Coming in for your aortic surgery

Preparing to have surgery

You should use the time before your operation to improve your fitness as this will increase your chance of avoiding a complication and mean you can leave hospital quicker:

  • Reduce or stop your smoking, if you smoke – even stopping for a few days before your surgery will increase the oxygen levels in your blood: https://www.nhs.uk/better-health/quit-smoking/
  • Take regular light exercise – don’t be afraid to exercise. Physical activity that makes you slightly out of breath will improve your fitness. Try brisk walking, cycling or moving in different ways, e.g. dancing. We recommend that you try to double your regular exercise.
  • Do strengthening and balance exercises – walk up and down the stairs, regular standing from sitting, or yoga to strengthen your muscles.
  • Nutrition – eating a balanced diet including plenty of fruit and vegetables will maintain a healthy immune system. Your diet should be low in salt and cholesterol. If you are overweight, try to lose weight.
  • Alcohol – reduce alcohol intake to below recommended safe limits and have alcohol-freedays if you currently drink alcohol every day.
  • Mental health – try to sleep well and look after your mental wellbeing. Learn some breathing techniques, try yoga or listen to relaxing music. Read about the benefits of mindfulness.
  • Dental care – see your dentist if you have not done so recently. Loose teeth or crowns can be damaged under an anaesthetic. Good oral health may reduce your risk for an aortic graft infection.

Hospital appointments

You will require a number of tests and assessments to choose the best treatment option for YOU. The 7 steps in this process are explained in this section. They will not always happen in this order, for example the CT scan might have been done before you first meet your vascular surgeon.

When attending for appointments, please bring a list of your medications with you (i.e. your prescription). Ideally, attend with someone who knows you well, and with whom you are happy discussing your health.

1. Consultant Vascular Surgeon (OPC)

You will usually first have a consultation with a vascular surgeon. This could be face-to-face, by telephone or online (‘attend anywhere ®’).

Your surgeon will assess your general health, review your tests and discuss the treatment options available with you.

2. CT scan (CTA)

The best treatment option for you will be based to a large extent on the position and shape (anatomy) of your aorta and its branches.

This is assessed using a CT scan that requires the injection of contrast into a vein. For this you will need a cannula (drip) inserted into your arm.

X-ray contrast can be harmful to the kidneys, so let your doctor know if you have poor kidney function or are under the care of the renal team.

3. Complex Medical Assessment (CMA)

A physician (specialist medical doctor) will assess you and talk to you about your treatment options. If they are concerned that the risks of surgery are greater than the benefit, they will discuss with you the option of ‘doing nothing’.

They will look at other medical conditions that you may have:

  • Assess all of your medical problems
  • Assess if you have disabilities which require extra support in hospital
  • Perform a clinical examination (i.e. listen to your heart and lungs)
  • Use specific tests for frailty, dementia, and other effects of aging
  • Review your medication, advising any changes
  • Recommend additional investigations. These might includ blood tests, heart tests, lung tests and a pacemaker test.
  • Refer to other clinics if necessary
  • Suggest ways to reduce the risk of early complications

4. Cardio-pulmonary exercise test (CPET)

This exercise bike test provides a measure of your ‘fitness’ for surgery. Let us know if you cannot take this test due to poor mobility or another condition.

An anaesthetist will supervise this test and discuss the result with you. You will be asked about your day-to-day activities and your health and then given an estimated ‘risk’ of complications following surgery and possibly more tests.

5. Pre-operative Assessment Clinic (POAC)

Attending this clinic may take several hours to allow time for our staff to make your aortic surgery as safe as we can.

