Aortic surgery - specialists and information on operations on the aorta

What is aortic surgery?

Aortic surgery encompasses all surgical interventions on the aorta. The aorta starts from the heart and runs downwards along the spine through the chest and abdomen. It splits into the two iliac arteries at navel level. The aorta supplies the entire body with oxygen-rich blood and plays a central role in the cardiovascular system.

Diseases of the aorta are constrictions or occlusions (arterial occlusive disease, PAD) or aneurysms.

Narrowing or occlusion leads to circulatory disorders in the organs and tissues.

This can lead to the following symptoms:

• Pain when walking(intermittent claudication)
• Pain at rest at night
• Wounds on the feet and lower legs that do not heal

However, the opposite, namely a widening of the vessel wall (aortic aneurysm), also represents a pathological vascular change. However, the danger here is not a circulatory disorder, but the bursting of the bulge, which usually leads to death from bleeding.

The aim of aortic surgery is

• Bypassing and bridging or diverting blood in the event of occlusion
• Elimination of aneurysms by replacing the diseased section of the vessel with a prosthesis

Reasons for diseases of the aorta

Arteriosclerosis isthe main cause of diseases of the arteries, including the aorta. This is often referred to as vascular calcification.

It is caused by risk factors such as

• High blood pressure
• High blood lipids
• High cholesterol levels
• smoking
• Diabetes

Calcification of the blood vessel wall makes it weak and less elastic. As a result, the wall is no longer as flexible and can leak.

On the other hand, the calcifications can also grow inwards and constrict or block the vessel.

In addition to arteriosclerosis, there are other diseases of the aorta such as:

• Congenital weakness of the connective tissue
• inflammation
• Autoimmune diseases

Surgical interventions on the aorta

As with all other vessels, doctors differentiate between open and endovascular (from the inside) procedures:

• In open procedures, doctors expose the vessel through an incision in the skin.
• In endovascular procedures, this is done from the inside using catheters, special stents, balloons or stent prostheses.

The following procedures are possible:

• Bypasses for occlusions (open)
• Dilation with balloon catheters (endovascular)
• Replacement for aneurysms (open)
• Splinting from the inside(stent prosthesis)

Bypass of the aorta

Bypasses are often necessary in cases of occlusion of the aorta.

These are artificial blood vessels that doctors sew onto the healthy blood vessels above and below the occlusion. The blood then flows through the bypass. This ensures a better blood supply to the downstream tissue.

The Y-prosthesis is in the bypass on the abdominal aorta. Doctors turn a Y-shaped plastic prosthesis around and sew it to the abdominal aorta at the top and to the iliac arteries at the bottom.

This allows doctors to bypass occlusions in the aorta and divert the blood. It is important that there are no constrictions above the occlusion of the abdominal aorta. It is also important that there are also inconspicuous vessels in the pelvis and leg below. Otherwise there is a high risk that the bypass will close.

In order to be able to sew the prosthesis into the aorta, doctors have to open the abdomen with a large abdominal incision. This usually runs lengthwise in the midline.

A heartbypass operation ensures sufficient blood supply to the heart muscle @ VectorMine /AdobeStock

Dilating the aorta with balloon catheters

Doctors use X-rays to perform dilation with balloon catheters, which are also accessed via the inguinal arteries.

When dilating constrictions, doctors sometimes insert a stent to keep the vessel open for longer. This often does not even require an incision. Doctors pierce the inguinal vessel through the skin.

It is therefore important that doctors press the groin for about 10-15 hours after the procedure. The patient must remain in bed for several hours (often 24 hours). Otherwise, there is a risk of bleeding or secondary bleeding.

Coated balloon catheters can be used to dilate arteries @ Matthieu /AdobeStock

Open aneurysm surgery

In the case of aneurysms, doctors have to cut out the entire bulge in the vessel and replace it with a prosthesis. This is also known as open treatment of an aortic aneurysm, as an abdominal incision is necessary.

The major difference between aneurysm surgery and surgery for narrowing and occlusion is

In aneurysm surgery, doctors replace the aneurysm completely with a prosthesis. This is intended to prevent the bulging abdominal aorta from bursting.

If the pelvic vessels are not affected by the bulge, a tubular prosthesis is used. As the name suggests, this is a prosthesis that is shaped like a tube.

However, if the pelvic vessels are also affected, doctors usually have to sew in a Y prosthesis.

The aortic stent

Open aneurysm treatment is the traditional procedure that has been around for a long time. Endovascular removal of an aortic aneurysm has been around since the end of the last millennium.

In contrast to open surgery, aortic stenting does not require doctors to open the abdomen with a large abdominal incision. It is sufficient to expose the inguinal arteries and to advance a stent prosthesis over them into the bulge.

As they advance the prosthesis from the inside via the interior of the vessel, this procedure is called endovascular (endo = inside and vascular = vessel). The correct position of the prosthesis can be checked using X-rays.

In the case of an abdominal aortic aneurysm, doctors push anaortic stent(endovascular procedure) up to the wall bulge @ peterschreiber.media /AdobeStock

Advantages of endovascular treatment

The endovascular procedure with an aortic stent is significantly less stressful for the patient than "open" surgery.

However, sometimes there are important reasons for the "open" procedure:

• The aortic stent must be inserted into the vessel from the inside. To do this, the doctor needs several centimetres of healthy vascular segments above and below the bulge. This is not always the case, which is why special custom-made prostheses are required.
• These prostheses must not block important branches of the aorta (arteries that supply the intestines and kidneys). In such cases, additional side branches are required in the prosthesis.
• In some cases, it may be necessary to expose the abdominal aorta in order to surgically (manually) sew in the prosthesis.
• The prosthesis may shift years after the operation. Leakage is also possible. For this reason, doctors must regularly check the position of the prosthesis in the body. This is often done using computer tomography. This examination is always associated with radiation exposure.
• Initially, checks are carried out every 3-6 months, then at annual intervals. This is important as the prosthesis can shift after many years. The aneurysm is no longer tight. If it then bursts (ruptures), there is a risk of bleeding to death.

When is surgery on an aneurysm of the aorta advisable?

Basically, the larger the aneurysm, the higher the risk of the vessel wall rupturing.

From a diameter of > 5.5 cm, the risk of rupture is greater than the risk of surgery. Surgery is therefore advisable from this diameter.

Whether the operation is open or endovascular depends on

• Location and extent of the aneurysm
• The patient's condition and treatment wishes
• Estimated life expectancy

Doctors tend to recommend open treatment for younger patients, as X-ray checks are usually no longer necessary afterwards.

Length of hospital stay

After open aortic surgery, the patient is usually hospitalized for 1-2 weeks, as the abdominal wound requires regular monitoring and care.

If necessary, it may be necessary to administer an antibiotic as an infusion if there is a risk of inflammation. In addition, a slow dietary build-up is required to gently get the bowel moving again. Older patients undergo rehabilitation after their hospital stay .

No special diet is necessary for aortic stenting. Wound healing disorders are also extremely rare. Therefore, patients are often discharged after 2-3 days. The rapid discharge from hospital is a decisive advantage.

Conclusion on aortic surgery

In summary, it can be said that open and endovascular treatment of aortic diseases are not competing but complementary treatment procedures.

Doctors should take the patient's wishes into account when deciding which procedure to use. However, patients must receive detailed information about the advantages and disadvantages, risks and follow-up treatment.

Endovascular therapy is often gentler, but is not possible for every patient. In addition, regular follow-up checks with X-rays are usually required afterwards.

Open procedures have been known for longer and are possible for almost every patient. However, they are more stressful for the body and involve a longer hospital stay.