The Johns Hopkins Hospital is proud to be selected as one of only 13 hospitals nationwide that can perform endovascular abdominal aortic aneurysm surgery above the renal arteries. Find out more about this procedure and the fenestrated stent graft used.
An aortic aneurysm is a weak spot in the wall of the aorta, the primary artery that carries blood from the heart to the head and extremities. There are three common types of aortic aneurysms: saccular, fusiform and dissecting.
Aortic aneurysms can occur in the following three locations:
- Abdominal aortic aneurysms (AAA)
- Thoracic aneurysms
- Thoracic abdominal aneurysms
Saccular and fusiform aneurysms are balloon-like swellings of the arterial wall that can occur in the portion of the aorta within the chest or just below the kidney in the abdomen. A dissecting aneurysm is a longitudinal, blood-filled split in the lining of the artery, usually occurring in the aortic arch near the heart. As blood is pumped through the aorta, the weak spot in the elastic arterial wall bulges outward.
The risk is that an aneurysm will eventually rupture, causing extensive internal bleeding and a complete collapse of circulation. Sudden severe pain, shock and loss of consciousness usually occur within seconds, and death is imminent in more than 50 percent of cases, even with emergency surgery. Thus, the goal is to detect and treat an aortic aneurysm before it ruptures. Aortic aneurysms generally affect people over 60 and are more common among men.
When to Call Your Doctor
Call a doctor if you experience symptoms of an aortic aneurysm, such as a pulsing sensation near the naval or abdominal tenderness. See your doctor regularly if you suffer from high blood pressure or high cholesterol, each a major risk factor for the different types of aneurysms.
In the majority of aneurysm cases, there are no warning symptoms. More likely, an aortic aneurysm is detected with an X-ray or during a routine physical examination.
If an individual experiences symptoms, they tend to be relatively specific, except for severe chest pain that may be mistaken for a heart attack (may signal a dissecting aneurysm).
- Hoarseness, difficulty in swallowing, or persistent cough may indicate a saccular or fusiform aneurysm in the chest area.
- A throbbing lump in the abdominal area, severe backache, leg pain or a feeling of coldness in the leg (due to an embolus from a clot formed in an abdominal aneurysm), or severe abdominal pain (due to the rupture of an abdominal aneurysm) may indicate a saccular or fusiform aneurysm in the abdominal area.
Though an exact cause of aneurysms cannot be named, there are several conditions and lifestyle factors that have been associated with their development. It is clear that a family history of aortic aneurysms substantially increases risk.
- Approximately 95 percent of aortic aneurysms are caused by atherosclerosis, the narrowing of an artery due to the buildup of fatty plaque.
- The muscular middle layer of the artery may be congenitally weak and thus prone to a dissecting aneurysm.
- High blood pressure (hypertension) intensifies the force of blood on the walls of the arteries and contributes to the development of dissecting aneurysms.
- Syphilis may cause a saccular or fusiform aneurysm near the heart.
- The arterial wall may be weakened as a result of trauma or complication of other diseases, possibly leading to saccular or fusiform aneurysms.
Diseases that cause aortic aneurysms:
- Marfan syndrome is a disease that can weaken the layers of the aortic wall, in turn increasing the risk of aneurysm.
- Loeys-Dietz Syndrome
- Turner’s Syndrome
Prevention measures include a diet low in cholesterol and saturated fats to reduce the risk of atherosclerosis. It is also important to take steps to prevent, detect and treat high blood pressure.
If you have a family history of aortic aneurysms, you are at an increased risk and should be aware of the symptoms, as they are more likely to develop at a young age. (They are also more likely to rupture, so early treatment is essential.)
If you are determined to be at high risk, you may want to consider periodic ultrasound screenings with your physician.
During your evaluation for aortic aneurysm of the heart, one of our physicians will examine you at our Outpatient Center or satellite facility at Green Spring Station. If necessary, you may be asked to undergo one or more of the following tests. Ultrasounds and X-rays are performed at the outpatient locations. The others are done in the hospital’s Cardiovascular Diagnostic and Interventional Laboratory.
- Regular physical exams. It is important that you have regular physical exams to detect an aortic aneurysm before it has a chance to rupture.
