How to recover from an aortic aneurysm

Thoracic artery aneurysm

The main artery (aorta) arises from the heart and ends at the level of the navel with the branching into the pelvic arteries. Aneurysms (enlargements) of the thoracic artery or the artery at the transition from the chest to the abdominal area are much rarer than the abdominal aortic aneurysm (classification according to Crawford). On the one hand, they arise from continuous growth in the context of increased blood pressure, chronic lung diseases or in smokers. On the other hand, an aneurysm can develop after a dissection (tear in the inner layer) because the wall is weakened. Connective tissue diseases, which can be inherited, are less common causes. The primary goal of treatment is obvious: namely, to prevent the aortic aneurysm from bursting, known as the aortic rupture, by means of prophylactic 'elective' surgery. The rupture of a main artery is usually a fatal event that only a few patients survive.

Clinical picture
Typically, a dilation of the thoracic artery causes no or very unspecific symptoms, at least no pain. Occasionally, new hoarseness, difficulty swallowing or breathing, or back pain may indicate this. They are often discovered purely by chance because an X-ray or a computer tomography was taken for other reasons. Typical symptoms and signs of aortic rupture are sudden collapse, sudden pain in the back, and bleeding shock.

Diagnosis
The risk of rupture depends primarily on the vessel diameter, but is exacerbated by other risk factors. These include smoking, the female sex, high blood pressure, related ruptures, certain lung diseases and an eccentric spherical aneurysm. The diagnosis is made with the help of computed tomography magnetic resonance angiography (MRI).

Time of treatment
It becomes critical in men with a maximum diameter of 5 centimeters and in women from 4.5 to 5 centimeters, or if the diameter increases by more than one centimeter within a year. The risk of the artery bursting and the patient bleeding to death inside then increases significantly. If the artery has not yet reached the critical size, the growth is regularly monitored with controls in the aortic consultation. We have set up the aortic consultation especially for patients with diseases of the thoracic artery. Extensive additional examinations of the heart, lungs and other organs are necessary before treatment so that the risk of treatment can be assessed.

Surgical technique
The therapy for enlarging the thoracic artery is essentially based on the anatomy. Localized aneurysms can be treated well with a coated wire prosthesis, a stent graft. The stent graft is then inserted through an inguinal artery and placed in the appropriate location under fluoroscopic guidance. This procedure is relatively short and easy to bear, which is why the treatment is also called minimally invasive. Ideally, no important branches of the aorta need to be covered by the stent graft. If this is the case, however, stent grafts with side arm prostheses or with recesses (fenestrations) can be made and inserted. These procedures can be time consuming and the exposure to x-rays can be significant. In addition, the vascular prostheses are very expensive. If the aforementioned method is not possible for anatomical reasons, we replace the aorta with a plastic tube with an open procedure. Under certain circumstances, both body cavities (chest cavity and abdominal cavity) have to be opened. Outgoing arteries are sewn into the plastic prostheses. Such interventions are carried out with the help of the heart-lung machine under one-lung ventilation and can take 6 to 9 hours. Here at Inselspital we have many years of experience with such interventions and work closely with the University of Maastricht in Holland to monitor spinal cord function. Before such an operation, the patient should be in good shape and trained in breathing with a view to the operation. In these cases, the duration of the hospital stay is 14 days followed by inpatient rehabilitation for 4 weeks.

Aftercare
After the stent graft treatment, we perform a CT angiography as a postoperative initial examination before the patient emerges. After the inguinal wounds have healed, these patients are usually fit again quickly and are rarely unable to work for more than 2 - 4 weeks. Because of the risk of the stent graft prostheses slipping or the occurrence of endoleakage, these patients must be examined regularly and clinically in the aortic consultation hour on a long-term basis using a computer tomogram. After an open aortic replacement, imaging is performed prior to exit. The incapacity for work is usually 3 months. It is paramount that patients recover well from the procedure and that they are not subjected to a rigorous exercise program for the first 3 months. After 6 months, the patients are called to the aortic consultation hour for a clinical and X-ray follow-up. Computed tomography or MR angiography (MRI) is usually performed on the same day beforehand. We recommend avoiding carrying weights over 5 to 10 kg for 3 months and not lifting more than 20 kg for a lifetime. Patients with thoracic artery disease should stay in control over the long term. If the aorta is stable, the intervals between controls will be longer and, in the best case, can be done every 5 years.