What is an abdominal aortic aneurysm repair?

Your healthcare provider may advise an abdominal aortic aneurysm (AAA) repair to treat an aneurysm. An aneurysm is a bulging, weak spot in the aorta that may be at risk for rupturing. In this case, the aneurysm is in part of the aorta that is in the abdomen (belly). Repair of an AAA may be done in 1 of 2 ways:

• Open repair. For this surgery, your doctor makes a large incision in the abdomen to reach the aorta. A graft is then used to repair the aneurysm. Open repair is the standard procedure for an abdominal aortic aneurysm repair.

• Endovascular aneurysm repair (EVAR). This is a minimally invasive option. This means it's done without a large incision. Instead, the doctor makes a small incision in the groin. They will insert small tools through a flexible tube (catheter) in an artery in the groin. The tools are gently pushed up to the aneurysm. Your doctor then places a stent and graft to repair the aneurysm.

The doctor will determine which procedure is right for you.

Minimally Invasive Surgery for Aortic Aneurysms | Q&A

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Johns Hopkins’ expert vascular surgeons can provide minimally-invasive aneurysm repair, with shorter hospital stays and quicker recovery. They even perform a hybrid surgery for those who aren’t eligible for the least invasive procedure but can’t have open surgery.

Why might I need AAA repair done?

An AAA may need repair for any of these reasons:

• To prevent the risk of rupture

• To relieve symptoms

• To restore a good blood flow

• Size of aneurysm greater than 5 centimeters in diameter (about 2 inches)

• Growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over 1 year

• When risk of rupture outweighs the risk of surgery

• Emergency life-threatening bleeding

There may be other reasons for your healthcare provider to advise an AAA repair.

What are the risks of AAA repair?

All surgery has risks. The risks of AAA repair are below.

Open repair risks

• Heart attack

• Irregular heart rhythms

• Bleeding during or after surgery

• Injury to the bowel

• Loss of blood flow to legs, feet, or bowel from a blood clot

• Blood clot

• Infection of the graft

• Lung problems

• Kidney damage

• Spinal cord injury

• Impotence

EVAR risks

• Damage to surrounding blood vessels, organs, or other structures

• Kidney damage

• Loss of blood flow to leg, feet, or bowel from a blood clot

• Groin wound infection

• Groin hematoma (large blood-filled bruise)

• Bleeding

• Endoleak (continual leaking of blood out of the graft and into the aneurysm sac with potential rupture)

• Spinal cord injury

• Impotence

• Graft infection

Tell your healthcare provider if you are allergic to or sensitive to any medicines, contrast dyes, iodine, or latex.

There may be other risks for you. These depend on your overall health. Be sure to discuss any concerns with your healthcare provider before the procedure.

How do I get ready for AAA repair?

Ask your healthcare provider to tell you what you need to do before your procedure. Below is a list of common steps that you may be asked to do.

• Your healthcare provider will explain the procedure to you and let you ask questions.

• If you smoke, stop smoking as soon as possible before the procedure. This will improve your recovery and your overall health.

• Tell your healthcare provider if you have a history of bleeding disorders or if you are taking any blood-thinning medicines. This includes aspirin or other medicines that affect blood clotting. You may be told to stop taking these before the procedure.

• Tell your healthcare provider if you are pregnant or think you might be.

• Tell your healthcare provider if you are sensitive to or are allergic to any medicines, latex, iodine, tape, contrast dyes, or anesthetic medicines (local or general).

• Tell your healthcare provider all medicines (prescribed and over the counter), vitamins, and herbal supplements that you take.

• You will be asked to not eat (fast) for 8 hours before the procedure.

• Your healthcare provider may give you a physical exam. This is to be sure you can safely undergo the procedure. You may also have blood tests and other tests.

• You will be asked to sign a consent form. This gives permission to do the procedure. Read the form carefully. Ask questions if something is not clear.

• You may receive a sedative before the procedure. This is to help you relax.

How is the AAA done?

How is AAA open repair done?

1. You will lie on your back on the operating table.

2. The anesthesiologist will watch your heart rate, blood pressure, breathing, and oxygen level during the surgery. Once you are sedated, your healthcare provider will put a breathing tube down your throat into your lungs. This will connect you to a ventilator. This will breathe for you during the surgery.

3. A healthcare provider will insert a catheter into your bladder to drain urine.

4. A healthcare provider will clean the skin over the surgical site with an antiseptic solution.

5. The healthcare provider will make a cut (incision) down the center of your abdomen from below your breastbone to below your navel. Or they may cut across your abdomen from under your left arm to the center of your abdomen and down to below your navel.

6. The healthcare provider will place a clamp on the aorta above and below the site of the aneurysm. This will temporarily stop the flow of blood.

7. The healthcare provider will cut open the aneurysm sac. They will stitch (suture) a long tube called the graft into place. This will connect both ends of the aorta together.

8. Your healthcare provider will remove the clamps. They will wrap the wall of the aneurysm around the graft. Your healthcare provider will then stitch the aorta back together and close your chest with stitches.

9. Your provider will apply a sterile bandage.

10. After an open procedure, your healthcare provider may put a tube through your mouth or nose into your stomach. This is done to drain stomach fluids.