You can learn more by watching this YouTube video

You will meet the following staff in this clinic:

  • Pre-operative nurse – checks your medical history; performs a clinical examination; takes blood samples and swabs; performs an ECG; explains to you about your hospital stay; gives health and fitness advice; and arranges further tests and support you may for your hospital stay and recovery.
  • Enhanced recovery nurse – explains the Enhanced Recovery After Surgery (ERAS) programme; supplies pre-surgery supplement drinks (Fortijuce/ Fortisip) unless you are diabetic; gives you a patient diary; and may invite you to attend an ERAS group session either face to face or online.
  • Pharmacist – gives medication advice i.e. for medication you should stop or start prior to coming to hospital.
  • Physiotherapist – assesses any disabilities or extra support you will need and teaches you breathing exercises for after your surgery.
  • Consultant anaesthetist – assesses whether you are ready to proceed to aortic surgery and the risk of major complications. Together you will discuss and agree an anaesthetic; this includes discussing choice of pain relief.

You will be given written advice on changes to your medication and arrangements for coming to hospital. Please put this somewhere safe!

It is important to let the POAC clinic know if either your health or medications change before you come in for your surgery.

6. Vascular multi-disciplinary team meeting (MDT)

Your surgeon will join with other vascular surgery, radiology and anaesthetic colleagues to review your case and agree the best management plan.

The vascular MDT will normally support the plan agreed already between you and your surgeon.

Occasionally, it will recommend additional investigations or that another treatment option be considered.

7. Consultant Vascular Surgeon (OPC)

A second consultation with your surgeon takes place once you have had your case has been discussed at the vascular MDT meeting.

Together with your surgeon, you will agree the correct treatment for you.

  • Discussing your understanding and concerns regarding your diagnosis
  • Discussing your planned treatment, with the risks and benefits
  • Talk about planned hospital stay, recovery and long-term follow up
  • Reinforcing how you can improve your long-term health

Waiting list

Most aortic procedures are scheduled within eight weeks of initial referral. There can be additional delay if more investigations are needed or a custom-made stent graft has to be manufactured.

You will be kept informed of the date for your surgery by the vascular patient pathways coordinators.

The coordinator contact details are on your vascular clinic letter and at the back of this leaflet.

All the members of these teams are ready to discuss concerns or answer any questions you may have regarding your diagnosis, treatment or recovery.

Consent - A shared decision

A ‘shared decision’ means we have provided you with the information you need regarding your diagnosis, what can happen without surgery, and the risks and benefits of different procedures (your options).

This is done so that you can decide what you want to do. If you prefer, you can ask you surgeon what he or she recommends that you do.

Consent, your permission, is always needed for before elective surgery. You will be asked to sign a consent form stating the planned procedure, the reason why this is being undertaken and its potential complications.

For aortic surgery, we will ask if we can submit your data to the National Vascular Registry: https://www.vsqip.org.uk/public/

Informed consent for aortic procedures routinely includes discussion of:

  • Bleeding – including the need for blood transfusion
  • Infection
  • Kidney injury
  • Cardiac injury (‘heart attack’ or ‘heart failure’)
  • Respiratory event (‘chest infection’)
  • Stroke
  • Injury to the blood supply to the bowel or to the legs
  • Hospital readmission
  • Later reinterventions
  • Death

For complex aortic procedures, your surgeon will discuss with you if there is the risk of a spinal cord injury, and the steps we use to reduce that risk.

Coming into hospital

How long will I be in hospital for?

Your likely length of stay in hospital depends on the surgery you are having:

  • 1 night for a standard aortic stent graft (EVAR)
  • 3-5 nights for a thoracic stent graft (TEVAR)
  • 3-5 nights for a complex aortic stent graft (FEVAR or BEVAR)
  • 5-14 nights for open aortic surgery

Most patients undergoing aortic surgery will require an intensive care unit (ICU) admission after surgery. You can learn more in this YouTube video

What do I need to bring with me?

Please only bring to hospital what you require for a comfortable hospital stay:

Eating and drinking

If in doubt, ask before you eat or drink anything on the day of your surgery. This is to prevent food from your stomach going into your lungs as you are anaesthetised.

Washing and shaving

Have a shower or bath the night before and on the morning of your operation. This will reduce the risk of a wound infection.

Please don’t shave the area where you are having surgery, as doing this too early increases the risk of a wound infection.

