Simply stated, an aneurysm is a widening of an artery. That is, the diameter of the artery increases to more than 50% of its “original” size.  As the diameter of an aneurysmal artery increases, the risk of the artery rupturing increases. Rupture of an aneurysm, anywhere in the body, carries with it significant clinical problems.

The most common location, but by no means the only location for aneurysms, to occur is the large artery in the abdomen, the adomnial aorta. This is the artery that begins at the heart and supplies bloods to all of the organ systems in the body as it travels downward towards the legs.  Branches spread from the aorta to all organs such as the brain, lungs, liver, and kidneys (to name a few) before the aorta “splits” into two arteries at the level of the umbilicus  providing one artery to each leg. Aneurysms most commonly occur in the portion of the aorta that is in the abdomen—below the level where the aorta gives off its branches to the kidneys. 

Most aneurysms are detected incidentally at the time of an examination for an unrelated problem.  Most often a patient will be undergoing a type of imaging study (ultrasound) of the abdomen when an aneurysm is discovered.  It is usually an unexpected finding for both the patient and the physician.

There are times when a careful examination of the patient’s abdomen may reveal an aneurysm which is then confirmed by an ultrasound or CT scan.  This is more common in thinner patients whose aorta may be more readily felt under the skin.  

When an aneurysm produces symptoms (something that makes the person recognize that they have this condition) it is often noted at the time that the aneurysm has ruptured or “leaked.”  rarely will a person notice a pulsating mass in their abdomen and bring it to the attention of their physician.  It is also unusual for a person to experience symptoms in the absence of a rupture of the aneurysm—such as abdominal, back or groin pain.

Radiographic procedures will confirm the presence of an abdominal aortic aneurysm.  An ultrasound is a simple, noninvasive test that will give rapid and accurate results.  If an aneurysm is detected, most physicians would rely on a CT scan to better define the anatomy of the aneurysm which would allow one to make treatment recommendations more accurate.  Angiograms are not generally obtained except in the planning stages for endovascular stent grafting procedures.

The standard treatment for abdominal aortic aneurysms (AAA) has been open surgical repair.  This operation entails replacement of the aneurysmal aorta with a synthetic fabric tube (Dacron or another substance) that extends from the normal aorta above the aneurysm to a point on the arterial tree below the aneurysm (that is, from “normal artery” to “normal artery”).  This involves a rather extensive operative procedure that is performed through an incision in the middle of the abdomen or one along the left flank. The hospital stay is typically 4-10 days and the recuperation varies from 3-4 weeks to 6-12 months.  The operation was first performed in the 1950s and has changed little since that time.  The durability is outstanding with very few recurrences at the same site! 

The development of Endovascular Stent Grafting (EVAR—EndoVascular Aneurysm Repair)has significantly reduced the early morbidity in the care of patients with AAA.  This procedure involves repair of the AAA using a much less invasive technique.  There are several devices available for insertion with full FDA approval (Cook Zenith, Medtronics AneuRx, Gore Excluder and EndoLogix Powerlink).  The procedure allows for repair of the abdominal aortic aneurysm through two small incisions on the lower abdomen or groin and a hospital stay of 24-48 hours.  The recuperation time is markedly improved ranging from 1-6 weeks since the post-operative course is much smoother.  Patients undergoing this procedure are usually able to walk that same day, a vast improvement over the standard open repair.

With a shorter healing time and a smoother post-operative course, most would question why every surgeon would not always perform an Endovascular Repair.  This question is actively debated in many centers in the United States and throughout the world—including ours!  There exists a subset of patients for whom endovascular repair is not an option.  When considering the currently approved devices, these include patients whose aneurysm begins too close to the level of the kidney arteries, vessels that may be severely calcified (hardened) or those vessels in patients between the groin and the aneurysm (iliac arteries) that are too small to accept passage of the device. 

What is most important, in our opinion, is the fact that long-term data is not yet available on endovascular stent grafting. Thus, when considering a patient for repair of their AAA, the patient’s longevity must be a factor taken into consideration. Once long-term data is available, the utility of endovascular stent grafting on a wider scale may become more prevalent.