Aorta surgery: what it is, when it is essential

By Cristiano Antonino On Apr 20, 2023

Aorta surgery treats problems with the largest artery in your body. Surgery can repair a stretched aorta that is in danger of rupturing

Your doctor can choose from different approaches ranging from open to minimally invasive.

Some people may need emergency surgery, but survival rates are better for planned surgeries that prevent problems.

What is aortic surgery?

Aorta surgery solves problems with your aorta, the largest artery in your body.

Your aorta, which connects to your heart, transports oxygen-rich blood from your heart to the rest of your body.

It goes from your heart to your belly area.

With a high volume of blood flowing through your aorta, its walls can weaken and stretch.

This is an aneurysm.

In addition, hypertension can separate the layers of the aorta wall, which is an aortic dissection.

These problems impair your aorta’s ability to send blood with oxygen to the cells and tissues of your body.

In some cases, the damage is life-threatening.

When do you need aorta surgery?

Your doctor will recommend surgery on an aneurysm if it grows about half an inch in diameter per year.

The timing of surgery for a slow-growing aneurysm varies.

However, many surgeons operate when an aneurysm is between 2 and 2.2 inches because dissections and ruptures are more likely at about 2.4 inches.

You need aortic surgery before the wall of the aorta is in danger of rupturing.

When the wall of the aorta stretches too far, this can lead to aortic dissection.

Many diseases and conditions can cause dilation (widening) of the aorta or aortic dissection (tear), increasing the risk of future life-threatening events.

Conditions that can lead to aortic aneurysm and aortic dissection include

Atherosclerosis (hardening of the arteries).
Hypertension (high blood pressure).
Genetic conditions (such as Marfan syndrome).
Connective tissue disorders.
Injury.

Aortic surgery treats different types of aortic aneurysms (weakened and protruding arterial walls in the aorta).

An aneurysm can develop anywhere along the aorta, such as:

In the part that runs through the abdomen (abdominal aortic aneurysms).
In the chest (thoracic aorta aneurysms). These may involve your aortic root (the section of the aorta that is attached to your heart), ascending aorta, aortic arch or descending aorta.
Both in the abdomen and in the chest (thoracoabdominal aortic aneurysms).
Aortic surgery also treats aortic dissection or separation of the layers of the aortic wall.
Blood flows through a tear in the inner layer of the aorta.

This is a life-threatening condition.

Even people born with rare heart diseases such as coarctation (narrowing) of the aorta or transposition (inversion) of the great arteries need aortic surgery.

Others need surgery for a problem with their aortic valve.

How important is aorta surgery?

Aorta surgery is important because the aorta sends oxygen-rich blood from your heart to your entire body.

Your body relies on a fully functioning aorta.

Like many things in medicine, aorta operations tend to go better when they are not delayed too long.

For example, survival rates are good when operating on an aneurysm before it ruptures.

How is aortic surgery performed?

Depending on your situation, your doctor may perform your aortic surgery:

Splitting the sternum (open-heart surgery).
Cutting between the ribs (thoracotomy).
Passing through the blood vessels (minimally invasive or endovascular method).

Endovascular means that your surgeon performs your operation inside your body using thin, long tubes called catheters.

Through small incisions in your groin, your provider uses the catheters to guide a stent graft through your blood vessels to the site of the aneurysm.

An endovascular stent graft is a small wire mesh tube (also called a scaffold) that reinforces the weak spot in the aorta.

By firmly sealing the area with the artery above and below the aneurysm, the graft allows blood to flow through it without pushing on the aneurysm.

Advantages of endovascular repair of thoracic aneurysms include:

Generally less painful than open-heart surgery.
Lower risk of complications compared to traditional open-chest surgery due to smaller incisions.
Better option for people who are not candidates for open-chest surgery, which has higher risks.
Shorter recovery time.

What happens before aorta surgery?

Inform your provider about all the medicines you take, even those without a prescription.

They may ask you to stop taking some of them for a certain period of time before surgery.

Go to any appointments required by your provider, e.g. for an electrocardiogram, imaging or blood test.

This gives them valuable information they will need for your surgery.

Ask someone to drive you to and from the hospital.

You may also want someone to stay with you for the first few days after you return home from the hospital.

Ask your employer if you can receive disability cover during your recovery.

Get instructions on how to prepare yourself, such as when to stop eating the night before surgery.

How long does aorta surgery take?

The time required for aorta surgery depends on the procedure you are undergoing, among other factors.

An abdominal aortic aneurysm surgery takes three to six hours.

However, if it is performed using an endovascular method, two to five hours are required.

Examples of other surgery times:

An endovascular thoracic aorta repair: about two hours.
A more complex repair: three to eight hours.
An aortic dissection repair: six hours.

What happens during aortic surgery?

Your surgical procedure depends on the type of problem you have with your aorta and the method used by your provider.

Surgery for aortic aneurysms

If you have an aneurysm, your surgeon will replace or strengthen the elongated part of your aorta.

They use a synthetic tissue such as Dacron to replace or repair the blood vessels.

