Abdominal Aortic Aneurysm

An abdominal aortic aneurysm (AAA) is an enlargement or bulge in the part of your aorta that extends through your belly or abdomen (abdominal aorta). The bulge forms in an area where your aorta’s wall has grown weak. Normally, your aorta’s wall is strong and flexible enough to manage the constant pressure of blood your heart pumps out. But various factors like aging, tobacco use and certain medical conditions can weaken your aorta’s wall. When the wall is weak, it can’t handle the forces of blood flow as well it should.

As a result, the weakened part of your aorta’s wall expands outward and enlarges. This expansion, or ballooning, continues to grow wider over time. Your healthcare provider will diagnose you with an AAA if a segment of your aorta expands to at least 50% of its normal diameter. For many people, this means the bulge is about 3 centimeters (cm) wide.

The larger an aneurysm grows, the more likely it is to burst open (rupture) and cause life-threatening internal bleeding. AAAs larger than 5.0 centimeters in people assigned female at birth (AFAB) and 5.5 centimeters in people assigned male at birth (AMAB) are particularly at risk. The larger they grow, the more dangerous they become. AAAs usually have no symptoms until they rupture or are close to rupturing.

Symptoms and Causes

Most people with an AAA don’t have symptoms until the aneurysm is close to rupturing. At that point, the patient may have:

• Steady, deep pain in the lower back or belly.

• Pain in the leg, groin or pelvic area.

• A pulsing sensation in the belly that feels like a heartbeat.

A ruptured AAA is a medical emergency. Symptoms begin suddenly and can include:

• Severe pain in the belly, lower back or legs.

• Shortness of breath

• Fast heartbeat

• Low blood pressure

• Dizziness or fainting

• Nausea or vomiting

• Clammy, sweaty skin

Management

AAAs are treated with surgical repair. When indicated, unruptured aneurysms can be addressed with elective surgery, whereas ruptured AAAs necessitate emergency repair. The primary methods of AAA repair are as follows:

1. Open - This requires direct access to the aorta via a transperitoneal or retroperitoneal approach

2. Endovascular - This involves gaining access to the lumen of the abdominal aorta, usually via small incisions over the femoral vessels; an endograft, typically a polyester or Gore-Tex graft with a stent exoskeleton, is placed within the lumen of the AAA, extending distally into the iliac arteries.

What happens during aneurysm surgery?

The healthcare team will make the patient comfortable before the aneurysm surgery begins. The patient will be given general anesthesia so he/she is  asleep during the surgery. Then, the surgery will include the following steps:

1. Incision. The  surgeon will make a long incision in the skin to open the chest or belly. The location of the incision depends on the location of the aneurysm. It may be on the front or left side of the chest, and it may extend down to just below the belly button.

2. Clamping. The surgeon will use clamps to block blood flow from the sections of the aorta above and below the aneurysm.

3. Graft insertion. Inserting a graft is the main goal of the surgery. The surgeon will replace the bulging section of the aorta with a tube called a graft. This graft now functions as a new lining for the artery. It’s made of an artificial material like polyester (fabric). It has strong walls to support the patient’s  blood flow. The surgeon will sew the graft in place with stitches.

4. Closure. The surgeon will close the incision in the chest or belly with stitches or staples.

Risks / Benefits

What are the advantages of aneurysm surgery?

Aneurysm surgery can save life. It can prevent an aneurysm rupture or dissection. It can also be performed in an emergency to repair damage from an aneurysm rupture or dissection.

Open surgery is a good option for people who can’t have endovascular aneurysm repair (EVAR). For example, the stent graft used in EVAR doesn’t always fit the shape of a person’s aorta. So, that person would need open surgery.

What are the risks and complications of aneurysm surgery?

• Bleeding

• Blood clots

• Breathing problems

• Damage to intestines or other organs.

• Heart attack or stroke

• Infection in the graft

• Infection in your lungs, urinary tract or belly

• Kidney failure

• Nerve damage

• Spinal cord injury

Pre and post operative nursing care:

For pre-operative care:

Patient assessments should be individualized and include:

• Identification of the patient with two identifiers, such as name and date of birth

• Mental and physiological status of the patient

• Functional status Cardiovascular and respiratory status

• Skin condition

• Nutritional status (how long has the patient been NPO)

• Range of motion and mobility

• Pain

• Any prosthetics or corrective devices

• Sensory impairments, language barrier, cultural/spiritual needs

• Anxiety

• Previous surgeries and anesthesia experience

• Allergies

• Medications, herbs, nutritional supplements, and drug abuse

References:

Centers for Disease Control and Prevention (U.S.). Aortic Aneurysm (https://www.cdc.gov/heartdisease/aortic_aneurysm.htm). Accessed 8/15/2023.

Society for Vascular Surgery. Repair of a Thoracic Aortic Aneurysm (https://vascular.org/patients/vascular-treatments/repair-thoracic-aortic-aneurysm#whyitsdone). Accessed 2/22/2022.

U.S. Centers for Disease Control and Prevention. Aortic Aneurysm (https://www.cdc.gov/heartdisease/aortic_aneurysm.htm). Accessed 2/22/2022.

Instruments and OR needs:

Intruments:

Adult Open heart set

Bookwalter ret. (standby)

Prep bowl and basin

Light handle

Deep balfour

Regular balfour

Deavers

Big richardsons

Double-ended richardsons

5 long instruments

Graft sizers

FUT

Vessel loops (3sets)

Suction pool with guard (standby)

Fish

OR needs:

Laparotomy pack or thoracic drape

Operative sponge

Gloves (all sizes)

Povidone iodine scrub

Povidone iodine paint

Blade 10, 11, 15

Sterile cotton balls

Cautery cord

Cautery plate

Asepto syringe

Silk strands 2-0, 3-0, 4-0

Silk 2-0 round needle

Liga clips small

Liga clips medium

Prolene 3-0 SH or any equivalent

Prolene 4-0 RB2 or any equivalent

Prolene 5-0 RB1 or any equivalent

Vicryl 0 or any equivalent

Vicryl 2-0 SH or any equivalent

Vicryl 3-0 SH or any equivalent

Vicryl 4-0 PC5 or any equivalent

Tegaderm medium

Tegaderm large