast track/overnight intensive recovery (OIR). These are areas where you will be monitored much more closely because of the nature of your operation or because of certain pre-existing health problems that you may have. If your surgeon or anaesthetist believes you should go to one of these areas after your operation, they will tell you and explain to you what you should expect.

If there is not a bed in the necessary unit on the day of your operation, your operation may be postponed as it is important that you have the correct level of care after major surgery.

Intended benefits

To surgically repair your aneurysm, to prevent it either bursting or blocking.

Risks

As with any major operation there is a very small risk that you may have a medical complication such as a heart attack, chest infection or kidney failure. There is a 5% (5 in a 100) risk of a stroke. The doctors and nurses will try to prevent these complications and to deal with them rapidly if they occur.

Sometimes after this surgery the blood supply to the legs can become compromised and further operations to restore the circulation are required. There is a 5% risk that the blood supply to the nerves in the spine can also be affected leading to weakness or paralysis of the legs. This can be either transient or permanent. If this occurs then a drain can be placed in the spine to remove some fluid around the spinal cord to try and help the nerves recover.

Overall, the incidence of major complications (including death) is in the region of 3-5% but the risks may be increased in those patients who have pre-existing health problems. The risk of death is lower in keyhole surgery than for open aneurysm repair.

Other complications include graft infection and wound infection, risks to the heart, kidneys and the blood supply to the legs with a very small risk of lower limb amputation due to the fact that the stent is passed through the arteries that supply the legs.

There is an extremely small chance that it may not be possible to manoeuvre the endovascular graft into the aorta and the surgeon may have to revert to open aneurysm repair or may have to abandon the procedure.

Endovascular TAA repair is still a relatively new procedure and we will keep a close eye on your endovascular graft for life after surgery with regular scans. Occasionally blood may leak around the endovascular graft ‘endoleak’ and up to one in six patients may require a further procedure at a later date. However this is likely to be a small procedure under a local anaesthetic. There is a very small chance that the endovascular graft may need to be removed at a later date and the aneurysm repaired by a conventional open surgical technique.

Alternatives

Monitoring only

If the AAA is larger than 6cms, the risk of rupture without surgery is usually higher than the risk of surgery. Therefore not operating and continuing to monitor the thoracic aortic aneurysm is not the safest option. This is determined on a patient-by-patient basis and is dependent in part on the overall general health.

Open aneurysm repair

This is an alternative technique. This is a larger complex operation where the aneurysm is repaired with a graft sewn into the aorta through a larger incision in the chest.

Medication

Bring all of your medicines (including inhalers, injections, creams, eye drops or patches) and a current repeat prescription from your GP.

Please tell the ward staff about all of the medicines you use. During your stay If you wish to take your medication yourself (self-medicate) please speak with your nurse. Pharmacists visit the wards regularly and can help with any medicine queries.

MyChart

We would encourage you to sign up for MyChart. This is the electronic patient portal at Cambridge University Hospitals that enables patients to securely access parts of their health record held within the hospital’s electronic patient record system (Epic). It is available via your home computer or mobile device

More information is available on our website: MyChart

Contacts

We may give you additional patient information before or after the procedure, for example, leaflets that explain what to do after the procedure and what problems to look out for. If you have any questions or anxieties, please feel free to ask a member of staff or contact the Vascular Specialist Nurses via email or on 01223 348526.

Further information is available from:

• The Vascular Society website (opens in a new tab)
• Circulation Foundation UK website (opens in a new tab)