Minimally Invasive Aortic Aneurysm Surgery
An aneurysm is the term used to describe a localized ballooning of an artery or the wall of the heart due to the loss of elasticity in that area. As a result of high blood pressure, the weakened wall of an artery or the heart expands outward, appearing as a bubble when viewed externally. If the ballooned tissue stretches excessively under pressure, the aneurysm sac can rupture, leading to life-threatening bleeding.
Cardiac aneurysms most commonly occur after a heart attack, usually in the left ventricle, where blood pressure is highest and heart attacks are most frequent. When a heart attack affects a region of the heart, the muscle tissue in that area loses viability. Over time, this tissue thins, weakens, and is replaced by non-contractile fibrous tissue (scar tissue). Pressure on this weakened area can lead to aneurysm formation. Because this region of the heart no longer contracts, the size of the aneurysm can contribute to heart failure. Another potential problem is the development of arrhythmias. Since the inner surface of the aneurysm loses its normal heart tissue characteristics, blood clots can form, which may break off and obstruct arteries supplying the brain, arms, or legs.
Aneurysms can develop in arteries throughout the body. The most common site is the aorta, the main artery of the body, and these are called aortic aneurysms. Depending on the segment of the aorta affected, symptoms may vary. Aneurysms in the chest portion of the aorta are generally referred to as thoracic aortic aneurysms (TAA), while those in the abdominal portion are called abdominal aortic aneurysms (AAA). These typically occur below the renal arteries.
Cerebral aneurysms are aneurysms of the arteries supplying the brain. Rupture of these aneurysms can result in brain hemorrhage, stroke, or death.
The main factors predisposing to aneurysm formation include congenital disorders (such as Marfan syndrome or Ehlers-Danlos syndrome), infections, long-term uncontrolled hypertension, smoking, and atherosclerosis. In many patients, aneurysms coexist with cardiovascular conditions such as hypertension and atherosclerosis. Within the aneurysm sac, the inner surface of the vessel loses its normal tissue characteristics, promoting clot formation. These clots may break off and block arteries supplying vital organs, arms, or legs.
Symptoms
The symptoms of an aneurysm vary depending on its type, location, and size. Symptoms typically arise from pressure exerted by the aneurysm sac on nearby organs, nerves, or blood vessels.
Types of aneurysms based on location:
Sections of the Aorta
The ascending aorta refers to the portion of the aorta from its origin at the heart up to the section called the aortic arch. This segment also includes the aortic valve, where the aorta emerges from the heart.
The aortic arch (arcus aorta) gives rise to three major arteries supplying the brain and arms, then continues downward through the chest cavity. The portion of the aorta extending from the arch to the diaphragm is called the thoracic aorta.
Below the diaphragm, the aorta enters the abdominal cavity and is referred to as the abdominal aorta. Branches supplying the abdominal organs emerge from this section. Around the level of the navel, the abdominal aorta bifurcates, giving rise to branches that supply the pelvis and both legs.
Aneurysms can develop in any of these segments individually or in multiple sections simultaneously. They are classified based on the aortic region in which they occur.
Ascending Aortic Aneurysm
These types of aneurysms are often detected during evaluations for aortic valve insufficiency. The aneurysm may extend up to the aortic arch and, in some cases, involve the entire arch.
Common symptoms include hoarseness, dry cough, chest pain, and shortness of breath. Once the aneurysm reaches a certain size, intervention is necessary to prevent spontaneous rupture.
The most commonly performed treatment today involves completely removing the aneurysmal sac and sewing an artificial graft (usually a Dacron graft) to the healthy portion of the aorta.
Surgical Treatment
The surgical management of ascending aortic aneurysms depends on the extent of the aneurysm. If aortic valve insufficiency is present, the valve may need to be repaired or replaced. When the aneurysm extends to the aortic arch, this portion is also replaced with a graft, and the vessels supplying the brain and arms are anastomosed to the graft.
During the procedure, the patient is typically placed on a heart-lung machine, and their body is cooled to around 18 °C for a period while blood circulation is temporarily stopped.
Postoperatively, patients usually remain in the intensive care unit for at least two days to ensure all vital functions stabilize. The duration may vary depending on the individual’s recovery. After stabilization, patients are transferred to a regular hospital room and, on average, can return home after about a week with instructions for continued rest and care.
Thoracic (Descending) Aortic Aneurysm
After giving off the artery supplying the left arm (left subclavian artery), the aorta descends through the chest cavity. Aneurysms involving this section are referred to as thoracic aortic aneurysms.
The most common symptom reported by patients is back pain, which can be felt in the left shoulder, chest, or between the shoulder blades (scapulae). Most patients also have uncontrolled hypertension.
When the aneurysm reaches a certain diameter, intervention is necessary to prevent sudden rupture and life-threatening bleeding.
Surgical Treatment
The surgical approach for thoracic aortic aneurysms varies depending on the extent of the aneurysm. In some cases, the use of a heart-lung machine may be required. Typically, this system is employed without stopping the heart, aiming to reduce cardiac stress and maintain blood flow to vital abdominal organs.
The aneurysm sac is completely removed and replaced with an artificial graft (usually a Dacron graft). If the resected section includes arteries supplying the spinal cord or abdominal organs, these vessels are also reattached to the graft. Because this part of the aorta supplies the spinal cord, one of the most concerning complications of this surgery is partial paralysis. Therefore, postoperative intensive care is critically important.
After surgery, patients generally stay in the intensive care unit for at least 2 days, during which all vital functions are closely monitored and stabilized. Following this period, patients are transferred to a standard ward and, typically within a week, discharged with recommendations for ongoing rest and care, depending on their recovery and any complications.
With the advancements in modern technology, many of these aneurysms can now be repaired without open surgery. In suitable patients, endovascular techniques allow aneurysm repair without traditional surgery. Detailed information on these methods can be found in the “Endovascular Methods” section.
Abdominal Aortic Aneurysm (AAA)
An abdominal aortic aneurysm is a pathological dilation of the aorta within the abdominal cavity. It most commonly occurs distal to the renal arteries that supply both kidneys, though in rare cases it can involve the renal arteries or other branches supplying abdominal organs.
The most frequent symptom is back pain caused by the aneurysm pressing on the spine and surrounding tissues. In thin patients, a pulsating mass that corresponds with the heartbeat may be felt in the abdomen, which is considered the most characteristic finding.
Once the aneurysm reaches a critical size, intervention is essential to prevent sudden rupture, which can be life-threatening.
Surgical Treatment
The standard surgical treatment for an abdominal aortic aneurysm involves completely removing the aneurysmal sac and replacing it with a synthetic graft, usually a Dacron graft. If the aneurysm involves the iliac arteries that supply the pelvic organs and both legs, a bifurcated “pants” graft is used. In this case, the graft limbs are connected to the femoral arteries in the groin region.
After surgery, patients typically stay in the intensive care unit for one day. If no complications arise, they are transferred to a regular hospital room and can usually be discharged within 5–7 days with instructions to continue their recovery at home.
Thanks to advances in modern technology, these aneurysms can also be repaired without open surgery. In suitable patients, endovascular techniques allow aneurysm repair without the need for traditional surgery. More detailed information on this approach can be found in the “Endovascular Methods” section.
Minimally Invasive Aortic Aneurysm Surgery
"Aneurysm is the term used to describe a localized ballooning of an artery or the wall of the heart due to the loss of elasticity in that area."
Minimally Invasive Aortic Aneurysm Surgery
Cardiac aneurysms most commonly develop after a heart attack. They are usually seen in the left ventricle, where blood pressure is highest and heart attacks occur most frequently.