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Abdominal Aortic Aneurysm Repair

What is an abdominal aortic aneurysm repair?

Abdominal aortic aneurysm (AAA) repair is done 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. Repair of an AAA may be done in one of two ways:

  • Open repair. For this surgery, a large incision is made in the abdomen to expose the aorta. Once the abdomen is opened, the aneurysm will be repaired with a graft. Open repair remains the standard procedure for an abdominal aortic aneurysm repair.
  • Endovascular aneurysm repair (EVAR). This is a minimally invasive option. This means it is done without a large incision. Instead, the doctor makes a small incision in the groin. He or she will thread special instruments through a catheter inserted in the artery to the aneurysm. At the aneurysm, a stent and graft are placed to support the aneurysm.

The doctor will determine which procedure is right for you.

Why might I need AAA repair done?

An AAA may need repair for the following 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 two inches)
  • Growth rate of aneurysm of more than 0.5 centimeter (about 0.2 inch) over one year
  • When risk of rupture outweighs the risk of surgery
  • Emergency life-threatening bleeding

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

What are the risks of AAA repair?

As with any surgical procedure, complications can occur. Some possible complications may include:

Open repair

  • Heart attack
  • Irregular heart rhythms
  • Bleeding during or after surgery
  • Injury to the bowel
  • Loss of blood flow to legs/feet from a blood clot
  • Blood clot
  • Infection of the graft
  • Lung problems
  • Kidney damage
  • Spinal cord injury

EVAR

  • Damage to surrounding blood vessels, organs, or other structures by instruments
  • Kidney damage
  • Loss of blood flow to leg/feet 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

Tell your doctor if you are allergic to or sensitive to medications, contrast dyes, iodine, or latex.

There may be other risks depending on your specific medical condition. Be sure to discuss any concerns with your doctor prior to the procedure.

How do I get ready for AAA repair?

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

  • Your doctor will explain the procedure to you and let you ask questions.
  • If you smoke, stop smoking as soon as possible prior to the procedure. This will improve your recovery and improve your overall health.
  • Tell your doctor if you have a history of bleeding disorders or if you are taking any blood-thinning medications, aspirin, or other medications that affect blood clotting. You may be told to stop these medications prior to the procedure.
  • Tell your doctor if you are pregnant or think you might be.
  • Tell your doctor if you are sensitive to or are allergic to any medications, latex, iodine, tape, contrast dyes, and anesthetic agents (local or general).
  • Tell your doctor of all medications (prescribed and over-the-counter) and herbal supplements that you are taking.
  • You will be asked to fast for 8 hours before the procedure, generally after midnight.
  • Your doctor may do a physical exam to be sure you can safely undergo the procedure. You may also undergo blood tests and other diagnostic tests.
  • You will be asked to sign a consent form that gives permission to do the procedure. Read the form carefully and ask questions if something is not clear.
  • You may receive a sedative prior to the procedure 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 monitor your heart rate, blood pressure, breathing, and oxygen level during the surgery. Once you are sedated, a breathing tube will be inserted through your throat into your lungs and you will be connected to a ventilator. This will breathe for you during the surgery.
  3. A catheter will be inserted into your bladder to drain urine.
  4. The skin over the surgical site will be cleansed with an antiseptic solution.
  5. Once all the tubes and monitors are in place, the doctor will make an incision (cut) down the center of the abdomen from below the breastbone to below the navel. Or, across the abdomen from underneath the left arm across to the center of the abdomen and down to below the navel.
  6. The doctor 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 doctor will cut open the aneurysm sac and suture into place a long tube called the graft. This will connect both ends of the aorta together.
  8. The clamps will be removed and the doctor will wrap the wall of the aneurysm around the graft. Then the aorta is sutured back together.
  9. A sterile bandage will be applied.
  10. After an open procedure, a tube may be inserted through your mouth or nose into your stomach to drain stomach fluids.
  11. You will be moved from the operating table to a bed, then 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 monitor your heart rate, blood pressure, breathing, and blood oxygen level during the surgery. Once you are sedated, a breathing tube may be inserted through your throat into your lungs and you will be connected to a ventilator. This will breathe for you during the surgery.
  3. The doctor may choose regional anesthesia instead of general anesthesia. Regional anesthesia is medication delivered through an epidural (in the back) to numb the area to be operated on. You will receive medication to help you relax and analgesic medication for pain relief. The doctor will be able to talk to you during the procedure. The doctor will determine which type of anesthesia is appropriate.
  4. The doctor will make an incision in each groin to expose the femoral arteries. Using fluoroscopy (a type of X-ray "movie" that transmits images to a TV-like monitor), the doctor will insert a needle into the femoral artery. Then a guide wire will be passed and moved to the aneurysm site. The needle will be removed and a sheath slid over the guide wire.
  5. Contrast dye is injected to visualize the position of the aneurysm and adjacent blood vessels).
  6. The doctor will use special endovascular instruments and X-ray images for guidance. A stent-graft will be inserted through the femoral artery and advanced up into the aorta to the site of the aneurysm.
  7. The collapsed stent-graft will be advanced up into the aorta and situated at the aneurysm site. The stent graft will be expanded and attached to the wall of the aorta.
  8. Dye is injected again to check for blood leaking out into the aneurysm area.
  9. Once no leak has been determined, the instruments will be removed.
  10. The incisions will be sutured back together.
  11. A sterile bandage/dressing will be applied.