Diabetes

If you are diabetic, good control of your blood sugar is essential. If you use Insulin you will be given specific instructions on preparing for surgery. If you take Metformin you may be asked to omit this medication.

Information sharing

We believe that relatives and carers should be kept informed. Tell us with whom, and how much, information you would like us to share?

Special requirements or disability

It is important to remind us again when you come to hospital if you have a specific requirement or a disability. This is to ensure that we provide you with the extra support you need.

Your hospital admission letter tells you where to come to and at what time. There is paid parking available at Southmead Hospital if required.

If you need help when you arrive at the hospital, there is a reception desk close to the entrance to the main Brunel building.

The day of your operation

Post-op bed

We will always check that we have a bed available on the day. If there is no bed, we have to postpone surgery – we recognise the distress that this causes for you and your family at an already anxious time.

Going into theatre

You will be taken to the operating theatre by an operating department practitioner (OPD). On arrival, you will be asked to check your name, date of birth and the planned operation. Before going to sleep, you will have a drip (small plastic tube) inserted into a vein in your arm. ECG stickers will be attached to your chest. We will also use other tubes:

  • Arterial line – this tube in your arm, usually at the wrist, that allows continuous monitoring of your blood pressure
  • Breathing tube – this connects you to a ventilator
  • Urinary catheter – this will drain urine from your bladder
  • Epidural catheter – a special kind of drip in your back to deliver pain relieving drugs close to the spinal cord
  • (Spinal drain – rarely, a tube is placed into the spinal canal to drain off excess spinal cord fluid and help protect against spinal cord injury)

Going to sleep

Your anaesthetist will ask you to breathe oxygen from a mask, drugs will then be given into the drip in your arm and you will slowly drift off to sleep.

During your surgery

Your anaesthetist is responsible both for keeping you asleep and controlling your blood pressure, heart rate, lungs, kidneys, temperature and blood volume during surgery.

Recovery in hospital

Waking up

Your anaesthetist will accompany you back to a Mediroom as you wake up. Once you are awake the breathing tube will be removed and replaced by an oxygen mask. Occasionally, patients are transferred to the ICU whilst asleep.

Accommodation

The ICU and all of our wards have single rooms. If you have specific care needs, or on step-down from ICU to the ward, you will be in a bay with up to three other patients of the same gender. All of our rooms have WiFi and a TV.

Breathing exercises

It is really important to take deep breaths and cough frequently to clear secretions from your chest. A physiotherapist will visit you to teach you breathing exercises such as this.

Sit upright (if able). Take a deep breath in through your nose, then sigh out through your mouth. Repeated these 6 to 8 times as shown below:

  1. Take 3-4 deep breaths 
  2. Take 2-3 normal breaths
  3. Take 3-4 deep breaths
  4. Take 2-3 normal breaths
  5. Next, take 2-3 ‘huffs’ – short sharp breath out – imagine steaming up a glass.
  6. Next, cough. If the cough is clear, stop. If your cough ‘rattles’ then repeat.

Pain relief

Pain relief immediately following surgery will be with Paracetamol and either morphine, given via a ‘drip’, or local anaesthetic, given via an ‘epidural catheter’. Morphine will be given by a nurse or by a device called a patient controlled anaesthesia (PCA) which you control.

Once you are able to eat, we will give you painkillers by mouth in tablet form.

Eating and drinking

At first your appetite may be poor, and your sense of taste altered. Your nurse will encourage you to eat and drink. Try to drink at least 8-10 cups of fluid (i.e. water) daily, unless you are ‘nil by mouth’ or on a ‘fluid restriction’.

Constipation and nausea

As your bowel function recovers following aortic surgery, constipation and nausea are both common. Try to drink plenty of water and eat foods containing lots of fibre (i.e. fresh fruit with their skin on and vegetables).

