6. Thoracic Aortic Aneurysm Surgery
A thoracic aortic aneurysm is a widening of the wall of the aorta which is the body's largest artery. They most often occur in the descending thoracic aorta while others may appear in the ascending aorta.
The most common cause of thoracic aortic aneurysms is the hardening of the arteries (atherosclerosis).
There are usually no symptoms in most patients until the aneurysm begins to leak or expand. If a non-leaking thoracic aortic aneurysms is detected by a test, usually a chest x-ray or a chest CT scan, it was usually done for other reasons. Chest or back pain may mean sudden widening or leakage of the aneurysm.
A chest x-ray and CT scan show if the aorta is enlarged. A chest CT scan shows the size of the aorta and the exact location of the aneurysm.
Treatment depends on the location of the aneurysm. If the aneurysm is at the ascending aorta, surgery to replace the aorta with a fabric substitute is recommended if the aneurysm is larger than 5-6 cm. This requires a heart-lung machine. There are two options for aneurysms of the descending thoracic aorta. If the aneurysm is larger than 6 cm, major, open surgery is done to replace the aorta with a fabric substitute. A less invasive option is endovascular stenting. A stent is a tiny metal or plastic tube that is used to hold an artery open. Stents can be placed into the body without cutting the chest. Catheters are inserted into the groin area where the stent is passed through and into the area of the aneurysm.
Serious complications after aortic surgery can include heart attack, irregular heartbeats, bleeding, stroke, paralysis, graft infection, and kidney damage.
The aorta is the largest artery in your body, and it carries blood away from your heart. Your aorta runs through your chest, where it is called the thoracic aorta. When it reaches your abdomen, it is called the abdominal aorta. The abdominal aorta supplies blood to the lower part of the body. Just below the abdomen, the aorta splits into two branches that carry blood into each leg.
When a weak area of the abdominal aorta expands or bulges, it is called an abdominal aortic aneurysm (AAA). The pressure from blood flowing through your abdominal aorta can cause a weakened part of the aorta to bulge, much like a balloon. A normal aorta is about 1 inch in diameter. However, an AAA can stretch the aorta beyond its safety margin. Aneurysms are a health risk because they can burst or rupture. A ruptured aneurysm can cause severe internal bleeding, which can lead to shock or even death.
AAA can cause another serious health problem. Clots or debris can form inside the aneurysm and travel to blood vessels leading to other organs in your body. If one of these blood vessels becomes blocked, it can cause severe pain or even more serious problems, such as limb loss.
Open Surgical aneurysm repair
A surgeon may recommend that you have a procedure called open aneurysm repair if your aneurysm is causing symptoms or is larger than about 2 inches or is enlarging under observation. During an open aneurysm repair, also known as surgical aneurysm repair, your surgeon makes an incision in your abdomen and replaces the weakened part of your aorta with a tube-like replacement called an aortic graft. This graft is made of strong man-made material, such as plastic, in the size and shape of the healthy aorta. The strong tube takes the place of the weakened section in your aorta and allows your blood to pass easily through it. Following the surgery, you may stay in the hospital for 4 to 7 days. It may also take 2 to 3 months for a complete recovery.
Endovascular stent graft
Instead of open aneurysm repair, your surgeon may consider a newer procedure called an endovascular stent graft. Endovascular means that the treatment is performed inside your body using long, thin tubes called catheters that are threaded through your blood vessels. This procedure is less invasive, meaning that your surgeon will need to make only small incisions in your groin area through which to thread the catheters. During the procedure, your surgeon will use live x-ray pictures on a video screen to guide a fabric and metal tube, called an endovascular stent graft (or endograft), to the site of the aneurysm. Like the graft in open surgery, the endovascular stent graft also strengthens the aorta. Your recovery time for endovascular stent graft is usually shorter than the open surgery, and your hospital stay may be reduced to 2 to 3 days. However, this procedure requires more frequent imaging procedures after placement to be sure the graft continues to function properly, and is more likely to require periodic maintenance than the open procedure.
The main artery which carries blood to your bad leg is blocked near your abdomen. The leg is in desperate need of blood. Because of this, there may be pain, infection and even loss of the limb. However, the artery carrying blood to your other leg is not blocked. Some of the blood from the good side can thus be led across to the bad side (bypass the problem) using a new piece of artificial artery (vascular graft). The blood will now run down the leg arteries below the blocked part. The pain and infection improve.