- Chest X-rays, computed tomography (CT) scans or ultrasound imaging is used to confirm the presence of an aneurysm. During a CT scan, you will lie on a table while an X-ray tube revolves around your body to direct X-rays through your chest at different angles and give the doctor a better picture of your blood vessels. Ultrasound uses high-frequency sound waves to examine your organs. One of our doctors places a small device called a transducer against your skin near the heart. As the doctor moves the transducer over a given area, it sends high-frequency sound waves to the heart. Once the information is recorded, it is electronically converted by a computer into detailed two-dimensional images and displayed on a monitor.
- Angiography, which is an X-ray of the arteries, examines the heart’s blood vessels and working capacity of the valves that control blood flow.
- Ultrasound examinations are performed periodically to follow the expansion of an aneurysm over time.
Our physicians may ask you to return for regular physical exams to track an aortic aneurysm and ensure that it doesn’t rupture.
The Johns Hopkins Hospital has been providing state-of-the-art patient care for over 100 years. As one of the few centers in the world that truly focus on diseases of the aorta, the Dana and Albert “Cubby” Broccoli Center for Aortic Diseases brings together the leading physicians and scientists in clinical and laboratory research at the nation’s best hospital. This cohesive program provides a continuing opportunity to make key advances in the field of aortic diseases, while offering the highest level of care and treatment available anywhere in the world.
Johns Hopkins is proud to be a leader in this field employing innovative surgical and anesthetic techniques to improve outcome. More importantly, continued improvement is our constant goal and the subject of intense research efforts in the Dana and Albert “Cubby” Broccoli Center for Aortic Diseases.
The Broccoli Center handles the full spectrum of aortic disease pathologies from newborns to the elderly. The linking of various disciplines within this center will allow the future development of successful prevention and treatment strategies for thoracic and abdominal aortic diseases. Through collaborative efforts within the center, Johns Hopkins will continue to be recognized as a world leader in the management of routine as well as complex aortic disease.
At Johns Hopkins, our doctors are committed to maintaining the highest standards of care available. Treatment options for aortic aneurysms can include the following:
- Beta-blocking medication that decreases blood pressure and the force of the heart’s contractions, thus reducing pressure against the walls of the aorta may be prescribed by your doctor.
- Certain aneurysms require immediate treatment, often involving surgical removal of the affected portion of the artery and replacement with a synthetic arterial graft. Surgery may also be required if an aneurysm is causing pain, is larger than six centimeters, or is rapidly expanding. Surgery on an unruptured aneurysm has an 80 to 90 percent success rate.
The Interventional Radiology Technique. Few fields in medicine have seen more exciting advances in recent years than interventional radiology: the use of imaging techniques that guide catheters and wires inside the body to open obstructed vessels, treat various forms of cancers and stop internal bleeding.
With these techniques, Johns Hopkins medical professionals are revolutionizing treatment of arterial occlusive disease, aortic aneurysms, vascular malformations, liver cancer, portal hypertension, uterine fibroids and gastrointestinal bleeding, among other conditions. By using small incisions, our minimally invasive procedures translate into shorter hospital stays, faster recovery and less pain for the patient.
- Stent grafting. Johns Hopkins is proud to be one of only sixteen centers in the U.S. to study stent grafting, a new and less-invasive method of repairing infrarenal abdominal aortic aneurysms. This interventional radiology technique for treating aortic aneurysms involves making a small nick in the groin and, under X-ray guidance, inserting a catheter into a blood vessel that leads to the aorta. A collapsed stent graft, also known as an endograft, is inserted through the catheter and moved to the site of the aneurysm, where it is deployed, reinforcing the aorta and creating a stronger pathway for the blood. Blood flowing through the stent graft no longer puts pressure on the ballooning walls of the aneurysm outside of the graft. Before the procedure, most patients are lightly sedated and given epidural anesthesia.
- At Johns Hopkins, a stent graft team comprised of an interventional radiologist, vascular surgeon and anesthesiologists performs the procedure. This combination of medical experts assures optimal care for patients undergoing the stent graft procedure at Johns Hopkins.
Who Is Eligible for the Stent Graft Procedure? Nearly three-quarters of people with an abdominal aortic aneurysm (AAA), a common life-threatening condition, may be eligible for this non-surgical procedure to correct the dangerous ballooning in the body’s main artery.
