An abdominal aortic aneurysm (AAA) is a bulge in the aorta (the aorta is the main blood vessel coming from the heart that supplies blood to all organs) in your abdomen. Aneurysms may occur in any blood vessel in the body, but the most common place is the abdomen below the renal arteries (blood vessels that provide blood to your kidneys). The aneurysm may continue to grow larger until, like a balloon, it bursts or “ruptures”. The larger an aneurysm becomes, the easier it grows. Aneurysm rupture can be a life-threatening event.

The goal of all aneurysm operations is to prevent the aorta from rupturing.  A normal aorta below the renal arteries measures about 2.3 cm in diameter (1 inch) in men and 1.9 cm in diameter in women, but varies with age and body size. An aorta is considered aneurismal when it grows more than 50% over its normal size. Aneurysms are four times more common in men than women and occur most often after 60 years of age.


Aneurysm rupture affects approximately 15,000 people per year making it the 13th leading cause of death in the U.S. The incidence of aortic aneurysm disease is increasing as the population ages in general. Early detection and diagnosis is increasingly possible as more sophisticated medical screening methods become available.

Causes and Symptoms of Aneurysms

Aneurysms are caused by a weakening or damage in the wall of a blood vessel.
There are many things known to contribute to the weakening of the artery wall such as:

Atherosclerosis (hardening of the arteries)
Cigarette smoking
High blood pressure
Inflammation or infection

Three out of four aneurysms show no symptoms at the time they are diagnosed. However, a rapid growth or rupture of an abdominal aortic aneurysm may cause intense back or abdominal pain and signs of shock such as shaking, dizziness, fainting, sweating, rapid heartbeat, and sudden weakness.

Diagnosis of Aneurysms

Aneurysms are most often found during a routine physical exam or when a doctor examines your heart, gallbladder, or kidneys. An abdominal aortic aneurysm can be felt as a pulsating mass at about the level of the belly button.

Test used to evaluate aneurysms are:

Ultrasound, which uses sound waves read by a probe that moves along the top of your abdomen

CT (computerized tomography) scan, which uses special x-rays and contrast dye to show your blood vessels

MRI (magnetic resonance imaging), which uses radio waves and a strong magnet to show your blood vessels

Arteriogram, which uses x-ray and contrast dye to show blood flow through your blood vessels

Treatment of Aortic Aneurysms: Two Options

Abdominal aortic aneurysms can be surgically treated either with traditional open surgery or with a minimally invasive repair known as endovascular procedure, meaning “within the blood vessels.”

Open Surgery

Traditional open surgery requires a large incision in the abdominal wall, from just below your breastbone to the top of your pubic bone. The muscles are then divided and the intestines and internal organs of the abdomen are pulled aside. The aorta is in the back of the abdominal cavity, just in front of the spinal column. The aorta is clamped and the aneurysm is cut open to reveal any plaque and clotted blood inside. This degenerative tissue is removed. The aortic graft is then sewn to the healthy aortic tissue above and below the weakened area so that, when finished, it functions as a bridge for the blood flow.

After the aortic graft has been sewn in place and all bleeding spots controlled, the aneurysm sac which has been opened along its length is sewn back up loosely over the new graft. This prevents the new graft from rubbing against the intestine, which can damage the intestinal wall. With graft now enclosed in the old aneurysm sac, the abdominal contents are allowed to return to their normal position. The muscle wall of the abdomen is then sewn back together and finally the skin is sewn or stapled back together.

Endovascular Procedure

The endovascular procedure requires two small incisions in the groin. Using an x-rays imaging device, a delivery catheter (tube) containing a vascular graft is guided up through a blood vessel in your leg into your aorta and the graft is placed inside your aneurysm. The graft contains metal hooks at either end that are used to secure it inside your aorta.

The main differences between traditional open surgery and the endovascular procedure are in the way the graft is placed inside your aorta and the way it is attached to the walls of your aorta. If you have to have the traditional open repair performed, you may experience more complications.



The Benefits of the Endovascular Procedure

Endovascular repair has several advantages when compared to traditional open surgery, including a significant reduction in medical complications. In clinical trials, and its use since approval by the FDA, endovascular procedures have reduced the occurrence of the most serious medical complications, including:

Myocardial Infraction (heart attack)
Arrhythmia (irregular heartbeat)
Congestive Heart Failure
Blood Loss during surgery

Shorter Hospital Stay The hospital recovery from traditional open surgery averages six days, with at least 24 hours in an intensive care unit. If no complications arise, the hospital recovery is generally a process of waiting for the intestines to recover so that normal eating and digesting can begin again. The hospital recovery of an AAA endovascular repair procedure usually last two days and fewer patients require time in intensive care.

As with any medical device or procedure, both traditional open surgery and endovascular procedures have risks in addition to benefits. You should discuss the risks and the benefits with your doctor.