General or spinal anesthesia may be used. A cut is made into the skin in the groin and thigh on each side. The left and right arteries are found below any blockages. The new artificial artery made of a special plastic material is stitched in place to join the two arteries under the skin. Hospital stay may be anywhere from 5 to 7 days.
After - In Hospital
There will be a fine, thin plastic drip tube in your arm vein which would be connected to a plastic bag containing a salt solution or blood. There will also be drainage tubes connected to plastic containers. These are for draining any residual blood or other fluid from the area of the operation. By the end of 4 days, there should be little pain. Dressings are taken off after 48 hours. There may be stitches or clips in the skin. The plastic drainage tubes are taken out after two days or so.
There may be some swelling of the surrounding skin which also improves in 2 to 3 days. After 7 to 10 days, slight crusts on the wound will fall off. You can wash with soap and warm water as soon as the dressing has been removed. Try to keep the wounds dry until the stitches/clips come out which is usually 10 to 14 days after the operation. You can shower or bathe as often as you want.
After - At Home
You need to rest 2 to 3 times a day for two weeks or more. There is gradual improvement so that by the time two months have passed, normal activity may be resumed.
If you have this operation under general anesthesia, there is a risk of complications related to your heart and lungs.
Sometimes the blood in the new artificial artery clots. This usually needs a second operation to clear the blockage. Sometimes the arteries further down the leg cannot take the extra flow of blood.
Wound infection is sometimes seen which can be treated with antibiotics in a week or two. If however, the infection spreads into your bloodstream or if the new artificial artery gets infected, you will need antibiotics for much longer or the new artificial artery has to be removed to allow the infection to clear.
There is a very small chance that you will experience “steal syndrome”, a feeling of pins and needles, numbness, coldness or even pain. This happens because the new artificial artery “steals” or diverts more blood than your healthy leg can afford to give to the diseased leg. The upper limb needs this blood to maintain its circulation and function.
Overall, results of this operation are very good. About 75% of the new artificial arteries of the femoro-femoral bypasses remain open five years after the operation and patients experience a good quality of life.
Your recovery depends on the state of the other arteries in the legs, but is usually relatively quick and good. You should never smoke after the operation because this causes the new artery to close up.
Thoracotomy is the process of making of an incision (cut) into the chest wall.
A physician gains access to the chest cavity (called the thorax) by cutting through the chest wall. Reasons for the entry are varied. Thoracotomy allows for study of the condition of the lungs; removal of a lung or part of a lung; removal of a rib; and examination, treatment, or removal of any organs in the chest cavity. Thoracotomy also provides access to the heart, esophagus, diaphragm, and the portion of the aorta that passes through the chest cavity.
For a thoracotomy, an incision is cut into the skin of the ribcage. Muscle layers are cut, and a rib may be removed to gain access to the cavity. Using retractors to hold the ribs apart, the lung is exposed. After any repairs are made, the cut rib is replaced and held in place with special materials. Layers of muscle and skin are stitched. If the breastbone was cut (as in the case of a median sternotomy), it is stitched back together with wire.
Opening the chest cavity means cutting through skin, muscle, nerves, and sometimes bone. It is a major procedure that often involves a hospital stay of five to seven days. The skin around the drainage tube to the thoracic cavity must be kept clean, and the tube must be kept unblocked.
The first two days after surgery may be spent in the intensive care unit (ICU) of the hospital. A variety of tubes, catheters, and monitors may be required after surgery.
The rich supply of blood vessels to the lungs makes hemorrhage a risk; a blood transfusion may become necessary during surgery. General anesthesia carries such risks as nausea, vomiting, headache, blood pressure issues, or allergic reaction. After a thoracotomy, there may be drainage from the incision. There is also the risk of infection; the patient must learn how to keep the incision clean and dry as it heals.
After the chest tube is removed, the patient is vulnerable to pneumothorax. Physicians strive to reduce the risk of collapse by timing the removal of the tube. Doing so at the end of inspiration (breathing in) or the end of expiration (breathing out) poses less risk. Deep breathing exercises and coughing should be emphasized as an important way that patients can improve healing and prevent pneumonia.