Heart Valve Surgery
Coronary By-Pass Surgery
Aortic Surgery And Aneurysms
Peripheral Vascular Diseases
Lymphatic System Diseases
• Prof. Suat BÜKET, MD
• Arzum KALE, MD
• Ulusal COŞKUN, MD
• Yılmaz DENİZ, MD
• Makbule KESİCİ, MD
AORTIC SURGERY AND ANEURYSMS
Aort is the main blood vessels providing blood flow to the body like main water pipe. The vesicles occurred without any symptoms on the body's largest artery of the body, aorta and aortic aneurysm caused by vasodilation pose a threat over life like a bomb ready to explode. For this reason, diagnosis and treatment methods are of vital importance.
Aort is the main artery that distributes blood to the body. The vessel called "aort" is the main artery that pumps blood to the body after being discharged from the heart. Diameter of aort is approximately 2,5 cm in the section it is discharged from the heart. There is no other vessel having such a large diameter in the body. Risk of aneurysm increases in parallel with expansion volume of the vessel.
Whole blood delivered to our body is provided by aorta. From this perspective, it is like the main pipe to the body. Circulation of blood throughout the body lasts approximately 1 minute. Problem occurred in aorta is of vital importance for human. Cessation in blood flow in aorta may stop blood flow in entire body; and it may lead to discharge of blood within minutes when there is blood leakage and rupture in a part of aorta and lose of human due to excessive blood loss.
What is an aneurysm?
Aneurysm is an abnormal ballooning of an artery on its wall. Arteries are blood vessels that carry oxygenated blood from heart to other parts of the body. Aneurysm expanding sufficiently may burst in a way that will generally cause fatal bleeding in the body.
Aorta comes from left ventricle of the heart and advances along chest and abdominal cavity. Aneurysms occurred in the part of the aorta chest cavity are called "thoracic aneurysms". Aneurysms occurred in the part of the aorta abdominal cavity are called "abdominal aneurysms".
Aneurysms may occur in brain, heart, neck, spleen, back of knee and veins in the other parts of the body. If aneurysm in the brain bursts, it may cause a stroke.
Why is aneurysm screening important?
Approximately 15.000 people die because of ruptured aneurysm each year. Ruptured aneurysms in men over the age of 50 often are the cause of in 10th rank. Most of the ruptured aneurysms can be prevented with early diagnosis and medical treatment because aneurysms can flourish before exhibiting any findings. For this reason, it is high importance to apply aneurysm screening in high-risk individuals. Once diagnosed, aneurysms can be treated successfully with medication or surgery. Once aort aneurysm diagnosed, the physicians prescribe the drugs that will reduce heart rate and blood pressure and this will reduce rupture risk. Once large aortic aneurysm is diagnosed, this is treated with a surgery in a way that diseased portion of aorta is generally replaced. The results are generally good.
What are the causes of aneurysm ?
• It may occur due to atherosclerosis (thickening and narrowing of the arteries). When Atherosclerosis develops, artery wall thickens and damages and lose their normal inner surfaces. This damaged portion of artery may be stretched or ballooned with pressure of blood inside. In this way, aneurysm occurs.
• Aneurysms can also occur due to constant high blood pressure within artery.
• It may occur with a trauma on the chest. (for example, trauma occurred as a result of car accident).
• Some medical conditions such as "Marfan syndrome" may cause aneurysm. Height of the persons with "Marfan syndrome" is very tall and their fingers are long and slender. Thinning may be in question in vessel structure in these persons.
• In rare cases, infections such as untreated syphilis (a sexually transmitted infection) may also cause aortic aneurysm.
Who is at risk?
Men are at more risk for 5-10 times for AAA (abdominal aortic aneurysm, a type of the most common aneurysm) when compared with women. AAA risk increases with age and occurs most often in people between the ages 60-80. Peripheral aneurysms are more common in the persons with 60-80 years of age.
What are the risk factors?
• Atherosclerosis (fat accumulation in the arteries)
• Smoking (Smokers have 8 times more risk)
• Overweight and obesity
• Familial history for aorta aneurysm, heart disease or arterial disease.
• Some diseases that weaken the aortic wall (Marfan syndrome, untreated syphilis, tuberculosis)
• Trauma, such as chest impact during a traffic accident.
• Serious and persistent high blood pressure between 35-60 years of age. (Uncontrolled pressure is dangerous.)
• Use of stimulant drugs such as cocaine
What are the findings and signs of aneurysm?
Findings and signs of aneurysms depend on its type, placement and whether they are ruptured or not or relationship with other structures. Aneurysms can occur and grow without causing any complaint throughout years.
Most AAAs (Abdominal Aortic Aneurysms): They can grow throughout years and they do not cause any complaints until they are ruptured. Sometimes, a mass pulse can be noticed on the belly of the patient during examination. If they lead to complaints, these complaints are deep pricking pain in the back or abdomen edge, constant burning pain lasting for hours or days on the belly, coldness or numbness in the legs. If AAA ruptures, complaints occurs as sudden and severe pain on the bottom part of belly or back, nausea and vomiting, sweating on the skin, dizziness and increased heart rate when standing up. Internal haemorrhage caused by a ruptured AAA may lead to shock in patient.
Thoracic aortic aneurysms may not lead to any complaints until they grow or rupture. Possible complaints are pain in jaw, neck, back or breast or coughing, hoarseness or difficulty in breathing.