Carotid Artery Surgery

Your doctor has told you that you may need surgery for a carotid artery problem. The two carotids arteries are blood vessels in the neck that supply oxygen-rich blood to your brain. When one of these vessels becomes narrowed, your brain can’t get enough oxygen. This can lead to a stroke.



Symptoms of a Stroke or Mini-Stroke

If blood flow to part of your brain stops, even very briefly, you may have symptoms of a stroke or “mini-stroke”. Seek medical help right away, even if the symptoms last for only a moment.  Although there are no symptoms specific to carotid artery disease, the warning signs of a stroke are a good way to tell if there is a blockage in the carotid arteries. Transient ischemic attacks (TIAs) are one of the most important warning signs that you may soon have a stroke. Sometimes called "mini-strokes," TIAs are temporary episodes of headache, dizziness, tingling, numbness, blurred vision, confusion, or paralysis that can last anywhere from a few minutes to a couple of hours. See a doctor right away if you or someone you know has the symptoms of a TIA.

Other signs or symptoms of a carotid artery blockage may be

A facial droop
Dizziness, confusion, fainting, or coma.
Loss of eyesight, or blurry eyesight in one eye.
Numbness or tingling of your arm, leg, or face on one side of your body.
Slurring your words
Trouble swallowing
Weakness or paralysis of your arm, leg, or face on one side of your body.

Reducing Your Risk

Carotid endarterectomy is a surgery to reopen a narrowed carotid artery. If you’ve had symptoms of a stroke, you may need surgery right away. If you haven’t had symptoms, your doctor may watch your problem over several months before deciding to operate.

What Can Cause a Stroke?

A healthy carotid artery is open, allowing blood to flow to the brain. But if the inside of the artery becomes narrow and rough, a stroke is more likely to occur. Certain health problems can cause narrowing and roughness. As the problem worsens, your risk of having a stroke can grow.

Open Carotid Arteries

The inside of the artery is open and has no signs of narrowing.
The inside of the artery walls is smooth and healthy.
Blood flows from your heart to your brain without any problems.
Your brain gets all the blood and oxygen it needs.

Narrowed Carotid Arteries

High blood pressure, diabetes, and other health problems can cause a fatty substance called plaque to build up on the inside of the artery walls. Lifestyle choices such as smoking and a fatty diet can also cause plaque to build up.

The path through the artery is narrowed by plaque buildup.

Plaque buildup makes the wall of the artery rough. This can cause blood clots to forms.

Narrowed arteries can prevent some parts of your brain from getting enough blood and oxygen to work normally.

The Dangers of a Narrowed Carotid Artery

Tiny blood clots and bits of plaque can break off and travel through the carotid artery. These are called embolus. Emboli can enter the smaller vessels in your brain. If the emboli are large enough, they can block blood flow and cause a stroke.

If you Have a Min-Stroke (TIA)

Smaller emboli can briefly interrupt blood flow in parts of the brain. This causes a "mini-stroke", also called a TIA (transient ischemic attack). It can last from a few moments to a full day. TIAs are very serious. They can be a warning sign of a stroke. Symptoms of a TIA and a stroke are the same. Get medical help right away.

If You Have a Stroke

Larger emboli can cut off blood flow to parts of the brain. This causes a stroke. Without oxygen-rich blood, that part of the brain dies. Symptoms after astroke depend on which part of the brain was affected. Some people have trouble walking after a stroke. Others can't speak. And in some cases, a stroke can kill. All strokes require emergency medical care.

Tour Medical Evaluation

Your doctor will evaluate you to learn more about your carotid artery problem. Depending on the results, you may have other tests. The goal is to pinpoint the problem and learn whether surgery is needed.

Medical History

Tell your doctor about your symptoms. This includes numbness, weakness, vision problems, or anything else you've noticed. Also tell your doctor about other health problems such as high blood pressure or diabetes. These can increase your risk of stroke. Since health problems can run in families, you may be asked about the health of your relatives.

Physical Examination

Your doctor will take your blood pressure and listen in your neck for a bruit. A bruit is the rumbling sound made when blood travels through a narrowed vessel. Your eyes also may be examined for tiny spots in their blood vessels. These spots can be a sign of carotid artery problems. Your doctor also may test your reflexes and strength. Based on the results of your exam, other tests may be ordered.

Do You Need Surgery?

You and your doctor will discuss the best course of treatment for you. Whether you need surgery depends on your symptoms and how severely narrowed your carotid artery is. In many cases, surgery won't be needed. Instead, your doctor may watch your problems over several months.

When Surgery is Required

If you have mild narrowing but have had TIAs, you may need surgery. Even if you haven't had any TIA symptoms, your risk of having a stroke may still be high if one of your arteries is severely narrowed. In that case, surgery also may be needed.

