Thoraco-Abdominal Repair

Aneurysms in the descending aorta generally result from atherosclerosis ("hardening of the arteries") in older patients. Evaluation usually begins with a CT scan or MRI, during which the surgeon carefully checks to see which type of repair may be best.

If an aneurysm is very small, it may not require surgery initially. In fact, most patients who are evaluated for aneurysms do not need surgery. Diagnosis of an aneurysm is a frightening thing to many patients, but in the majority of cases, it is a dilated aorta that can be monitored with CT scans, and will not worsen to a point that requires surgery. The risk of leaving an enlarging aneurysm is that it may reach the point where it spontaneously ruptures causing death.

Almost all operations on the heart will be performed under general anaesthetic. Your anaesthetist will review you before the operation and discuss the anaesthesia and the risks involved. The anaesthetist will outline what lines will be used for the procedure but usually these involve:

• A drip in your arm to put you to sleep
• A radial artery pressure monitoring line in your wrist
• An endotracheal tube (breathing tube) to help your breathing under anaesthesia
• A line in your neck to administer drugs
• A Transoesophageal (TOE) probe to assess your heart during surgery
• A catheter in your bladder
• Pad protection for your eyes

During the procedure a cut (incision) about 25cm long is made in your chest to access your heart. The surgeon uses a heart-lung machine (cardiopulmonary bypass machine) to take over the work of the heart and lungs whilst the thoraco-abdominal surgery is being performed. Occasionally, the patient is cooled to a very low temperature (<15 degrees) so that the circulation can be stopped for a brief period of time – circulatory arrest. This increases the risk of the operation in terms of stroke and overall outcome.

The aorta is replaced with new tubing reattaching the aorta in the chest and abdomen. The procedure is often performed in conjunction with vascular surgeons who perform the reattachment of the abdominal organs. The surgeon will need to reattach the main blood vessels supplying the spinal cord with blood.

Surgery to the heart valve and vessels is usually not required when operating on the thoraco-abdominal aorta alone.

The breastbone is put back together with steel wire until the bone heals itself in 4-6 weeks.

After your operation you will be moved to intensive care for close monitoring until you wake up. The intensive care staff will only wake you once they are satisfied that you are stable. When you wake up you will notice that you still have the various lines inserted by the anaesthetist at the start of the operation but not the TOE probe.

Pain is usually controlled with strong painkillers in the first 24-48 hours after the operation, but most patients find that the chest wound is comfortable after that with only paracetamol required to ease the discomfort.

You will also notice some drains at the bottom of your wound that help monitor any bleeding that invariably happens to a degree after heart surgery as the blood can be very thin and may not clot (stop bleeding) properly after surgery. Occasionally if there is excessive drainage from the tubes before you wake up, then the surgeon may decide to take you back to theatre to reopen the wound and wash out the area around your heart. Whilst the surgeon hopes not to have to do this, it is always safer to do this if needed. The drains are usually removed on the first or second day after the operation.

You may also notice thin wires near the drains called pacing wires. These are often placed onto the surface of your heart at the end of the operation to help regulate the heart rate. They are attached to a device called a pacing box which provides the electrical stimulus to regulate the heart rate during recovery. If they are no longer needed, then they are removed on the third or fourth day after surgery. Occasionally, if they are still needed after four or five days, a permanent pacemaker will be fitted before you leave for home. Your heart surgeon and cardiologist will discuss this with you if needed.

Once your condition is stable, you will be moved to the high dependency unit or the cardiac ward. You should be out of bed in a day or two and return home after a week, with full recovery after two or three months depending on your fitness, age and how complex the operation was.

The goals of treatment for aortic arch repair include restoring:

1. Normal thoraco-abdominal aorta function
2. Normal abdominal organ blood supply

This will ensure that your aorta keeps functioning well and your risk of spontaneous tearing of the aorta, and therefore death, is reduced.

Unfortunately, because the blood supply to the spinal cord may be affected, the risk of paraplegia of the lower body is increased compared to other procedures.

The risks of heart bypass surgery are different from person to person, depending on the severity of heart disease, type of operation, age, and current state of health. You can visit our risk page on this website to help you understand these risks [link].

In many hospitals, after a heart operation, a member of the cardiac rehabilitation team will see you on the ward to give you information about your condition and the treatment you have had.

They will talk to you about making lifestyle changes and how to reduce your risk factors (the things that increase your risk of heart disease) to help protect your heart in the future. You can also ask the rehabilitation staff any questions about your recovery.

There are limited options for treatment of damage to this area of your heart and aorta other than surgery.

1. Medication – If you choose not to want any intervention on your heart then medication can help control a number of the symptoms. Medication may help reduce blood pressure and therefore the stress on the aorta and reduce the risk of further dilatation and rupture. Medication will not treat the aortic disease itself. Many patients, who are very frail, will however benefit from continuing with medication alone.
2. Stenting – Some patients benefit most from repair using a stent, others need traditional open surgery, and still others benefit from hybrid procedures that blend open repair with the use of stent grafts.