Abdominal Aortic Aneurysm

Transcription

1 Procedures for Abdominal Aortic Aneurysm Understanding a weakness in the aorta Endovascular and surgical repair Keeping your arteries healthy

2 A Weakened Blood Vessel What does it mean to have an abdominal aortic aneurysm (AAA)? This is a balloon-like bulge in a major blood vessel, the aorta. The bulge forms at a weak place in the vessel wall. An AAA is dangerous because it can rupture. This is serious, and can be fatal. But now that you know you have an AAA, steps can be taken to treat the problem and prevent a rupture. A Silent Problem An AAA is called a silent problem because it usually causes no symptoms. It s sometimes found by a healthcare provider during a routine exam. More often, it s detected when tests are done for an unrelated problem. Once an AAA is found, tests can be done to measure its size and follow its growth. Who Develops an AAA? Anyone can have an AAA. But certain factors increase the risk that an AAA will form or rupture. These include: Having a close relative (parent, brother, or sister) who has had an AAA Smoking Having high blood pressure Having blood vessel disease in another part of the body Being over age 55 if you re a man, or over age 65 if you re a woman 2 This booklet is not intended as a substitute for professional medical care. Only your doctor can diagnose and treat a medical problem. 2005, 2011 The StayWell Company All rights reserved. Made in the USA.

3 The Next Step Learning that you have an AAA can be a shock. Understanding your treatment options can help you feel more in control. Your healthcare team can answer your questions about your condition and treatment. This team may include your primary healthcare provider, nurses, and a vascular (blood vessel) specialist. Treatment often depends on several factors. These include your age, your overall health, the location of your AAA, and the shape, size, and condition of your blood vessels. Read this booklet to learn more. Table of Contents Understanding AAA How blood vessels work, and what can go wrong Your Evaluation Gathering information about your AAA Treatment Options Weighing your risks Artery Repair Techniques Endovascular and surgical procedures Endovascular Repair: Your Experience What to expect with endovascular repair Open Surgery: Your Experience What to expect with open surgery After Open Surgery What to expect as you recover from open surgery Living a Healthier Life Ways to reduce your risks, now and in the future

4 Understanding AAA Blood vessels are tubes that carry blood throughout the body. Arteries carry oxygen-rich blood from the heart to the rest of the body. (Blood vessels that carry the blood back to the heart are called veins.) AAA occurs when a part of the largest artery in the body, the aorta, weakens and expands. Heart Veins (blue) Arteries (red) Kidney Iliac arteries (to legs) Abdominal aorta Renal artery Abdominal aorta Smaller arteries branch off the aorta to supply blood to the kidneys, other organs, and legs. The abdominal aorta carries oxygen-rich blood from the heart to the lower body. What Is the Aorta? The aorta is the artery that carries blood directly from the heart. Blood then flows from the aorta into smaller arteries that supply the rest of the body. A healthy artery is smooth inside, allowing blood to flow easily. The part of the aorta that travels through the abdomen (stomach area) is called the abdominal aorta. Smaller arteries branch off the abdominal aorta to carry blood to organs in the abdomen. These arteries include the renal arteries, which supply the kidneys. Lower down, the aorta divides into the two iliac arteries, which supply blood to the legs. 4

5 When an AAA Forms The problem starts when the lining of the aorta is damaged. Or, the aorta may become weakened due to certain factors that run in families. The weakened artery stretches outward, expanding like a balloon. The resulting bulge is called an aneurysm. As it expands, the artery wall becomes thinner and weakens even more. High blood pressure further strains the artery wall. It may become so thin that it ruptures (leaks, bursts, or tears open). This is fatal if not treated right away. Abdominal aortic aneurysm Iliac aneurysm Normal aorta width Aortic wall weakens Blood pressure expands weakened artery wall Plaque Blood clot An aneurysm forms when part of the wall of the aorta weakens and balloons outward. Aneurysms can form in the iliac arteries, too. Plaque (a fatty substance composed of cholesterol and other particles) may be found in the weakened artery wall. Blood may thicken (clot) inside the artery. Blood can still flow through the clot, so this may not cause symptoms. AAA and Arterial Disease If you have an AAA, it s possible that you also have disease in other arteries. If so, you re at risk of a heart attack, stroke, and vascular problems in the legs and other areas of the body. Your healthcare provider may recommend that you be screened for these conditions. Brain If the arteries supplying the brain are blocked, a stroke may result. Kidneys Clogged renal arteries can cause kidney problems. Heart A blockage in an artery supplying the heart muscle can cause a heart attack. Legs A blockage in a leg artery causes a painful condition called peripheral arterial disease. 5

