Aortic Surgery – Vascular Surgery for Conditions Affecting the Aorta Near the Heart

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

Diseases of the aorta include narrowings or blockages (peripheral arterial disease, PAD) or bulges (aneurysms).

Narrowing or blockages lead to impaired blood flow to organs and tissues.

This can lead to the following symptoms:

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

However, the opposite condition—namely, a bulge in the vessel wall (aortic aneurysm)—also constitutes a pathological vascular change. The danger here, however, does not lie in impaired blood flow, but rather in the rupture of the bulge, which usually leads to death from hemorrhage.

The goal of aortic surgery is:

• Bypass surgery and blood diversion in cases of occlusion
• Treatment of aneurysms by replacing the diseased section of the vessel with a prosthesis

The primary cause of arterial disease—and consequently, aortic disease—is atherosclerosis. This is commonly referred to as hardening of the arteries.

It is caused by risk factors such as:

• High blood pressure
• High blood lipid levels
• High blood lipid levels
• Smoking
• Diabetes

Calcification of the blood vessel wall weakens it and reduces its elasticity. As a result, the wall is no longer as flexible and may bulge outward.

On the other hand, the calcifications can also grow inward, narrowing or blocking the vessel.

In addition to atherosclerosis, there are other conditions affecting the aorta, such as:

• Congenital connective tissue weakness
• Inflammation
• Autoimmune diseases

As with all other blood vessels, doctors distinguish between open and endovascular (internal) 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 grafts.

The following procedures are possible:

• Bypasses for blockages (open)
• Balloon angioplasty (endovascular)
• Replacement for aneurysms (open)
• Internal stenting (stent graft)

When the aorta is blocked, bypasses are often necessary.

These are artificial blood vessels that doctors suture to the healthy blood vessels above and below the blockages. The blood then flows through the bypass, which ensures a better blood supply to the tissues downstream.

The Y-shaped graft is used in a bypass of the abdominal aorta. In this procedure, doctors invert a Y-shaped plastic graft, suturing it to the abdominal aorta at the top and to the iliac arteries at the bottom.

In this way, doctors bypass occlusions in the aorta and redirect the blood flow. It is important that there are no narrowings above the occlusion in the abdominal aorta. It is also important that there are unobstructed vessels in the pelvis and leg below the occlusion. Otherwise, there is a high risk that the bypass will become occluded.

To suture the graft to the aorta, doctors must open the abdomen with a large incision. This incision usually runs longitudinally along the midline.

Heart bypass surgery ensures an adequate blood supply to the heart muscle @ VectorMine /AdobeStock

Using X-ray guidance, doctors perform the dilation with balloon catheters, again accessing the arteries through the groin.

When dilating narrowings, doctors sometimes insert a stent to keep the vessel open longer. Often, not even an incision is necessary. Doctors access the femoral artery through the skin.

It is therefore important that medical professionals apply pressure to the groin for about 10–15 minutes after the procedure. The patient must remain on bed rest for several hours (often 24 hours). Otherwise, there is a risk of bleeding or post-procedure hemorrhage.

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

In cases of aneurysms, doctors must excise the entire bulge of the vessel and replace it with a prosthesis. This is also called open repair of an aortic aneurysm, as an abdominal incision is necessary.

The main difference between aneurysm surgery and surgery for narrowings and blockages is:

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

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

However, if the pelvic vessels are also affected, doctors generally have to implant a Y-shaped prosthesis.

Open aneurysm repair is the traditional procedure that has been in use for a long time. Endovascular treatment of an aortic aneurysm has been available since the end of the last millennium.

Unlike open surgery, the aortic stent procedure does not require doctors to open the abdomen with a large incision. It is sufficient to expose the femoral arteries and advance a stent prosthesis through them into the aneurysm.

Since the stent is advanced from the inside through the lumen of the vessel, this procedure is called endovascular (endo = inside and vascular = vessel). The correct position of the stent can be verified using X-rays.

In cases of abdominal aortic aneurysm, doctors advance an aortic stent (endovascular procedure) to the site of the aneurysm @ peterschreiber.media /AdobeStock

The endovascular procedure using an aortic stent is significantly less stressful for the patient than “open” surgery. 

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

• The aortic stent must be positioned inside the vessel from the inside. To do this, the doctor needs several centimeters of healthy vessel segments above and below the aneurysm. This is not always the case, which is why special custom-made prostheses are required. 
• These prostheses must not occlude important branches of the aorta (arteries that supply the intestines and kidneys). In such cases, additional side branches are needed in the prosthesis.
• In some cases, it may be necessary to expose the abdominal aorta through open surgery in order to suture the prosthesis in place manually.
• The prosthesis may shift years after the operation. A leak is also possible. For this reason, doctors must regularly check the position of the prosthesis in the body. This check is often performed using a CT scan. This examination always involves exposure to radiation.
• Initially, checkups are performed every 3–6 months, and subsequently at annual intervals. This is important because the prosthesis can shift after many years. The aneurysm is no longer sealed. If it then ruptures, there is a risk of death from hemorrhage.

As a general rule, the larger the aneurysm, the higher the risk of the vessel wall tearing. 

For diameters greater than 5.5 cm, the risk of rupture is greater than the risk of surgery. Therefore, surgery is recommended for aneurysms of this size or larger.

Whether the surgery is open or endovascular depends on:

• the location and extent of the aneurysm
• The patient’s condition and treatment preferences
• Estimated life expectancy

For younger patients, doctors tend to recommend open surgery, as follow-up X-ray examinations are usually no longer necessary afterward.

Following open aortic surgery, the hospital stay is usually 1–2 weeks, as the abdominal incision requires regular monitoring and care.

If necessary, an antibiotic may need to be administered via IV in cases of impending infection. In addition, a gradual return to a normal diet is required to gently restore bowel function. For older patients, rehabilitation follows the hospital stay.

With an aortic stent, no special dietary progression is necessary. Wound healing complications are also extremely rare. Therefore, patients are often discharged after just 2–3 days. This rapid discharge from the hospital is a key advantage.

In summary, open and endovascular treatments for aortic diseases are not competing but rather complementary treatment approaches.

Doctors should take the patient’s preference regarding which procedure to use into particular consideration. To this end, however, patients must receive detailed information about the advantages and disadvantages, risks, and postoperative care.

Endovascular therapy is often less invasive, but it is not suitable for every patient. In addition, it usually requires regular follow-up examinations involving X-rays.

Open procedures have been in use longer and are suitable for nearly every patient. However, they are more taxing on the body and involve a longer hospital stay.