Aneurysms, Dissections, and When to Intervene
Types of Aortic Disease
The aorta - the main artery carrying blood from the heart to the body - can develop life-threatening conditions that require carefully timed surgical or endovascular intervention.
Abdominal Aortic Aneurysm (AAA):
- Localised dilation of the abdominal aorta (typically below the renal arteries)
- Present in approximately 2-8% of men over 65 and is usually asymptomatic until rupture
- Current guidelines recommend elective repair when the AAA reaches 5.5 cm (men) or 5.0 cm (women), or when growth rate exceeds 1 cm per year
- Ruptured AAA carries 90%+ mortality without immediate surgery; elective repair - 1-2%
Thoracic Aortic Aneurysm (TAA):
- Involves the ascending aorta, aortic arch, or descending thoracic aorta
- Can be associated with bicuspid aortic valve, Marfan syndrome, or atherosclerosis
- Intervention threshold: ascending aorta >5.5 cm (or >5.0 cm in connective tissue disease or combined with valve surgery); descending >6.0 cm
Thoracoabdominal Aortic Aneurysm (TAAA):
- Extends from thoracic into abdominal aorta
- Complex repair involving spinal cord protection strategies (CSF drainage, intercostal re-implantation)
Type B Aortic Dissection (Chronic):
- A tear in the thoracic aortic wall creating a true and false lumen
- Type A dissection (involving the ascending aorta) is a surgical emergency - handled immediately; Type B is managed medically or with TEVAR for complicated cases (malperfusion, expansion, persistent pain)
- Elective TEVAR for suitable Type B dissection to prevent long-term enlargement of the false lumen
EVAR, TEVAR, and Fenestrated/Branched Devices
Endovascular vs. Open Aortic Repair
The choice between endovascular and open repair depends on aortic anatomy, patient fitness, and centre expertise.
EVAR (Endovascular Aneurysm Repair) - for AAA:
- Stent graft delivered via femoral artery catheters; deployed inside the aneurysm sac to exclude it from circulation
- Requires adequate proximal neck (length >15 mm, angulation <60-) and iliac access vessels of sufficient calibre
- Hospital stay: 2-4 days; recovery 1-2 weeks vs. 5-7 days / 4-6 weeks for open surgery
- Annual CT surveillance required post-EVAR to monitor for endoleak and sac expansion
TEVAR (Thoracic Endovascular Aortic Repair) - for TAA and Type B dissection:
- Covered stent graft deployed in the thoracic aorta via femoral artery access
- Particularly well-suited for descending thoracic aneurysms; landing zones must avoid critical vessels (left subclavian artery - may require re-routing if proximal landing zone needed)
- Spinal cord protection: staged procedures, CSF drainage for extensive coverage
Fenestrated EVAR (FEVAR) and Branched EVAR (BEVAR):
- Custom-manufactured devices with fenestrations or branches for the renal arteries and visceral vessels
- Extends endovascular repair to juxtarenal and pararenal AAA where standard EVAR cannot provide adequate seal zone
- Available at specialist centres with planning and manufacturing lead time (4-6 weeks for custom device)
Open Aortic Repair:
- Midline or flank incision; aorta clamped; dacron graft sewn end-to-end
- Required for hostile necks, atheromatous access vessels preventing catheter delivery, young patients with long life expectancy (no endoleak risk), or when aortic valve or visceral vessels need simultaneous reconstruction
- Remains the gold standard for complex thoracoabdominal disease
CT Angiography Planning to Hotel Discharge
Operative Planning, Procedure, and Recovery
Pre-operative planning:
- High-resolution CT angiography of the entire aorta (aortic protocol): 3D reconstruction and device sizing
- Vascular team case conference: approach selection, device selection (EVAR/TEVAR vs. open)
- Cardiac assessment for open surgery: coronary angiogram if significant risk factors
- Anaesthesia review: regional vs. general, planned monitoring requirements
EVAR/TEVAR procedure:
- Femoral artery access (bilateral groin cut-down or percutaneous)
- Fluoroscopic guidance - intraoperative angiography confirms position before deployment
- Stent graft deployed and ballooned to seal
- Completion angiogram checks for endoleak
- Duration: 2-3 hours; general or spinal anaesthesia; ICU overnight then ward
Open AAA repair:
- General anaesthesia; arterial line; urethral catheter; central venous access
- Midline laparotomy; aorta approached retroperitoneally
- Clamp above/below AAA; graft sewing; clamps removed sequentially
- Duration: 3-5 hours; post-op ICU 1-2 days
- Hospital 5-7 days
Recovery and follow-up:
- EVAR: 10-14 days hotel recovery - fly home; CT at 1 month, 6 months, and annually via home radiologist
- Open repair: 14 days hotel - fly home; heavier activity restriction 6 weeks
- All CT reports and device sizing documentation provided for home vascular surgeon surveillance
Cost guide:
- EVAR Turkey: -14,000-22,000 all-inclusive; UK NHS waiting list; UK private: -20,000-40,000
- Open AAA repair Turkey: -12,000-18,000; UK private: -25,000-45,000