6 Your Evaluation An exam and tests give your doctor more information about your AAA. Certain tests measure the size of the aneurysm. They can track changes in the AAA over time. Other tests assess blood flow. These may be done if it s decided that you need surgery. History and Physical Exam After an exam of your abdomen, you ll be asked about your family medical history. Your doctor will also ask about your own health history. Contrast fluids used for tests may contain iodine, so you ll be asked about allergies to iodine or seafood. Imaging Tests Imaging tests create pictures of the arteries. This helps determine the size and shape of the aneurysm. Tests include: Ultrasound. Sound waves are used to create an image of the blood vessels. For this test, your healthcare provider moves a sensor across your abdomen. CT (computed tomography). A series of x-rays are taken with a special x-ray machine. Computers use these x-rays to create a picture of the aneurysm. Before this test, you may be given contrast fluid through an IV (intravenous) line. This helps arteries show up clearly. MRI (magnetic resonance imaging) makes images by analyzing energy released by tissues in the body after exposure to a strong magnet. A different type of contrast is used for this test. A CT scan creates an accurate 3-dimensional image of your aneurysm. 6 Other Tests These tests may be done before repair of the artery: Arterial Doppler study. Blood flow in the legs is measured with a special probe and blood pressure cuffs placed on the leg. Arteriography. This test creates an x-ray image (arteriogram) showing the blood flow through the aorta and other arteries. Contrast fluid is used for this test. Arteriogram of a normal aorta Arteriogram of an aortic aneurysm

7 Treatment Options Your options for treatment depend on many factors. How big is the aneurysm? Is it growing? If so, how quickly? How is your overall health? Considering these and other factors can help you weigh the risks and benefits of each type of treatment. Then you and your doctor can decide what to do. Before making a decision, be sure that all your questions have been answered. Watchful Waiting A small aneurysm is unlikely to rupture. So if your AAA is small, your doctor may suggest watchful waiting. This includes: Regular monitoring. You ll have imaging tests at least once a year to track your rupture risk. If the aneurysm reaches a certain size, or is growing quickly, repair may be needed. Reducing your rupture risk. Controlling factors such as blood pressure may make your AAA less likely to grow or rupture. It can also help improve the health of your arteries. This helps you prepare for surgery if that becomes necessary. See page 15 for more details. Being alert for symptoms of rupture. These include severe back pain and tenderness in your stomach area. You may also feel lightheaded or dizzy. If you notice these changes, CALL 911 right away: A ruptured AAA is an emergency! Imaging tests can tell you when and if the aneurysm needs to be repaired. Considering Surgery If an aneurysm is large, or growing quickly, the risk that it will rupture may outweigh the risks of a procedure to repair the artery. If so, you ll be advised to consider surgical repair. There are two basic ways to repair the artery: endovascular repair and open surgery. Which type of repair is best depends on many factors. You may even have a choice between the two. See pages 8 and 9 for more details on these repair methods. 7

8 Artery Repair Techniques An AAA can be repaired with endovascular repair or open surgery. Both methods involve placing an artificial graft inside the damaged artery. Each type of procedure has risks and benefits that you should discuss with your doctor. What Is Endovascular Repair? For this procedure, very small incisions are made in the groin. The graft is inserted into an artery through an incision and guided to the aneurysm. The procedure often has a short recovery, allowing a quick return to normal activities. This type of repair is new compared to open repair. Close follow-up is needed, even if you feel fine. Also, be aware that in some cases the size and shape of a person s blood vessels rule out endovascular repair. See pages 10 and 11 for more on this method. Preparing for an Endovascular Procedure Before an endovascular graft: Have tests as advised by your surgeon. Tell your surgeon about any medications, herbs, or supplements you take. Your surgeon may advise you to make certain changes before surgery. Arrange to take a week off work. Pack a bag for a hospital stay of 1 to 3 days. Don t eat or drink after the midnight before the procedure. Risks and Complications of Endovascular Repair Risks include, but are not limited to: Injuries to the blood vessels used for access and to other nearby blood vessels A leak around or behind an endovascular graft Back pain and fever Blood clot on or in the graft Blood clots in the legs Kidney failure Conversion to open surgery Infection Injury to nearby structures Heart attack, stroke, or death 8

