Endovascular Stent Graft Repair

What is an endovascular stent graft?

An endovascular stent graft is a tube composed of fabric supported by a metal mesh called a stent.  It can be used for a variety of conditions involving the blood vessels, but most commonly to reinforce a weak spot in an artery called an aneurysm. Over time, blood pressure and other factors can cause this weak area to bulge like a balloon and eventually enlarge and rupture. The stent graft seals tightly with your artery above and below the aneurysm. The graft is stronger than the weakened artery and allows blood to pass through it without pushing on the bulge. Physicians typically use endovascular stent grafting to treat abdominal aortic aneurysms (AAAs), but they also use it to treat thoracic aortic aneurysms (TAAs) and less commonly, aneurysms in other locations.

Aneurysms often affect the aorta, your body’s largest artery. Your aorta carries blood away from the heart and runs from your heart through your chest and abdomen. The normal diameter of the aorta in the abdomen is about 2 centimeters, which is a little less than 1 inch. An aneurysm forms if the aorta grows to more than 1½ to 2 times its normal diameter.

Aortic aneurysms are potentially serious health problems.. Endovascular stent graft repair is designed to help prevent an aneurysm from bursting. The term “endovascular” means "inside blood vessels." To perform endovascular procedures, vascular surgeons use special technologies and instruments.  Generally, endovascular treatments allow you to leave the hospital sooner and recover more quickly, with less pain and a lower risk of complications than traditional surgery, because the incisions are smaller.

Surgical Overview

As the procedure begins, you will receive a sedative and a regional anesthesia, or general anesthesia. Your vascular surgery team will clean your skin and shave hair around the insertion points to help decrease your chances of infection. An incision will then be made into the skin overlying the femoral artery in your groin. Your vascular surgeon threads a guide wire into your femoral artery and advances it to the aneurysm. Because you have no nerve endings inside your arteries, you will not feel the wires or catheters as they move through your body.

Using x rays that appear as moving images on a screen, your vascular surgeon inserts a catheter over the guidewire. The catheter carries a compressed form of the graft so it can move through your blood vessels. When the graft has reached the aneurysm site, your physician withdraws the catheter, leaving the graft in place. The graft expands to fit snugly against the walls of your artery. Often additional components of the graft are placed in a similar fashion through incisions in each groin to extend to the arteries supplying each leg.

Usually you will spend 2 to 3 days in the hospital. During the first recovery day you will be permitted to eat and encouraged to walk.

After you leave the hospital, you should not drive until your physician approves. You may be permitted to shower but should avoid soaking your groin incisions until they have healed. You should also avoid lifting more than about 5 to 10 pounds for approximately 4 to 6 weeks after the procedure.

Your physician will instruct you to return for a follow-up visit after about 7 to 10 days. At that visit, your physician will check your incisions and assess your overall condition.

You will undergo follow-up imaging tests 1 month and 3-6 months after the procedure to ensure that the stent is still functioning without significant problems and in the proper location.   After that, you will probably undergo yearly imaging tests if your aneurysm is shrinking and no problems are found.

Risks

If you have kidney disease called chronic renal insufficiency, your chances of complications from endovascular stent grafting may be increased. If you have an unfavorable aneurysm shape, blockages in arteries near the aneurysm, or have already had an AAA repaired, you also may be at increased risk for complications. Other conditions, such as heart or lung disease, may also increase the risk for treatment.

Other potential complications following endovascular stent grafting include:

• Leaking of blood around the graft
• Infection
• Movement of the graft away from the desired location
• Graft fracture
• Blockage of the blood flow through the graft

Endovascular stent grafts can sometimes leak blood through the areas where the graft components join together, or they can allow blood to leak back into the aneurysm sac through small arteries feeding the aneurysm sac. These leaks are called "endoleaks". Some of the leaks stop by themselves and are not dangerous.  Other endoleaks need to be treated immediately. These leaks can even occur years after your procedure and can be dangerous if the aneurysm continues to enlarge.  Because of this, physicians require their patients to undergo periodic surveillance with CT scans for the rest of their life to detect and treat problems before they become threatening.

Since problems with the graft or endoleaks can occur even years after successful placement, it is important to comply with the follow-up regimen advised by your vascular surgeon.

What you can do to stay healthy

To help with the long-term results of endovascular stent graft repair of AAA, you may need to change your lifestyle.  Recommended changes include:

• Maintain a diet low in cholesterol, fat, and calories
• QUIT smoking
• Regular aerobic exercise (20-30 minutes, 5x a week)
• Maintain your ideal body weight

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