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Descending aortic surgery
The aorta is the main artery of the human body, responsible for distributing oxygenated blood after it leaves the heart. Its birth occurs at the exit of the left ventricle of the heart. The aortic valve separates both structures. The descending aorta is divided into:
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Descending thoracic aorta: it is the portion between the aortic arch and the diaphragmatic area. It gives rise, among others, to arteries that supply the spinal cord and the thoracic wall.
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Abdominal aorta: it is the final section of the aorta that runs between the diaphragmatic area and the aortic bifurcation, where it divides into the right and left common iliac artery. Branches of the abdominal aorta are the arteries that supply the abdominal viscera (liver, stomach, spleen, pancreas, intestines ...) including the celiac trunk and the superior and inferior mesenteric arteries.
What are the most common diseases of the descending thoracic and abdominal aorta?
An aneurysm is a dilation of a blood vessel. When a patient has a descending thoracic or abdominal aortic aneurysm, if it is larger than a certain size, they are at risk of rupture or dissection of the aorta. Abdominal aortic aneurysms can be infrarenal if they lie below the renal arteries (most common) or juxtarenal if they are encompassing the renal arteries.
An aortic dissection is the separation of the layers of it by blood entering between them, with the consequent risk of rupture. It may be acute or chronic.
When there is a potential risk of a sufficiently great aortic rupture, a treatment must be instituted, which will be surgical or endovascular, depending on the disease that the patient presents, its time of evolution, the location of the aneurysm, the age and other comorbidities that present.
What does the intervention consist of?
Surgery of the descending thoracic and abdominal aorta can be open, thus consisting in the replacement of the diseased section of aorta with a graft of prosthetic material. The approach route will depend on the section of the diseased aorta. In the case of thoracic aneurysms, it will be through an incision on the left side. In the case of infrarenal abdominal aneurysms, the preferred approach is usually the median laparotomy (longitudinal incision along the abdomen). In juxtarenal aneurysms, we usually use a retroperitoneal approach, which allows access to the upper portion of the abdominal aorta.
In other cases, it may be more convenient to perform endovascular surgery, consisting of introducing a prosthesis folded into a catheter (endoprosthesis) from the femoral vessels of the groin and under fluoroscopic vision, which is released in the diseased section, sealing that area from the inside. It is a technique especially indicated in elderly patients or patients with diseases that advise against open surgery. Currently this technique is performed routinely in collaboration with a vascular radiology team.
Who is in the operating room during the intervention?
During an aortic intervention, a highly trained group works as a team. The following is a list of the people who are in the operating room during an aortic procedure.
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The cardiovascular surgeon, who leads the surgical team and performs the intervention.
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The assistant cardiovascular surgeons.
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The vascular radiologist, specialized in the management of fluoroscopy equipment and in the interpretation of the images generated by them, in the event of an endovascular intervention.
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The cardiovascular anesthesiologist, who administers the medications that make the patient sleep during the intervention (anesthesia). It ensures that the patient receives the correct amount of drug during surgery and is in charge of controlling the monitors that monitor the patient's condition during the operation.
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The perfusionist, who controls the heart-lung machine, if it is needed.
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Cardiovascular nurses, who have received specific training to help during the intervention.
Before the intervention
Except in urgent cases, the intervention will be carried out on a date suitable for you and with the availability of an operating room by the surgeon. You should inform him of your recent health status including if you have had a cold, tooth decay, or fever. Remember to bring the medications you are taking or have taken in recent days to the Hospital. You will probably enter the day before or the morning of the intervention.
You will need to bathe with an antiseptic solution and the area near the surgical field will be shaved. With this we avoid future infections. You will remain fasting for 6 hours prior to the intervention, in order not to suffer anesthetic complications. For this same reason, it is advisable that in case of smoking, do not do so for at least two weeks prior to the intervention.
After admission, an electrocardiogram, a blood test and a chest X-ray will be performed (if not already done).
As part of your pre-anesthetic medication, you will likely be given a sedative to help you relax before going to the operating room. Once in the operating room, you will be given a route through which to administer anesthetic drugs. You probably do not remember this after the intervention.
During the intervention
Once you are asleep, a series of tubes and probes will be inserted:
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Endotracheal tube: allows connection to a respirator during surgery
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Bladder catheter: it is introduced through the urethra and reaches the urinary bladder, which allows urine to be collected during the intervention, preventing the bladder from filling up and making it possible to know the functioning of the kidneys.
If the use of extracorporeal circulation is required, during the intervention you will be administered heparin, an anticoagulant that prevents the blood from clotting while you are being operated on. Before ending the intervention, an "antidote" is administered, protamine, which reverses this action.
In cases of endovascular surgery, this can be carried out using spinal or even local anesthesia with sedation, not requiring an endotracheal tube or bladder catheter.
Postoperative
Initially, you will be admitted to the intensive care unit (ICU) where you will wake up between 3 and 9 hours after the end of the operation if you were not awakened in the operating room.
Life after an intervention on the descending thoracic and abdominal aorta:
After this intervention, recovery may take a variable time depending on the initial disease and the state of health that occurred before the operation. In some cases, you must keep a relative rest after the intervention.
You will also need to continue taking drugs in some cases. This also depends on the initial disease. You will need to closely monitor and control your blood pressure figures.
In 4 to 6 weeks you will be able to return to an office job. In case your job requires physical exercise or significant stress, this time may be extended or even require a leave or change of employment in extreme cases.
In cases of endovascular surgery, recovery can be much faster, and you can return to your daily activities after the wounds have healed.