Visitors

Advice for visitors is available on the website: https://nbt.nhs.uk/visitors

Preventing other complications

After major surgery you are at risk of:

  • Slips, trips or falls
  • Blood clot in a leg (‘deep vein thrombosis’)
  • Blood clot in your lung (‘pulmonary embolus’)
  • Pressure damage to your skin

There is information on preventing these on the NBT website: https://www.nbt.nhs.uk/patients-carers/coming-hospital

Leaving hospital

Please give some thought to how you will manage after you leave hospital.

You may feel especially vulnerable once back home. If you live alone we advise that you have a relative, friend or carer stay with you for 2-3 days.

Rehabilitation

You may require a longer period of supported recovery, called ‘rehabilitation’, between hospital and home. We would usually transfer you for this to nearer your home (i.e. your local hospital, a community hospital or a nursing home).

If you require this, our vascular discharge co-ordinator will discuss the proposed arrangements with you.

Travelling home

You should plan this before going home. You should arrange your own transport home – an ambulance will only be arranged if your doctor considers that this is medically necessary. You should have suitable outdoor clothes and shoes to travel home in and remember to collect any valuables given in for safe keeping

Hospital @ Home

This is a North Bristol Trust service whereby a nurse from the hospital visits you at home until your Consultant is satisfied that you no longer require this. You can learn more from this video: www.nbt.nhs.uk/our-services/a-z-services/hospital-at-home

This service is unfortunately only available for patients living within an accessible distance for the nurses to travel out from Southmead Hospital.

Medication changes

The ward pharmacist will explain changes to your medication. These changes will also be written on your hospital
discharge letter.

The hospital you will give you a two-week supply of tablets. This should give you time to arrange a repeat prescription from your GP – who should have received an electronic copy of your hospital discharge letter.

If you have drugs at home that you are no longer taking return them to your pharmacist for safe disposal.

Common medication following aortic surgery are:

  • Statin – to reduce risk of future heart attack or stroke
  • Blood pressure medication
  • Aspirin (or clopidogrel)
  • Anti-coagulation – DOAC or warfarin. Make sure you have your warfarin levels monitored.
  • Pain relief

It is helpful to keep a list of your medication (i.e. on your mobile phone).

Problems or concerns

The ward nurses can be contacted for advice during the first 48 hours after you leave hospital.

After 48 hours, you should contact NHS 111, your district nurse (for wounds) or make an appointment to see your GP.

If you need immediate assistance (e.g. chest pain, breathlessness or fever) call 999 for an ambulance or attend your local Emergency Department.

Making a full recovery

Guide to what you will be able to do each week

The following is a guide for if you have ‘open’ aortic surgery. If your operation is a stent graft, then you can expect a quicker recovery, of around six weeks.

  • Week 1: Move about. Take it easy i.e. walking around your house and garden for 5 minutes each morning, and more if you feel able. Carry on the breathing exercises. Rest in the afternoon. Try to get 8-10 hours sleep.
  • Weeks 2-3: Do more activities at home i.e. walking for 10-15 minutes once or twice a day. Take short rides in the car as a passenger. Do not get overly tired. Do not lift or push anything heavy, e.g. do light gardening but do not dig.
  • Weeks 4-7: You should manage most household tasks but avoid strenuous tasks like cleaning windows and heavy gardening. You can travel within the UK.
  • Weeks 8-10: Be as active as normal whilst still avoid heavy lifting or digging.You can by now plan longer car trips or travel abroad.
  • Week 11+: You should be fully recovered other than some aches and pains. If you feel strong enough you can start building back to lifting and digging.

It is important to remember that you are unique, and that you may recover from surgery quicker or slower than this.

Eating and Drinking

Prior to your surgery, you may have been advised to lose (or gain) weight. Immediately following surgery, to allow your body to recover and to heal, you should not restrict your diet. Wait until 8-10 weeks before starting a restrictive diet (if this is necessary to achieve weight loss).

Driving

You are responsible for checking with your insurer that you remain covered.

