Treatment of Aortic Aneurysms

Regardless of the aneurysm’s location, treatment involves a two-pronged approach based on lifestyle modification and efforts to correct risk factors, which is complemented by an assessment of potential aneurysm-associated complications. The assessment of possible complications may lead doctors to recommend preventive surgery if the inherent risk of the aneurysm is greater than that posed by the intervention.

If surgery is indicated, the specific treatment will be individualised to each case (conventional or open surgery versus endovascular surgery) depending on the aneurysm’s location and each patient’s particular anatomy and characteristics. Occasionally, more extensive defects may be repaired using a combination of both open and endovascular interventions.

The type of intervention is selected according to the specific features of each patient’s aneurysm. To this end, we take into account patient (age, previous diseases, and so on) and aneurysm characteristics (size, location, relationship with other structures, etc.). In addition, it is vital that this assessment, and the treatment itself, is carried out at a centre that is highly experienced in this type of disease and which can provide multidisciplinary treatment (from a team of different specialists), so they may offer the best option for each case, optimise the chances of survival and prevent potential complications.

Below is a general description of the different surgical options available depending on the aneurysm’s location in the aorta:

Proximal aortic aneurysms (aortic root and ascending aorta). Aneurysms in this area are, due to their proximity to the heart, almost always treated through conventional surgery by performing a sternotomy (splitting of the sternum) and with the aid of a heart–lung machine which keeps oxygenated blood circulating around the body throughout the operation. Aortic root aneurysms can sometimes coexist with aortic valve dysfunction, so this problem may also need correcting or the valve may even need to be replaced. These operations involve manipulation of the coronary arteries and their subsequent implantation on the stent graft used to replace the damaged section of the aorta.

Aortic arch aneurysms. Some very important arteries, which supply blood to the arms and head (nervous system), branch off from the aortic arch. Aneurysms in this section of the aorta tend to be repaired via conventional surgery assisted by a heart–lung machine. Patients are often placed in a state of controlled hypothermia (reduced body temperature throughout the operation) to reduce the organs oxygen requirements and minimise the risk of complications. Endovascular repair techniques are also often a valid option, but with the use of special custom-made stents or in combination with other surgical procedures to guarantee enough blood reaches the brain and arms.

Descending aorta aneurysms. These are located in the section of the aorta that runs beyond the left subclavian artery up to where the aorta leaves the chest cavity as it passes through the diaphragm. Aneurysms in this region are generally well suited to endovascular treatment, which is often preferred as it is a less aggressive technique. In cases that are not candidates for endovascular surgery, open surgery (via an incision in the left side of the chest) offers equally curative treatment outcomes.

Thoracoabdominal aortic aneurysms. These tend to require complicated aneurysm treatments because they affect a large portion of the aorta that spans both the chest and abdominal sections and because several vitally important arteries supplying the blood to the kidneys, liver and intestine branch off from these areas. Thoracoabdominal aneurysms can be treated by either conventional surgery, normally using a heart–lung machine, or endovascular surgery by implanting special custom-made stents. The choice of one approach or the other is complicated, it should be individually adapted to each case and always consider the advice given by different specialist healthcare professionals with expertise in both endovascular and conventional surgical treatment of aortic aneurysms.

Abdominal aortic aneurysms. In this section of the aorta, aneurysms tend to occur below the level of the renal arteries. Again, both endovascular and open surgery offer very good treatment outcomes. Open surgery is often preferred in young patients who have a low surgical risk because it provides more long-lasting results. In elderly or frail patients or those with medical factors that imply a risk for open surgery, endovascular surgery is minimally aggressive and associated with very good outcomes and a much quicker recovery.