11. You will be moved from the operating table to a bed. You will then be taken to the intensive care unit (ICU) or the postanesthesia care unit (PACU).

How is EVAR done?

1. You will be placed on your back on the operating table.

2. The anesthesiologist will watch your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, your healthcare provider may put a breathing tube down your throat into your lungs. This will connect you to a ventilator. This will breathe for you during the surgery.

3. The healthcare provider may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medicine sent through a tube in your back. It is known as an epidural. It will numb the area to be worked on. You will also have medicine to help you relax and prevent pain. The healthcare provider will be able to talk to you during the procedure. The healthcare provider will determine which type of anesthesia is best for you.

4. The doctor will make an incision in your groin to reach the femoral arteries. Using moving X-ray images called fluoroscopy, the doctor will put a needle into your femoral artery. Then they will thread a guide wire to the aneurysm site. Your doctor will remove the needle and slide a sheath over the guide wire.

5. Your provider will then inject contrast dye into the artery. This is done to show the position of the aneurysm and the blood vessels next to it.

6. The doctor will use endovascular tools and X-ray images for guidance. They will insert a stent-graft through the femoral artery. This is gently pushed up into the aorta to the site of the aneurysm.

7. They will expand the stent graft and attach it to the wall of the aorta.

8. Your provider will inject dye again. This is to check for blood leaking out into the aneurysm area.

9. If your healthcare provider sees no leaks, they will remove all of the tools.

10. Your healthcare provider will stitch the incisions back together. A healthcare provider will apply a sterile bandage or dressing.

What happens after the AAA repair?

In the hospital after AAA open repair

After the procedure, a member of the surgical team will take you to the recovery room or the intensive care unit (ICU) to be closely watched. You will be connected to monitors that will display your vital signs (heart activity, blood pressure, breathing rate, and your oxygen level).

You may have a tube in your throat to help you breathe until you can breathe on your own. As you wake up from the anesthesia and start to breathe on your own, a healthcare provider will adjust the breathing machine (ventilator). This will allow you to take over more of the breathing. When you are awake enough to breathe fully on your own and you are able to cough, the healthcare provider will remove the breathing tube.

After the breathing tube is out, your nurse will help you cough and take deep breaths every 2 hours. This may be uncomfortable due to soreness. But it is very important that you do this. It is to keep mucus from collecting in your lungs. This can lead to pneumonia. Your nurse will show you how to hug a pillow tightly against your chest while coughing to help ease the discomfort.

Your nurse may give you pain medicine as needed. You may be on IV medicines. These are to help your blood pressure and your heart, and to control any problems with bleeding. As you recover, your doctor will slowly decrease then stop these medicines.

Once your provider removes the breathing tube, you may be able to drink liquids. Your diet will go back to more solid foods as you are able to handle them.

If you have a drainage tube in your stomach, you will not be able to drink or eat until the tube is removed. Your provider will remove the tube when your intestines work again. This is usually a few days after the procedure.

When your healthcare provider decides that you are ready, you will be moved from the ICU to a postsurgical nursing unit. Your recovery will continue here. Your activity will be gradually increased. You will get out of bed and walk around for longer periods.

Your healthcare team will talk with you about your discharge from the hospital. You may have prescriptions for new medicines and directions for a follow-up visit with your healthcare provider.

In the hospital after EVAR

A member of the surgical team may take you to the intensive care unit (ICU) or a postanesthesia care unit (PACU). You will be connected to monitors that will display your vital signs. These include heart activity, blood pressure, breathing rate, and your oxygen level.

You will remain in either the ICU or PACU for a time and then moved to a regular nursing care unit.

Your nurse will give you pain medicine. Or you may have an epidural in place. An epidural is anesthesia that is sent through a thin catheter into the space that around the spinal cord in the lower back. It causes numbness in the lower body, abdomen, and chest.

Your activity will be slowly increased. You will get out of bed and walk around for longer periods. You will eat solid foods as soon as you can handle them.

Your healthcare team will talk with you about your discharge from the hospital. You may have prescriptions for new medicines and directions for a follow-up visit with your healthcare provider.

At home

Once you are home, make sure to keep the incision clean and dry. Your healthcare provider will give you bathing instructions. Your provider will remove the stitches or surgical staples during a follow-up office visit. In some cases, they are removed before you leave the hospital.

The incision may be sore for several days. Take a pain medicine as advised by your healthcare provider.

You should not drive until your healthcare provider tells you it's OK. You may have other restrictions on your activity.

Tell your healthcare provider if you have any of the following:

• Fever or chills

• Redness, swelling, or bleeding or other fluid leaking from the incision site

• Increase in pain around the incision site

Your healthcare provider may give you other directions after the procedure.

Next steps

Before you agree to the test or the procedure make sure you know:

• The name of the test or procedure

• The reason you are having the test or procedure

• What results to expect and what they mean

• The risks and benefits of the test or procedure

• What the possible side effects or complications are

• When and where you are to have the test or procedure

• Who will do the test or procedure, and what that person’s qualifications are

• What would happen if you did not have the test or procedure

• Any alternative tests or procedures to think about

• When and how will you get the results

• Who to call after the test or procedure if you have questions or problems

• How much will you have to pay for the test or procedure