9 What Is Open Surgery? With this method, a single large incision is made in the abdomen. The graft is then sewn into the artery above and below the aneurysm. Open surgery involves a longer recovery than an endovascular repair. But for some people, open surgery may be the only way to repair the aorta. Open surgery has been used for many years, and it has a good long-term track record. It may be recommended for younger people, to ensure that the graft lasts over time. See pages 12 to 14 for more on open surgery. Preparing for Open Surgery Before open surgery: Have tests as advised by your surgeon. Stop taking aspirin and ibuprofen as directed. Also, mention any medications, herbs, or supplements you take. Your surgeon may advise you to stop taking some of them before surgery. Arrange to take time off work. Plan for recovery to take 6 weeks or more. Pack for a hospital stay of 7 to 10 days. Don t eat or drink after the midnight before the procedure. Risks and Complications of Open Surgery Risks include, but are not limited to: Heart attack or other heart problems Pneumonia or other respiratory problems Kidney failure Blood clots in the legs Bleeding Infection at the incision site Injury to the blood supply of the colon or spinal cord Impaired sexual function (in men) Infection or blood clot at the graft Injury to the ureters Stroke Death 9

10 Endovascular Repair: Your Experience In this procedure, a graft made of wire mesh and fabric is placed inside the abdominal aorta. This takes pressure off the weak artery wall. Recovery often takes a week or less. Imaging tests then track the condition of the graft over time. Before Surgery At the hospital, you will be asked to fill out certain forms. You ll then be taken to a prep room, where you ll change into a hospital gown. At this time: You ll discuss your anesthesia (medication used to keep you pain-free during surgery) with a doctor or nurse. Your anesthesia options may include medication to keep you relaxed, to block pain, or to make you sleep. An IV line will be started to give you medication and fluids. Any hair may be removed from the skin where the catheter will be inserted. You ll be taken to the room where the procedure takes place. Once there, you ll lie on a table beneath x-ray cameras. These cameras are used to help place the graft. During Surgery Incision sites Catheter Graft Catheter Catheter Two small incisions are made in the groin. A catheter (thin, flexible tube) is threaded through an artery at each incision. The collapsed graft is placed inside one of the catheters. The surgeon uses x-ray guidance to move the graft through the arteries toward the damaged part of the aorta. The catheters are then used to place the graft in position. Once the graft is in position, the surgeon expands it. Metal springs or hooks hold it in place above and below the aneurysm. The catheters are then removed. 10

11 After the Procedure When the procedure is complete, your surgeon may do some tests to check the graft. The incisions in your groin will then be closed. You ll be taken to your hospital room. You can expect to stay in the hospital for 1 to 3 days. During this time you ll be closely monitored. Your IV and urinary catheter (tube to drain urine) may remain in place until shortly before you leave the hospital. Going Home Your surgeon will most likely clear you to go home when you are alert, your pain is under control, and you are able to eat and digest food. Have an adult family member or friend drive you home. Once home, take medications as directed. Be as active as you can. You ll most likely feel back to normal within a few days. Follow-up Care After endovascular repair, you ll need follow-up tests often. Your first follow-up visit will be about 1 week after the procedure. At this time, imaging tests will be done to check the graft. In most cases, imaging tests are needed every 3 to 6 months for the first 2 years. After that, you will most likely have yearly tests. If there is a problem with the graft, further endovascular repair or open surgery may be needed to fix it. When to Call Your Doctor Following an endovascular procedure, call your doctor if you have: Swelling or bleeding at the insertion site Chest pain or trouble breathing A temperature of 100 F (37.8 C) or higher A change in the temperature or color of your feet or legs Pain in the low back or stomach area 11

12 Open Surgery: Your Experience During open surgery, the weakened wall of the abdominal aorta is replaced with a graft made of strong, flexible fabric. This enables blood to flow safely through the aorta to the lower body. After surgery, you ll be cared for in the hospital for several days. Before Surgery At the hospital you will be asked to fill out certain forms. You ll then be taken to a prep room, where you ll change into a hospital gown. At this time you ll discuss your anesthesia (medication used to keep you pain-free during surgery) with a doctor or nurse. An IV line will then be inserted into your arm to provide fluids and medications. The anesthesia will be given to you just before surgery begins. General anesthesia is used to make you sleep and keep your muscles relaxed during surgery. You may also be given pain medication through a thin, soft tube inserted into the spine (an epidural). During Surgery Wall of aorta Graft Aorta wall closed over graft Surgery begins with an incision in your abdomen. Two possible positions for this incision are shown above. (The one shown here as a dotted line may continue around the side of the body.) The size and shape of your own incision may vary. The surgeon gently moves aside the organs to reach the aorta. The aorta is clamped to stop blood flow. The surgeon then opens the aneurysm and clears any blood clot. The graft is sewn to the aorta above and below the aneurysm. Some of the aorta wall may be removed. This helps make a snug fit when the aorta is wrapped around the graft. The aorta is then sewn together, helping to protect the graft. The incision site is closed. 12

