AAA occurs when the arterial wall of the aorta weakens and bulges beyond its normal size. An AAA has particularly serious consequences because the aorta is the largest blood vessel in the body. The aorta carries oxygen-rich blood directly from the left ventricle of the heart through the abdominal area. From there, the aorta forks into two arteries that transport blood to the legs. The aortic wall must be thick and strong to handle the forceful blood flow. A normal aorta is about 1.5-2 centimeters (.59-.78 inches) in diameter.

When an AAA ruptures or tears, it can cause severe internal bleeding. By the time a patient gets to the hospital, it’s often too late. But it is possible to fix an aneurysm when it is caught in time. The tricky part is finding an AAA early enough.

“AAA is like high blood pressure. It’s a silent killer,” explains Stacey Mazzacco, MD, Lancaster Surgical Group. “Some people don’t see it coming until it’s too late.”

Risk factors for AAA

• Smoking
• High cholesterol
• Diabetes
• Heredity (a family history of AAA)
• Gender (more common in males)
• Age (males, over age 55; females, over age 70)
  

Diagnostic tests for AAA include:

• Ultrasound – sound waves create an image of your blood vessels
• CT Scan/MRI – using X-rays or magnetism to make cross-sectional views of the body
• Arteriography – catheterization procedure that uses an X-ray image to show the flow of blood through the aorta
  

The diagnostic tests will help the doctor determine the size and location of the AAA. If the aneurysm is 5 centimeters (1.96 inches) or less, the doctor may recommend “watchful waiting.” Patients return for testing once or twice a year so the doctor can monitor the size of the AAA.

“Sometimes an aneurysm may stay small for a long time and you never need to have anything done. We evaluate whether the risk of watching it (following up with CT scans and ultrasound) is higher than the risk of surgery,” says Steven Woratyla, MD, Surgical Specialists of Lancaster. “Aneurysms never shrink. At best, they may stay the same size. You know when it’s time to operate when the risk of rupture is greater than the risk of surgery.”

The type of approach a doctor uses to repair an AAA depends partly on the size and location of the AAA, as well as the patient’s overall health. During traditional surgery, the doctor replaces the damaged part of the aorta by sewing in a graft (a strong, hollow fabric tube) and re-wrapping the aorta around the graft.  This surgery requires a large incision in the abdomen as well as general anesthesia. Most patients remain in the hospital for 5-7 days and require a few weeks to get back on their feet.

While surgeons have had great success with traditional surgery, it is not necessarily the best approach for all patients. Some patients may have heart disease, lung disease, diabetes or other conditions that make open surgery a greater risk than a rupture. But a newer, less-invasive procedure—endovascular stent grafting—can help some of these patients.

“For patients who could not physically tolerate open surgery, endovascular stent grafting may be a better option. But not everyone is a candidate because one device does not fit all, and some patients may not fit any device” says Leigh Shuman, MD, Lancaster Radiology Associates and Chairman of the Department of Radiology & Diagnostic Imaging at Lancaster General Hospital.

Endovascular stent patients must:

• Be healthy enough to undergo a 2-4 hour procedure
• Pass anesthesia clearance
• Have an AAA located below the renal arteries
• Have access blood vessels in their legs that are large enough for the stent
• Commit to a lifetime of attending regular doctor’s visits after surgery
   

During the endovascular stent grafting procedure, doctors insert a tube-shaped stent (graft) into the dilated part of the aorta. The stent provides a new lining for the damaged section of the aorta. The stent is inserted using a catheter placed inside an artery in the groin and guided into position in the aorta. Patients usually stay in the hospital for 1-3 days and can return to normal activities within a few days.

Surgeons at Lancaster General Hospital have been using endovascular stent grafts since 2000. Because it is a newer technology, doctors monitor rehabilitation closely.

 “With traditional surgery, once we fix the aneurysm, we know it’s fixed. But because this is a newer procedure, we need to continue to screen the patients for delayed leaks, ruptures or movement of the stent,” explains Matthew Bacharach, MD, who was the first surgeon to perform the endovascular stent procedure at Lancaster General Hospital.

Doctors who can perform this type of procedure include vascular surgeons, cardiologists, cardiothoracic surgeons and interventional radiologists.

Following an AAA repair, doctors may also recommend making lifestyle changes.

 The Lancaster General Wellness Center offers programs to help, including:

• Smoking Cessation classes to help break the smoking habit
• LEARN weight management classes teach adults how to make healthy choices, including choosing foods that are low in fat and sodium
• Stress Management, Yoga, Tai Chi or Qigong classes to lower stress
  

 Return to Generally Speaking Summer 2004 Issue