Interventional radiologists at Johns Hopkins perform the stent grafting procedure, which requires less anesthesia and a shorter hospital stay and results in less overall risk to the heart than surgery.
The hospital stay usually is four days or less; recovery takes an average of 11 days and there are fewer complications than with surgical repair. The alternative, surgical replacement of the damaged portion of the aorta, is performed under general anesthesia. A doctor makes a large incision in the abdomen to reach the site, clamps off the aorta, cuts out the aneurysm and sews an artificial artery or graft into place. Typically, the hospital stay is eight to 10 days and the average recovery time is 4 to 7 days.
About 15 to 20 percent of patients who have the stent graft procedure experience leakage into the aneurysm sac. Many need no treatment, but are followed closely. Others may undergo embolization, an interventional radiological technique that cuts off blood flow to the problem area to prevent further leakage.
What Are the Risks? Like any new procedure, there are known and unknown risks associated with aortic stent graft placement. The known risks are those associated with deployment of the device and include:
- Failure of the device to expand properly.
- Disruption of thrombus (clot) or vessel wall with embolization.
- Reaction to contrast media.
These problems have been noted infrequently during recent worldwide experience.
Other risks are common to both the open and endovascular repair technique and include:
- Myocardial infarction (heart attack).
Overall, the mortality and morbidity associated with the endovascular repair of aortic aneurysms, (the stent graph procedure), appears to be about half of those associated with the standard open repair. Most patients undergoing the endovascular repair are discharged within two days of the procedure.
The unknown risks involved with aortic stent graft placement center around its long-term durability. Theoretical (but unlikely) risks include metal fatigue or further degeneration of the aortic wall years after successful deployment. This could result in leaks around the graft and, in turn, expansion of the aneurysm and possible rupture. It is likely that the vast majority of early and late leaks can be remedied with another stent graft.
Because of these potential risks, Johns Hopkins utilizes a strict protocol to carefully monitor all patients receiving an aortic stent graft; it includes periodic spiral CT, abdominal radiographs and ultrasonography.
Other Treatment Options. For patients who are not candidates for the new procedure because of anatomic reasons, Johns Hopkins offers standard aneurysm repair utilizing a small incision in the left flank, comparable to that used for kidney surgery. G. Melville Williams, M.D., of Johns Hopkins pioneered this retroperitoneal approach to the aorta, which appears to be less stressful to patients, resulting in a more rapid return of gastrointestinal function and an overall tendency toward reduced hospital stay.
- Surgical techniques. More extensive aneurysms involving the thoracic aorta (chest) or the abdominal aorta providing blood supply to the visceral and the renal arteries are repairable only by open surgical techniques. Since 1994, 145 consecutive patients have undergone complex aortic root repairs at Johns Hopkins, with over 50 of these patients requiring deep hypothermia and circulatory arrest. Of these patients, none has experienced permanent debilitating neurological deficits, and overall mortality is only 1.4 percent. The success with patients who have Marfan syndrome has also been exemplary, with only two hospital deaths recognized in over 218 patients undergoing extensive aortic root repairs since 1976.
The most feared complication associated with the repair of extensive aneurysms involving the thoracic and abdominal aorta (thoracoabdominal aneurysm) is paraplegia, paralysis of both lower extremities and generally the lower trunk. Johns Hopkins is one of few institutions in the U.S. that routinely attempts to identify the source of blood supplying the spinal cord prior to operation.
The spinal artery (artery of Adamkiewicz) is localized in approximately half of patients studied and, over the last five years, has predicted a successful outcome with regards to preventing paraplegia. Over this period, no patient with successful localization has developed paraplegia.
- Partial bypass. All patients are managed with partial bypass (left heart bypass) around the occluded aorta, which sustains functions of the kidney, gut and liver while reducing cardiac afterload. Controlled moderate hypothermia with other adjuncts protects both the spinal cord and other vital organs. The overall incidence of paraplegia and paraparesis, weakness of the lower extremities, over the last five years has been 3.7 percent and 1.4 percent respectively.
The repair of extensive aneurysms is now a routine procedure at Johns Hopkins, as over one- third of all patients undergoing aortic procedures have complex aneurysms.