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Abdominal and Thoracic Aortic Aneurysm Treatment: Open Surgery [Transcript]
Featuring James Black, MD, Associate Professor of Surgery
Describe what you do.
My name is James Black. I’m a vascular surgeon here at Johns Hopkins Hospital in Baltimore. I deal with diseases of the arteries and veins outside of the heart.
Describe the procedures for open abdominal aortic and thoracic aneurysms.
Open repair of abdominal aortic aneurysms is performed usually through two approaches. Sometimes, we perform an incision through the center of the abdomen that brings us right down to the aneurysm itself. The aorta is then opened and replaced with a graft. Those grafts, we’ve been placing in patients since the 1950s and are quite durable and will last the patient their entire lifetime.
The repair of a thoracic aortic aneurysm using open techniques usually implies that the patient has to lie on the right side and then the incision comes down between the ribs. And thereafter we flex the chest open and we can get to the thoracic aorta in that location. Similar to the abdominal aortic aneurysm repair, we also replace the aorta in the chest with a Dacron graft, which can last a patient a lifetime with little fear of degeneration down the road.
What can a patient expect after the surgery?
Routine abdominal aortic aneurysm repair when we do an open, traditional surgical procedure usually requires the patient to come into the operating room on the day of surgery and they are in the hospital usually between five and seven days. Usually one or two of those nights includes a stay in the intensive care unit, mostly so we can monitor the patient to make sure that they come out of anesthesia safely, then thereafter we get them out into the regular hospital floor and start working on moving their diet forward and getting people up and around. On average most of our patients with a simple, straightforward abdominal aortic aneurysm repair are going home within five to seven days after the procedure.
For a thoracic aortic aneurysm repair, when we do an open repair, the stay is usually longer. Mostly because the incision through the chestwall is by its nature more painful than that of the abdomen. So we tend to see patients who are in the hospital a little bit longer while we wait to take them off appropriate intravenous medications to help control their pain, move towards oral pain medications and then go home.
What follow up is required for these patients?
Follow up after open aortic procedures is dramatically different than that of an endovascular repair. For an endovascular repair, we almost always have to have the patient coming back in the first year, a month after surgery, potentially at six months, then twelve months after the procedure. For an open repair, we generally have the patient come back between six and eight weeks after surgery. At that point, we’re mostly beginning to discuss getting back to activity in terms of limiting the weight restrictions that they have upon lifting items, getting back to exercise; we talk about driving. And generally most of the patients after an open aortic repair are back in the workforce between two and three months after surgery.
What are the complications during and after surgery?
Open treatment of aneurysms is, by its nature, a more risky procedure than that of an endovascular repair. This has been born out in many studies throughout the last five to ten years. The things we worry about after an open aneurysm repair are mostly related to dysfunction of the kidneys or trouble with the lungs. Of course, people who go into the operation as active smokers are at a higher risk for lung problems than non-smokers. And unfortunately smoking is one of the conditions that leads people to have aneurysms. So we have the base problem as the cause of the aneurysm as well as the cause of most of the complications. We have an excellent ICU [intensive care unit] team here and our nurses are quite strong in terms of managing the pulmonary aspect and the lung aspect of the operation. Luckily, we have had a relatively low rate of pulmonary complications, as well as renal complications or kidney complications, after any the open repair.
What is the most rewarding thing about what you do?
The best part about working at Hopkins is working around people who are truly excellent. There is a very high caliber of physicians that we have here at Hopkins. Everybody works as a team. There is no one-upping each other to get ahead; the patient is at the center of the game and everyone works to get that patient in better shape. I enjoy coming to work because what I do is by its nature inherently difficult and somewhat complex, but I like making it look routine.
Why choose Johns Hopkins?
The best reason that patients should consider coming to Hopkins is because we really put the patient at the center of the equation. We know, based upon our own research here at Hopkins, what the best treatments are for a patient in their given medical fitness. There are many physicians here at Hopkins who have expertise in many things. There are many people here who are really good at what they do and we can bring it all together to deliver the best outcome for the patient.