What happens after the AAA repair?

In the hospital after AAA open repair

After the procedure, you may be taken to the recovery room or the intensive care unit (ICU) to be closely watched. You will be connected to monitors that will display your 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 continue to wake up from the anesthesia and start to breathe on your own, the breathing machine will be adjusted to allow you to take over more of the breathing. When you are awake enough to breathe completely on your own and you are able to cough, the breathing tube will be removed.

After the breathing tube is out, your nurse will help you cough and take deep breaths every two hours. This may be uncomfortable due to soreness, but it is very important that you do this 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.

You may receive pain medication as needed, either by a nurse, through an epidural catheter, or by giving it yourself through a device connected to your intravenous line.

You may be on IV medications to help your blood pressure and your heart, and to control any problems with bleeding. As your condition stabilizes, these medications will be gradually decreased and discontinued as your condition allows.

Once the breathing tube has been removed and your condition has stabilized, you may start liquids to drink. Your diet will move gradually 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. The drainage tube will be removed when your intestines work again. This is usually a few days after the procedure.

When your doctor 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 as you get out of bed and walk around for longer periods.

Arrangements will be made for discharge from the hospital. This will include prescriptions for new medicines and directions for a follow-up visit with your doctor.

In the hospital after EVAR

You may be taken to the intensive care unit (ICU) or a postanesthesia care unit (PACU). You will be connected to monitors that will display your 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.

You will be given pain medication for incisional pain or you may have had an epidural. This is anesthesia that is infused through a thin catheter into the space that surrounds the spinal cord in the lower back. It causes numbness in the lower body, abdomen, and/or chest.

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

Arrangements will be made discharge from the hospital. This may include prescriptions for new medicines and directions for a follow-up visit with your doctor.

At home

Once you are home, it will be important to keep the surgical area clean and dry. Your doctor will give you specific bathing instructions. The sutures or surgical staples will be removed during a follow-up office visit, if they were not removed before leaving the hospital.

The surgical incision may be tender or sore for several days after an aneurysm repair procedure. Take a pain reliever for soreness as advised by your doctor.

You should not drive until your doctor tells you to. Other activity restrictions may apply.

Tell your doctor to report any of the following:

  • Fever and/or chills
  • Redness, swelling, or bleeding or other drainage from the incision site
  • Increase in pain around the incision site

Your doctor may give you other instructions after the procedure, depending on your particular situation.

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
  • The risks and benefits of the test or procedure
  • When and where you are to have the test or procedure and who will do it
  • When and how will you get the results
  • How much will you have to pay for the test or procedure