There are two primary treatment options for aortic aneurysms. These include open surgical repair and a less invasive approach called endovascular repair. Both are considered complementary procedures and each has its own advantages. Patients that have other health problems such as a weak heart might be more suited for the less invasive procedure while those with inadequate aortic anatomy might be better candidates for open surgical repair. Patients treated at The Nebraska Medical Center have the advantage of having access to both procedures.

Open repair

Open surgery repair involves the removal of the aneurysm. During the procedure, the surgeon makes an incision in the chest and repairs the aorta by replacing the diseased section with a synthetic graft or tube that is sewn into place with sutures. The flow of blood to the aorta is stopped while the graft is being placed. Open surgical repair is typically performed under general anesthesia and takes about four to six hours to complete. Patients also normally spend time in the intensive care unit after surgery and several days in the hospital. Depending on your general health and healing time, hospitalization and recovery may take up to three months.

Minimally invasive (endovascular) repair

A new, less invasive approach for surgical repair of aneurysms called endovascular repair received FDA approval in March of 2005. The endovascular repair recently became available at The Nebraska Medical Center. Ali Khoynezhad, M.D., a cardio-thoracic and endovascular surgeon, is certified to perform endovascular repair using the Gore Tag device. He has served as an instructor of endovascular stent repair and endovascular ultrasound to other out-of-state physicians.

Dr. Khoynezhad has performed more than 60 aortic endovascular procedures during his endovascular and vascular surgery training at Harbor-UCLA Medical Center, Los Angeles. He is the only surgeon in Nebraska to offer the minimally invasive repair technique using the Gore TAG device on the entire spectrum of aortic disease. These include: aortic aneurysms, aortic dissections, aortic ulcers, intramural hematomas, embolizing (shaggy) aortas and aortic transactions (aortic ruptures due to car accidents).

The graphic is a representation of the minimally invasive endovascular repair procedure using the Gore Tag device to treat a thoracic aortic aneurysm. The stent is introduced in a compressed form through a groin vessel and advanced to the enlarged portion of the aorta. At the target location, the stent is deployed, and excludes blood flow through the weakened and enlarged portion of the aortic wall.

To perform the procedure, surgeons use a catheter to thread a stent-graft through an artery in the leg to the site of the aneurysm. Once in place, the graft is inflated, reinforcing the weakened section of the aorta to prevent rupture.

Candidates for endovascular repair

Candidates for the procedure must meet the following requirements:

• can not have a tissue disorder (such as Marfan)
• aneurysms must be greater than 5 cm
• the proximal and distal land zone of the aneurysm should be at least 2 cm long and between 23 to 37 mm
• the illial aortic vessels should be at least 8 mm

Aneurysms less than 2 inches in diameter with no symptoms may qualify for observation and should be monitored with CAT scans every six months. The typical aneurysm will grow at about 1 to 3 mm per year. Aneurysms that grow more than 5 mm per year have a high risk for rupture. About half of all aneurysms will remain stable for several years. If the aneurysm still remains small after a one-year follow-up screening, subsequent screenings can be scheduled annually.

Once a patient has been diagnosed with an aneurysm, a total body scan should be performed to check for the existence of aneurysms in other locations as well as regular screenings to monitor the size of the aneurysm. Approximately one-third of patients diagnosed with an aneurysm will develop an aneurysm in another location. Once an aneurysm has been detected and it is deemed unstable, surgery to repair the aneurysm should be considered. Aneurysms that reach 5 cm or greater stand a 15 percent risk of rupturing.

Benefits to endovascular repair

Individuals who have a thoracic aortic aneurysm and receive treatment have over a 95 percent chance of survival. With no treatment and depending on location of the aneurysm, a person's chance of survival drops to 20 percent in just five years.

Endovascular repair is considered a safer alternative to open repair surgery. Patients experience improved treatment outcomes, shorter ICU care and reduced hospital stays.

A study of 139 patients undergoing endovascular repair for thoracic aortic aneurysm was completed between 1999 and 2001 and published in the Jan. 2005 issue of the Journal of Vascular Surgery. It revealed the following benefits of endovascular repair versus open repair surgery:

• mortality of 2 percent versus 9 percent
• average ICU stay of 2.6 days versus 5.2 days
• average hospital stay of 7.6 days versus 14.4 days
• 3 percent incident of spinal cord injury versus 14 percent
• 50-minute procedure time compared to double that for open repair surgery.

Benefits to open repair

One of the primary advantages to open repair surgery is that it is a one-time procedure. There is no need for follow-up CAT scans, no concern for endoleaks or migration of the stent.

Open repair has been performed for 50 years. The longevity and durability of open repair is well documented, while there is no long-term data on the endovascular repair.