Aneurysm in the ascending aorta: For an aneurysm in the ascending aorta (ascending towards the head), the surgeon can use a tube graft to replace the damaged section. They get there through a sternotomy or by cutting the sternum. They will also use this approach to operate on your aortic arch, a curved part that goes up towards your neck.

Depending on the location of the aneurysm, the surgeon will have to replace or repair the aortic valve and/or the aortic root near the valve.

Aneurysm in the descending thoracic aorta: If your aneurysm is in the descending thoracic aorta, which goes towards your stomach, your provider can reach it through a cut between the ribs (thoracotomy). They can also perform the repair by inserting a stent through the arteries and placing it inside the aneurysm. This is an endovascular thoracic aortic repair.

Ascending and descending aortic aneurysm: complex aortic procedures treat people with aneurysms that require replacement of the aorta from the aortic valve to the aortic bifurcation (where the aorta separates into two).

Generally, if your aneurysm extends from the aortic root to the aortic bifurcation, your surgeon operates on the aortic root, the ascending aorta, and the arch (the initial part of the aorta as it exits the heart) as the first stage.

Then, after recovery, the surgeon plans a second stage for the remaining descending thoracic and abdominal aneurysm.

This is not always the case.

Sometimes they have to customise their approach for each person.

During the procedure, the axillary artery (the part of the main artery in the arm) provides blood flow to the body’s organs.

Surgeons can perform descending aortic aneurysm repairs involving the thoracic and abdominal aorta (also called thoraco-abdominal aneurysm) through a single operation using combined incisions in the chest and middle abdomen.

In the first stage, the surgeon can replace the aortic valve, ascending aorta and arch.

They place a tubular ‘elephant trunk’ graft that hangs in the descending aorta.

They will use it later in a second phase as a proximal attachment.

The second phase involves the repair of the thoracoabdominal aneurysm, which surgeons traditionally perform by making an incision in the chest and abdomen to fix the aorta up to the aortic bifurcation (up to the legs).

More recently, as part of the second stage, they first deploy stents in the descending thoracic aorta to facilitate the thoraco-abdominal component.

In cases where the aneurysm extends from the root to the descending thoracic aorta above the abdominal aorta and its branches to the abdominal organs, the second phase involves only an endovascular approach.

They deploy stents in the ‘elephant trunk’ up to the ‘normal’ abdominal aorta.

Aortic root aneurysm: David’s valve-sparing aortic root replacement method and its modifications repair aortic root aneurysms while preserving the aortic valve. They can use a bioprosthetic valve (a valve made of organic material) if your aortic valve is unusable.

Surgery for aortic dissection

If you have an aortic dissection in the aortic root or ascending aorta, you will need emergency surgery.

Your surgeon will cut the sternum (sternotomy).

They will use a heart-lung machine to manage breathing and blood circulation.

They will use a tissue graft to replace a damaged ascending aorta.

It may also be necessary to replace the aortic valve, aortic root or aortic arch.

Some people may be able to obtain an aortic dissection repair without a sternal incision if the dissection does not involve the root, ascending aorta or aortic arch.

With an endovascular thoracic aortic repair, the surgeon works a stent graft through the arteries to place it in the descending thoracic aorta.

What happens after aortic surgery?

You start in the intensive care unit. You may wake up there and have a breathing tube in your throat.

They will remove it when you can breathe on your own.

When you are able to do that, you will start walking a little bit.

You will move to another room when you no longer need to be in the intensive care unit.

You will talk to your provider about going home when you have met the criteria for discharge.

What are the advantages of aorta surgery?

Aortic surgery can save your life.

It can prevent rupture of an aneurysm.

What are the risks or complications of aorta surgery?

Complications vary depending on the type of aorta surgery you have.

For aortic dissection repair, complications include:

Bleeding.
Stroke.
Heart attack.
Renal failure.
Leg paralysis and ischaemia.
Breathing problems.
Blood clots.
Intestinal ischaemia.

Complications of aneurysm repair include:

Bleeding.
Breathing problems.
Kidney problems.
Leg paralysis.
Blood clots.

How long does it take to recover from aorta surgery?

After aortic surgery for an aneurysm, people generally spend a week in hospital.

In addition, they need at least a month to recover.

If you have minimally invasive surgery, you may only be in hospital for one or two days.

After aortic dissection, you can expect to stay in hospital for about a week. However, if you have complications, it may take three or four weeks.

What is the survival rate for aortic surgery?

The survival rate for aortic surgery depends on the type of surgery and other factors.

Survival rates for aortic surgery are better for elective (preventive) surgery than for emergency surgery.

For an abdominal aortic aneurysm, 99% of people survive 30 days after elective endovascular repair.

The 30-day survival rate ranges from 96% to 98% for surgical removal of the same aneurysm.

However, only 50% to 70% survive surgery after aneurysm rupture.

Survival rates for ascending aorta and aortic arch aneurysms were 81% to 95% after one year.

After eight to ten years, they were 60% to 73%.

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Source

Cleveland Clinic