Aneurysm Surgery: Vascular Surgical Procedures for Aortic Aneurysms

An aneurysm is a spindle-shaped or sac-like bulge in a blood vessel. It most commonly affects the aorta. This is referred to as an aortic aneurysm.

The cause is usually a weakness in the vessel wall. Under constant blood pressure, the wall gives way and bulges out. Risk factors such as high blood pressure, smoking, and atherosclerosis contribute to the aneurysm’s growth. What makes this condition particularly insidious is that small aneurysms often cause no symptoms at all. Only when the bulge reaches a critical size is there a risk of rupture, which leads to massive internal bleeding.

The following video shows how an aortic aneurysm develops:

To understand aortic aneurysm surgery, it’s helpful to look at the anatomy of the aorta. It originates directly from the heart, runs through the chest via the aortic arch (thoracic aneurysm), and extends as the abdominal aorta all the way to the pelvis.

• Abdominal aortic aneurysm: This is the most common type (abdominal aortic aneurysm).
• Aorta in the chest: Less common, but anatomically more complex, as blood vessels branch off here to the brain.

An aortic aneurysm is a sac-like dilation in the walls of the aorta @ Oleksandr Pokusai /AdobeStock

Not every aneurysm requires immediate surgical treatment. The decision to proceed with surgery depends on weighing the risk of rupture against the risks of the surgery itself.

Vascular surgery guidelines generally recommend surgery:

1. When the diameter reaches approximately 5.0 to 5.5 cm in the abdominal region (often sooner in women).

2. If the aneurysm is growing (rapid increase in size within 6 months).

3. For symptomatic aneurysms (pain in the back or abdomen).

4. In cases of “eccentric” aneurysms (bulging), which are more prone to rupture.

If the aneurysm is still small, a “watchful waiting” approach is taken: The size of the aneurysm is monitored regularly via ultrasound.

Comparison of a normal aorta and an aortic aneurysm @ Alila Medical Media / AdobeStock

If aneurysm surgery becomes necessary, there are two established surgical procedures to choose from in vascular surgery. Which procedure is used depends on the patient’s age and the anatomy of the aorta.

1. Endovascular therapy (EVAR/TEVAR) Endovascular therapy is a minimally invasive procedure and is often the standard of care today.

• The procedure: Under X-ray guidance, doctors insert a catheter through the femoral artery to the affected aorta.
• The technique: A folded stent graft (a metal scaffold covered with fabric) is deployed at the site of the aneurysm. This stent bridges the bulge from the inside.
• The advantage: Blood flow is directed through the stent, relieving pressure on the vessel wall. No large abdominal incision is required, which speeds up recovery. This is also known as aortic repair using catheter technology.

2. Traditional open surgery In open surgery, the surgeon opens the abdomen or chest to expose the aorta.

• The procedure: The diseased section of the vessel is clamped off, the aneurysm is incised, and it is replaced with an artificial vascular prosthesis (a plastic tube).
• When is it appropriate? This procedure offers a very long-lasting solution and is often used in younger patients or when a stent graft is not anatomically feasible.

Endovascular treatment for an abdominal aortic aneurysm @ bilderzwerg /AdobeStock

Whether open surgery or endovascular surgery, the procedure takes place at a specialized clinic or a hospital with a vascular surgery department.

• Preparation: CT scans measure the aortic aneurysm with millimeter precision.
• Anesthesia: Open surgery is performed under general anesthesia; stent surgery is often possible under local anesthesia or spinal anesthesia.
• Duration: Depending on its complexity, an aneurysm surgery takes between 1.5 and 4 hours.

Like any surgical procedure, the treatment of an aortic aneurysm carries risks. Since patients are often older and have pre-existing conditions, specialists carefully assess their suitability for the procedure. Possible complications include:

• Bleeding or impaired wound healing.
• Circulatory problems in the legs or kidneys.
• Endoleaks (only with stents): When the prosthesis does not seal tightly and blood continues to flow into the aneurysm sac.
• Cardiovascular problems during anesthesia.

Nevertheless, a ruptured aneurysm is acutely life-threatening. Therefore, once the aneurysm reaches a certain size, the planned surgery is almost always the lesser risk compared to not intervening.

If the aneurysm has been surgically treated, the prognosis is usually very good. With endovascular treatment, however, stents must be monitored for life using ultrasound or CT scans to ensure they do not slip out of place. After open surgery, the vascular prosthesis is usually maintenance-free.

Important for long-term success:

• Maintain optimal blood pressure.
• Quit smoking (nicotine causes massive damage to the vessel wall).
• Regular checkups with a vascular medicine specialist.

How long is the hospital stay after an aneurysm surgery?

With endovascular treatment, patients can often leave the hospital after just 2 to 4 days. Traditional open surgery usually requires a hospital stay of 7 to 12 days, often followed by rehabilitation.

What is the difference between an aneurysm and an aortic dissection?

An aneurysm is a dilation of the aorta. An aortic dissection is a sudden tear in the inner wall of the aorta, causing the wall layers to separate. Both are medical emergencies, but the mechanisms are different.

Can you live a normal life with a stent?

Yes. A stent prosthesis does not restrict daily life. Sports and physical activity are possible again once the wound has healed. However, regular follow-up care is important to ensure that the abdominal aortic aneurysm remains permanently closed off.

How do I find the right doctor?

Look for a certified vascular center. Experienced specialists perform a high volume of these procedures, which increases safety. In the Leading Medicine Guide, you’ll find selected specialists for the treatment of aneurysms.