Left untreated, abdominal aortic aneurysms (AAA) can rupture, often with fatal consequences. A new technique, endovascular graft repair, can help some patients avoid the complicated and risky abdominal surgery that is typically needed to repair the aneurysm.

(Pictured Left: An Abdominal Aortic Aneursym)

Mr. Flores's aneurysm was small and not in need of immediate repair. That was fortunate, because soon after the attic incident, he had a stroke and a recurrence of his gastric lymphoma. Dr. Peter Pappas-chief of vascular surgery at University Hospital, an associate professor of surgery at New Jersey Medical School, and Mr. Flores's surgeon-wanted to give his patient time to become stronger before he operated.

In August 2001, the time was right for Mr. Flores's surgery. The question was, which surgery was right for him? "High-risk patients like Mr. Flores cause the surgeon to ask, 'Will this person be able to withstand the toll traditional AAA repair takes on the body?'" says Dr. Pappas. "It's a major abdominal surgery that has possible complications of myocardial infarction, embolism, hemorrhaging, limb ischemia and kidney failure. Afterward, there's usually a several-day hospital stay followed by a two- to three-month recovery period."

An Abdominal Aortic Aneursym

There was another option for Mr. Flores: He qualified as a candidate for an endovascular graft repair, a procedure that causes significantly less stress on the body than traditional open surgery. During this technique, the patient is given either local or general anesthesia. Special x-ray imaging is used to guide a catheter from the femoral artery to the aneurysm site in the aorta. Then, a polyester graft material is placed within the aneurysm and held in place with stents. There are many benefits to endovascular graft repair. Instead of a large abdominal incision, there are two small incisions made in the groin; complications are significantly reduced, as well. Patients typically are home one to two days after the surgery and back to their routines in about one week.

Weighing the Alternatives

With all of the advantages of endovascular graft repair, there is something that patients must consider. The leading complication of endovascular graft repair, says Dr. Pappas, is an endoleak-a leakage of blood back into the aneurysm sac. "When an endoleak occurs, the aneurysm is still pressurized, and there remains a chance of rupture," says the surgeon. "Because there is no way to predict if or when an endoleak will occur, patients must have CT scans about every six months over a number of years. If an endoleak is found, it can be repaired." Despite the possibility of endoleak, he notes, many patients want to be evaluated for endovascular graft repair because of the shorter hospital stay and recovery period.

Just as not every person with AAA is a candidate for endovascular graft repair, not every hospital offers it. The FDA has established a protocol for specialized CT scanning that hospitals must follow when screening patients for endovascular graft repair. Similarly, surgeons must receive certification of expertise with each of the available devices by participating in industry sponsored training programs before being allowed to perform the procedure. University hospital has certified vascular surgeons for each of the devices available and the CT scan endograft protocols in place. University Hospital meets these FDA requirements and has medical staff, including an interventional radiologists and operating room nurses, who are specially trained in this procedure.

Ultimately, a patient's anatomy can be the deciding factor as to which procedure is used or even which endovascular device is chosen. As part of the patient's evaluation, a specialized CT scan is taken to view the vascular structure and the shape of the aneurysm. Those images help the surgeon determine whether the patient is a good candidate for endovascular repair. If an endovascular option is not possible, Dr. Pappas notes that traditional surgery is often still an option which offers significant advantage over endovascular repair. "Once the open surgery is successfully completed, the AAA is repaired and doesn't require constant checks for leakage," he says. "And yet, there are pros and cons for both procedures. For patients considered high risk, the endovascular repair offers greater benefits."

Who's at Risk for AAA?

Mr.Bernardino "Ben" Flores has since recovered well from his surgery, but not everyone who has an AAA is as fortunate. The actor George C. Scott died following a ruptured AAA, and every year, about 15,000 others suffer the same fate.

The aorta is the major passageway for blood leaving the heart, threading its way through the chest and into the abdomen. An aneurysm forms when a section of the aorta weakens. Over time, that worn area gets larger and "balloons out." There are usually no symptoms of AAA until the vessel wall begins to tear, or rupture. At that point, there's typically severe abdominal pain and sometimes a radiating lower back pain. Once an AAA ruptures, hemorrhaging occurs, and the chance of survival is slim. It is the country's 13th leading cause of death.

However, many unruptured AAAs are detected during routine physical examination. As the patient's belly is palpated, the physician may feel a pulsation. The presence of AAA can then be confirmed by X-ray, ultrasound or CT scan.

"When the aneurysm is smaller than 5 centimeters, the usual approach is 'watch and wait,'" says Dr. Peter Pappas, chief of vascular surgery at University Hospital, noting that an aneurysm grows about a half a centimeter every twelve months. "Once it reaches about 5- 5 1/2 centimeters, surgical repair is typically recommended."

Hardening of the arteries-which weakens the arterial wall-is the leading cause of AAA, with smokers and people with a family history of aneurysm also at high risk. AAA tends to occur in people over age 60, with men five times more likely than women to develop the condition. With Baby Boomers reaching their 50s and 60s, it's likely that there'll be an increase in the incidence of AAA.

For more information about treatment of abdominal aneurysms or to make an appointment with Dr. Pappas and his colleagues, call 1-800-827-2362 or (973) 972-9372.