Minimally Invasive Abdominal Aortic Aneurysm Repair

An abdominal aortic aneurysm is an enlarged dilated blood vessel, which supplies blood to body and lower limbs. The aneurysms usually remain silent, until they rupture and cause death. Large aneurysms can cause abdominal discomfort and back pain but are usually missed. Countries like USA & UK have screening programs where aneurysms are picked up during routine scans in people who are at high risk. In India, there is no data about the incidence of aneurysms because of lack of awareness and lack of screening programs unlike in western countries.

A 69 yr old retired gentleman presented to me with complaints of dull aching abdominal pain. He was a known case of liver cirrhosis and portal hypertension and was on treatment for the same from another tertiary care hospital. He had a history of smoking and alcohol intake since 35 to 40 yrs but had allegedly stopped after his liver diagnosis. Abdominal CT revealed a 5.4cm abdominal aortic aneurysm in the infra renal segment with thrombus lining the walls of the iliac arteries. However the anatomy of the aneurysm was well suited for an Endovascular Aneurysm Repair Procedure (EVAR) of the abdominal aorta.

Pre operative clearances were taken and the patient underwent Endovascular Aneurysm Repair on the 29th of November 2018 (Monday) at Holy Spirit Hospital Cath Lab. Platelet transfusion was given intra op in view of low platelet count due to the liver pathology. Under General Anaesthesia, bilateral groin cutdowns were done and bilateral femoral arteries were exposed and controlled. After sheath insertions and angiograms the aneurysm was visualised and planning of the proximal and distal landing zones of the stent graft was done. The Main Aortic Bifurcated Body of the Stent Graft System was introduced from the left femoral and positioned in the infra renal portion such that the lowest renal (left) was perfused and the proximal seal of 2cm was achieved. After partial deployment of the main body the contralateral gate opened up and cannulation was done from the right femoral into the graft limb. The contralateral limb was deployed from top down into the right common iliac artery. The Main body deployment was then completed from the left and graft interstices were ironed using a complaint balloon. Check angiograms revealed no endoleak / leak into the aneurysm sac and blood flow was diverted from top to bottom via the graft with no blood filling the aneurysm sac. Post procedure both femoral arteries were repaired and groin incisions were closed.

Post operatively the patient was monitored in the ICU for a day and then shifted to the ward for care. He was ambulant from post op day 1 and eventually was discharged on post op day 3 as he walked home unassisted.

Abdominal aortic aneurysms have to be treated when they grow up to more than 5cm in size, because there is a growing risk of sudden rupture beyond this size. The average growth rate of aneurysms is around 0.4cm per year if untreated. We have no idea as to how many sudden deaths in elderly are due to rupture of aneurysms, especially in our country where hypertension, smoking and fatty food intake is highly prevalent. Size is the best determinant of rupture where 40% of untreated aneurysms 5.5-6cm or larger will rupture within 5 years. The average survival without treatment is around 17 months.

 Although there is seriousness attached to this condition, there is no need to worry, as these can be tackled very efficiently by key-hole surgeries (EVAR). Open aneurysm repair is reserved for difficult anatomies and younger presentations in most cases. With adequate planning and good aneurysm morphology, EVAR has the ability to treat almost any aneurysm with minimal mortality and morbidity rates. We are proud to be able to serve patients with this modern modality at Holy Spirit Hospital.

Author :

Dr. Aniruddha Bhuiyan

MS (Gen Surgery), MCh (Vascular Surgery), FVES (NUHS Singapore)

Consultant Vascular and Endovascular Surgeon