13 Right After Surgery After surgery, you ll be taken to an intensive care unit (ICU). Your blood pressure, pulse, and breathing will be checked. You ll also be given pain medication as needed. If you were given an epidural, it may stay in place to help control pain. At first, you ll have several tubes in place to help your body function. They will be removed when they re no longer needed. These may include: A catheter to drain urine. A tube that is passed through the nose into the stomach (nasogastric tube). A tube to help you breathe. If you have this, it may prevent you from talking. Beginning Your Recovery In your room, you ll be checked often to be sure you re healing well. Your IV line will remain in place to give you fluids. Your recovery will also involve: Getting up and around. You ll be helped to walk as soon as possible. As you gain strength, you ll walk farther and be up for longer periods. Pain control. Medication may be given through a pump that lets you control the dose within limits set by your surgeon. This is called a PCA pump. Breathing exercises. These help prevent lung infection. For these exercises you ll use a device (spirometer) that helps you practice taking deep breaths. Your family can visit you briefly in the ICU. Walking as soon as possible after surgery helps prevent blood clots. It also helps your digestion work normally again. Going Home Before you go home, you ll meet with your surgeon. He or she will go over the results of the surgery and give instructions for home recovery. You will most likely be cleared to go home when you are alert, your pain is controlled, and you can eat and digest food. Have an adult family member or friend drive you home. 13

14 After Open Surgery Recovery from open surgery doesn t happen overnight. You may be recovered as soon as 4 weeks after you go home. Or it can take a few months. As you recover, try to be active. But be sensible: If what you re doing hurts, stop. If you re tired, rest. Your First Weeks at Home Follow your surgeon s instructions on caring for yourself at home. Ask a family member or friend to help with shopping, cooking, and other chores. Your appetite and digestion may not be normal at first. If so, try soup and other liquids. You may be prescribed a mild laxative. You should also: Shower instead of taking tub baths for the first week. Take medications exactly as prescribed. Avoid strenuous exercise. Don t lift anything that weighs over 10 pounds. Don t drive until your surgeon says you can. Keep any follow-up appointments with your surgeon. Your Long-Term Recovery Even after you re back to your normal routine, you may have less energy than usual. This may last for 2 to 3 months, or even longer. As long as you don t overdo it, exercise can help you get back to your full strength. So be as active as you feel able to be. And discuss any ongoing concerns with your healthcare provider. When to Call Your Doctor Call your doctor if you have these symptoms, or any others that concern you: A very red, very tender, or draining incision Fever over 100 F (37.8 C) Pain in your legs, abdomen, or back 14

15 Living a Healthier Life Part of watchful waiting is reducing the risk that the AAA will rupture. Even if your AAA has been fixed, you re still at risk of artery disease in other parts of the body. Below are some actions you can take to reduce your rupture risk and keep your arteries healthier. Ask your healthcare provider for help getting started. Reducing Rupture Risk High blood pressure can make your AAA grow more quickly. To reduce high blood pressure: Quit smoking. Smoking raises blood pressure and makes blood clots more likely. So get medical help and quit for good! Change your diet. An eating plan based on vegetables, fruits, whole grains, and low fat dairy products can help lower blood pressure. Cutting sodium (salt) helps, too. Exercise. Daily exercise can lower your risk of artery problems. If you re new to exercise, start gradually and work up to 30 minutes most days of the week. Maintain a healthy weight. If you re overweight, losing as little as 5 or 10 pounds can improve your health. Start by setting a goal you know you can reach. Take medication as prescribed. When used correctly, medications can help control blood pressure. If your doctor has prescribed medication, set up a routine so you won t miss any doses. Using nicotine replacement products may be part of your stop-smoking plan. If You Have Diabetes Diabetes is a disease that raises the level of glucose (sugar) in the blood. This damages arteries and worsens artery disease. But controlling blood sugar levels can reduce the damage. Control involves exercise, watching what you eat, and monitoring blood sugar daily. Many people with diabetes must also take medication or insulin. Discuss your treatment options with your healthcare provider. You may be advised to work with a dietitian or a certified diabetes educator to help you improve your control. 15

16 Screening for AAA You learned about your AAA in time to do something about it. But you re not the only one who should take heed. AAA runs in families. This means that your brothers, sisters, and children could be at risk. Screening could save the life of someone you love. So urge your family members to ask their healthcare providers about screening for AAA. Consultant: John R. Crew, MD, Vascular Surgery With contributions by: Frank R. Arko, MD, Vascular Surgery Martin R. Back, MD, Vascular Surgery G. Edward Bone, MD, Vascular Surgery Karen R. Bruni, RN, MSN, NP, CVN, Vascular Surgery Paul S. Collins, MD, Vascular Surgery Mitzi Ekers, ARNP, Vascular Surgery Julius H. Grollman, Jr., MD, Interventional Radiology Patricia A. Lewis, MSN, FNP, Vascular Nursing Rasesh M. Shah, MD, FACS, Vascular Surgery Also available in Spanish