If you were excluded from driving because of a large aortic aneurysm you must wait until you see your surgeon back in the clinic before re-applying for your driving licence: www.dft.gov.uk/dvla/medical.aspx

You are safe to drive once you are able to safely control your vehicle i.e. you must have recovered sufficiently to safely perform an emergency stop.

For most drivers this is by 4-6 weeks.

You must inform the DVLA if you remain unsafe to drive 3 months after having had surgery: www.gov.uk/surgery-and-driving

Bathing and showering

Ideally take a shower or a bath daily. If possible, shower rather than a bath for the first 4 weeks. If you do take a bath, empty the water before you stand up, use a non-slip mat and get assistance if needed.

Surgical incisions

Dressings can usually be removed once you are home. If you have visible stiches these need to be removed. Washing scars once stiches our out keeps your them clean and encourages them to heal.

You should contact your practice nurse of your GP if an incision is:

  • Getting more painful
  • Discharging fluid
  • Red, hot or more tender to touch
  • Bleeding

Your mood

Immediately after your operation you may have days when you feel down or depressed, this is known as the ‘post-op blues’.

You may feel irritable, more emotional and tearful. This can happen at any time, and without warning.

Both you and your family will be affected by these feelings, so it is important that you discuss with them how you are feeling.

If you continue to feel low or anxious you should see your GP.

Sexual intercourse

It is advisable to wait 2- 4 weeks after aortic surgery before sex and/or sexual stimulation. If you are a man, you may find that your ejaculate is different. If you have a problem with impotence, you should see your GP.

Holidays and flying

You are responsible for informing your travel insurance company of the details of the surgery you have had.

It is important to cover surgical scars with sun block when sunbathing for at least the first 6 months to avoid sunburn.

Returning to work

There is no set time for returning to work, but you may need to wait 6-12 weeks. You should ask your surgeon about this. If you drive for a living, especially HGVs, you will need to be fully recovered before returning.

A healthier lifestyle

You should continue the health and lifestyle changes that you made to get fit for your surgery. There is emerging evidence that good dental hygiene is important; you are advised to see a dentist at a least once every 2 years.

Follow up

Four to six weeks

You should be sent a letter with a follow-up appointment with your vascular consultant. You may also be booked for a CT scan.

If you have not received a follow up appointment by 4 weeks, then contact the vascular patient pathway coordinators to ask what has happened.

Long term

Aortic disease typically affects the whole aorta and you may therefore require long term (even ‘life-long’) follow-up.

This is especially important if you were treated with an aortic stent graft.

Telephone numbers

https://www.nbt.nhs.uk/our-hospitals/southmead-hospital-bristol/southmead-hospital-telephone-numbers

Pre-operative assessment clinic 0117 414 0635 / 0637

Enhanced recovery nurses 0117 414 3610

ntensive care unit 0117 414 1400

Vascular ward (Gate 26A) 0117 414 1336

Hospital @ Home team 0117 414 0268 / 0700

PALS team

Being a patient, relative or carer can be a worrying or confusing time. Our PALS team provide support and listen to concerns and complaints.

Contact PALS on 0117 414 4569 or ask a member of staff to do this for you.

Aortic support group

We hope in the future to form an ‘aortic group’ to allow people with an aortic condition the opportunity to discuss what it means to them.

The group will provide support for both patients and families. The group will also act as a steering group, focusing on up-coming aortic events and research.

To register your interest in participating in such a group please contact Deborah on 0117 414 8800 or Deborah.grimwood@nbt.nhs.uk.

Further information

Fitter Better Sooner
www.rcoa.ac.uk/patient-information/preparing-surgery-fitter-better-sooner/fitter-better-sooner-general-information

Vascular Services Quality Improvement Programme
www.vsqip.org.uk/public/

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

How to contact us:

Brunel building
Southmead Hospital
Westbury-on-trym
Bristol
BS10 5NB

Vascular clinical nurse specialists:
0117 414 5302/3/4

Patient pathway coordinators:
0117 414 0798

© North Bristol NHS Trust. This edition published September 2020. Review due September 2022. NBT003284

Coming in for your aortic surgery