Possible complaints of Peripheral aneurysms are pulsing mass in neck, arm or leg, arm or leg pain, exercise cramp.
How is aneurysm diagnosed?
Aneurysms can be detected by chance during a routine physical examination. They are often detected by chance during ultrasound, x-ray or computed tomography conducted for other reasons such as chest or abdominal pain. The methods such as x-ray, ultrasound, computerized tomography, magnetic resonance imaging, angiography are used for diagnosis of aneurysm.
How are aneurysms treated?
Aneurysms that are very small and not causing any pain can be treated with careful observation. The others should be treated to prevent growth and complications. Purposes of the treatment are to ensure preventing growth of aneurysm, damaging other body structures and rupture and maintaining normal daily activities of the patient.
Medication and surgery are two treatment options of aneurysms. Medications can be used before surgery or instead of surgery.
Medications are used for reducing blood pressure, relaxing blood veins and reducing rupture risk. If aneurysm is large and has rupture risk, surgery is recommended. If a complication has developed such as dissection in aneurysms, urgent surgery is required.
Why early diagnosis is important?
Examination of smoking men between 65-75 years of age with ultrasound in terms of abdominal aortic aneurysm is recommended for early diagnosis. Treatment recommendations for aortic aneurysms are determined by the size of the aneurysm. Small aneurysms that are early diagnosed can be treated with close observation. If aortic diameter is small (less than 3 cm) and if there is no complaint, an examination will be required for 5-10 years in close follow-up. If aortic diameter is between 3-4, the patient should visit the doctor for conducting ultrasound once a year. If aortic diameter is between 4-4.5 cm, a test should be conducted every 6 months. If aortic diameter greater than 5 cm or there is growth more than 1 cm in a year, surgery should be performed as soon as possible.
Most peripheral aneurysms do not cause symptoms. They rarely rupture. Treatment of peripheral aneurysms depends on whether there is a complaint, settlement place of aneurysm and it prevents artery or not. Surgery is generally required in an aneurysm at the back of neck greater than 2.5 cm.
Why is dissection of aneurysm an emergency case?
Acute aortic dissection is the most common aortic dissection that requires urgent surgery. Aortic dissection refers to presence of rupture between layers of aortic wall and penetration of blood to pseudo-lumen occurred between layers of wall. It is generally common in elderly people. Since survival chance is reduced in case of rupture of aort, newly formed aortic dissection is an urgent and life-threatening condition.
This case is generally classified as Type A (rupture containing the ascending thoracic aorta) and Type B (rupture containing the descending thoracic aorta). Type A dissections have high death risk like 1 % for each hour when no surgery is performed. The patients with Type B dissection do not require any surgery unless there is rupture or circulatory disorder in organ. Standard tube graft placement is applied in dissection surgery.
How to decide on surgical treatment?
Heart and vascular surgeons decide on whether surgery is required for aneurysm treatment. If surgery is necessary, type of surgery is decided according to settlement and size of aneurysm and function of valve.
Surgical Treatments in Aneurysm
If surgery is necessary for treatment of aneurysm, type of surgery is decided according to settlement and size of aneurysm and function of valve. Surgery methods to be selected for treatment of thoracic aortic aneurysms.
Ascending aneurysm repair with a tube graft placement: IF aortic valve is normal and aorta is not badly expanded and aneurysm is in ascending aorta, repair of aneurysm can be performed in a way of tube graft placement. Expanded portion of ascending aortc is cut off and artificial tubes known as Dacron or Gorotex are placed. Artificial tubes are durable for lifetime.
Repair of aneurysm performed by protecting aortic valve: If possible, it is preferred to perform a surgery by protecting aortic valve instead of replacing aortic valve. Such type of a procedure can be applied in the patients with aneurysmal aortic root and having regurgitation in aortic valve but aortic leaflets are normal in terms of forms. Aortic valve and coronary arteries are stitched again to artificial vessel. The patients having undergone such a surgery do not have to use anti-coagulant drugs for longer terms.
Replacing composite aortic root: If replacing aortic valve together with aortic root in patients is required, composite aortic root replacement operation is conducted. An artificial aortic valve is in advance placed inside an artificial tube vessel in this surgery and is used for replacing aorta. Both mechanical and biological valves can be used in this surgery.
Aortic arch surgery: Aortic arch surgery is technically fairly difficult. A branched graft is used for protecting brain during surgery and the body is cooled (hypothermic circulatory arrest) and blood rich with oxygen is sent to the brain with a procedure called "antegrade cerebral perfusion". Use of such techniques reduces death and stroke risk.
Repair of thoracoabdominal aneurysm: Repair of thoracoabdominal aortic aneurysms requires complex and sophisticated surgical procedure. Potential complication of the surgery is feeding of spinal cord is impaired due to the fact that artery feeding spinal cord protrudes from this area. A procedure performed by anaesthesia specialist is used for reducing this complication.
Placement of stent graft (endovascular repair): In some cases, there is a new repair method called "stent graft repair" in some aneurysms not containing ascending aorta. This is a minimally invasive treatment for repair of abdominal aneurysm. Such type of stent graft placement can be performed by facilities having sufficient equipment for this job. This procedure is carried out with success in our hospital. This procedure can be carried out only if aorta anatomy of the patient is eligible. If not, standard open aortic surgery should be performed.
Repair of abdominal aortic aneurysm: Placement of tube graft is performed in surgical treatment of abdominal aortic aneurysms. In some cases, if iliac artery is aneurysmal, pants grafts are also used.