Open repair of abdominal aortic aneurysm (AAA)

What does an open AAA repair involve?

Open surgery for your abdominal aortic aneurysm (AAA) involves opening your abdomen (tummy) to repair your aneurysm with an artificial piece of artery (surgical graft). An aneurysm is an enlarged artery caused by weakened artery walls.

In the UK, 37% of planned (elective) AAA repairs are performed by open surgery. 63% are performed using an endovascular aortic stent graft (EVAR).

The procedure itself

Anaesthetic surgery is under general anaesthetic (asleep on a ventilator).

An incision is made on your tummy to access the aneurysm. This may be ‘up and down’ or ‘across’. You may also have an incision in one or both groins (to access the femoral arteries). Your specialist team will assess you, and your arteries, on CT to decide the most appropriate incision to use.

All patients go to ‘intensive care’ after open aortic surgery. There is therefore a risk that the operation may be cancelled on the day due to a lack of an ICU bed.

Open AAA repair

  1. The small intestine is moved out of the way, either across into the right-hand side of the abdomen or up out of the abdomen into a bag.
  2. Healthy aorta is exposed above the aneurysm. This may be above (supra-renal) or below (infra-renal) the arteries to the kidneys.
  3. Healthy artery is exposed below the aneurysm, usually onto arteries in your pelvis which supply blood to your legs.
  4. A drug called Heparin is given to reduce the risk of blood clots.
  5. Clamps are applied above and below the aneurysm. The aneurysm is then cut open and the graft sewn into place.
  6. The sac of the aneurysm is then wrapped around the graft, to reduce bleeding and lower the risk of other structures sticking to the repair.

More information on preparing for your surgery, your admission to hospital and recovery are explained in the booklet ‘Coming in for your aortic surgery’.

Potential early (first 30 day) risks

Undergoing open surgery places a greater stress on your body than having an aortic stent graft. On average, 1 in 5 patients have a complication in hospital. According to the UK National Vascular Registry Report 2019, the risks are:

  • Death (3.2%)
  • Chest infection or breathing problem (10%) – the risk is higher if you smoke.
  • Return to theatre (6.1%)
  • Readmission to hospital (5.5%)
  • Kidney problem (4.5%)
  • Heart problem (4.3%)
  • Reduced blood supply to legs (3.2%) – if this is the case, we usually need to perform emergency surgery, which has a risk of amputation (1%)
  • Problem with bleeding (1.5%)
  • Reduced blood supply to the pelvis and buttocks – this is sometimes done intentionally when we treat an aneurysm that extends down into the pelvis. The most common problems are lower back or buttock pain when walking (buttock claudication). Very rarely, the blood supply to the skin around the buttock can be lost.
  • Reduced blood supply to the bowel in the colon – this leads to inflammation in the bowel (ischaemic colitis) which can lead to the bowel bursting. The symptoms can be mild with diarrhoea for a short period while more severe problems result in the need for emergency bowel surgery and a colostomy (stoma). It is very uncommon for patients to have problems with the bowel in planned operations (1-2%).
  • Bowel injury – this is more likely if you have had previous abdominal surgery or an episode of peritonitis (burst bowel or ulcer).
  • Abdominal adhesions – this causes bowel problems (obstruction).
  • Clots in the legs or lungs – as with any major surgery, there is a risk of Deep Vein Thrombosis (DVT) or Pulmonary Embolus (PE). Whilst in hospital you will receive daily injections in your tummy to reduce this risk, you will also be encouraged to start to walk.
  • Reduced blood supply to the spinal cord or nerves – (0.3%) this can result in weakness in one or both legs (paraplegia) but it is very rare after open AAA repair.
  • Blood transfusion may be required.
  • You will experience some pain – your anaesthetist will talk to you before your operation about how this will be managed (i.e. epidural catheter or patient controlled anaesthesia – PCA)
  • The incisions in the groin may cause problems, like bleeding or blockage of the artery in the groin, burning pain in thighs due to bruising, wound infection, fluid discharge or ‘lumpiness’.
  • Complications of anaesthesia – your anaesthetist will talk to you about these in the pre-operative assessment clinic and on the day of your surgery.

Potential later problems (from 30 days)?

  • For men, reduced sexual function (60%) – this is due to damage to pelvic arteries and nerves. Men with AAA may already have experienced impotence.
  • Re-intervention (10%)
  • Abdominal wall hernia (5% in 4 years) – this may require wearing a support, or even further surgery.
  • The bowel can block due to abdominal adhesions.
  • Graft limbs can block (2% in 10 years) unexpectedly causing one or both legs to lose the blood supply, this then requires emergency surgery which has a small risk of amputation (2%).
  • Aorto-enteric fistula – a rare complication where the graft erodes into the bowel. This can cause life threatening bleeding or infection.
  • False aneurysm (1% in 10 years) – weakening of the stitch line between the aorta and the graft resulting in a new aneurysm which requires surgery.
  • Aortic graft infection (0.5% in 10 years)
    • Grafts can pick up bugs from the skin at the time of the operation or bugs can later stick to the graft.
    • These bugs slowly multiply over time and can weaken the aorta or cause a collection of fluid around the graft.
    • Such infection can be difficult to diagnose; symptoms can range from feeling tired with flu-like symptoms to being very unwell with bleeding problems.
    • Good dental care may reduce the risk of infection.
    • We rarely need to convert to open surgical repair as we can only 100% treat infection by removing the stent graft.

Long-term outcomes

It is not usually necessary to have long term surveillance of your aorta.

Healthy lifestyle

Adopting a healthier lifestyle and diet will give you the best outcome:

  • Stop smoking
  • Reduce alcohol intake
  • Exercise more regularly
  • Lose weight
  • Control high blood pressure
  • Take statin medication

Where can I find out more about AAA treatment?

The Circulation Foundation
www.circulationfoundation.org.uk

The Vascular Society of Great Britain & Ireland
www.vascularsociety.org.uk

Society for Vascular Surgery (USA)
https://vascular.org/patient-resources

National Institute for Clinical Excellence (NICE)
www.nice.org.uk

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

AAA screening programme: 0117 414 8610

Patient pathway coordinators: 0117 414 0798

© North Bristol NHS Trust. This edition published September 2020. Review due September 2022. NBT002488

Open repair of abdominal aortic aneurysm (AAA)