Your Treatment Plan

If surgery is needed, you'll have a carotid endarterectomy. The surgeon removes plaque, reopening and smoothing your carotid artery. This reduces the chance of emboli forming.

Even if you don't need surgery, your doctor may suggest lifestyle changes. Controlling blood pressure, quitting smoking, eating healthier, and exercising regularly can help reduce your risk of stroke. You also may be given medication to help improve your blood flow.

Peripheral Artery Disease

What Your Leg Pain Means

Does your leg hurt or give out when you climb stairs or take a stroll? Pain or Fatigue in your buttock or calf may be due to peripheral artery disease. Because this condition reduces blood flow to your lower body, your muscles cramp during activity. There’s no magic cure for peripheral artery disease. But, lifestyle changes and medical treatment can help you become more active again and may prevent progression of the disease.

Warning Signs

Peripheral artery disease is silent in its early stages. As it worsens, walking even short distances may become painful. The pain may be relieved by rest-only to return when you move again. This pain cycle, called claudication, may be your first warning sign of peripheral artery disease.

Risk Factors

Certain physical traits and unhealthy habits are risk factors that increase your chances of developing this disease. Heredity and aging are risk factors that can’t be controlled. But you can control others, such as smoking, eating foods high in fat, and having high blood pressure. Even diabetes, a condition that speeds the progression of this disease, can be controlled.

Your Condition Can Be Improved

After diagnosing peripheral artery disease, your doctor may suggest tests to determine the severity of your condition. Depending on the extent of the disease, medical procedures or, possibly, surgery may be needed to improve blood flow. Reducing your risk factors and getting regular exercise can also help both before and after treatment.

How Blood Circulates

Nonstop flow of blood from the heart to the body and back to the heart is called circulation. It’s the process that keeps you alive. Blood vessels carry blood throughout your body, much like pipes circulate water in your home. Arteries are vessels that deliver oxygen-rich blood to your body. Veins in your legs are vessels that return oxygen-poor blood to the heart.




Anatomy of an Artery

An artery is a muscular tube with a smooth inner wall that allows blood to pass freely. Arteries supply your body tissues with oxygen. During physical activity, when muscles and organs use more oxygen, your heart and arteries boost blood flow to meet the increased demand.

How Circulation Becomes Impaired

As you age, artery walls thicken and lose their elasticity. Plaque (a build-up of fat and other materials) may collect at the artery wall. Plaque narrows the artery, a condition called atherosclerosis or hardening of the arteries. Eventually, the artery becomes so narrowed that the blood can no longer flow freely.

A Damaged Artery

Peripheral artery disease begins when the artery’s smooth inner wall is damaged. Risk factors cause damage to occur more quickly by depositing chemicals and fat in the blood. These materials collect within and along the artery wall, forming plaque. At this stage, symptoms aren’t likely.

A Narrowed Artery

If plaque keeps collecting, the artery narrows and blood flow is reduced. During activity, blood flow may not be adequate to meet the body’s need for extra oxygen. Your leg may cramp (claudication) or feel tired after walking a short time. So far, no lasting tissue or muscle damage has occurred.

A Blocked Artery

Blood flow may be completely blocked b plaque or by a blood clot that lodges in a severely narrowed artery. You may feel pain, even during rest. Without a constant supply of oxygen, tissue below the blockage is permanently damaged and may die (gangrene). This often occurs in the feet, especially in the toes.

Your Medical Evaluation

Your doctor may suspect peripheral artery disease after hearing about your symptoms of claudication. If your medical history and exam suggest this disease, you may have test to measure blood flow or to locate a blockage. These test help your doctor evaluate the severity of your condition.

Your Medical History and Physical Exam

Your medical history and exam often provide enough information for your doctor to diagnose peripheral artery disease. You may be asked about risk factors, as well as how far you can walk, if the pain is worse going uphill, and how you make the pain stop. During the exam, your doctor checks the circulation in your legs. Artery pulses, nerve sensation, and muscle strength may all be tested.

Measuring Blood Flow

You may have tests to measure blood flow. These noninvasive tests do not use needles, dyes, or x-rays.

Understanding Arteriography

If earlier test reveal a severe drop in blood flow and surgery is being considered, you may have an arteriogram (also called and angiogram). Using special dye that is injected into your lower body, this series of x-rays shows how blood is flowing and provides a detailed image of narrowed or blocked arteries.

Knowing the Risks of Arteriography

After talking with you about the risks or Arteriography, the doctor will give you a consent form to sign. The risks or Arteriography include:

Bleeding at the needle insertion site
Allergic reaction to the dye
Kidney damage from the dye
Damage to the artery

During the Arteriogram

This procedure is usually done in the hospital or at a special x-ray lab. You’ll be awake, but you will be given medications to help you relax. You may feel pressure when the needle is inserted into your artery. As the dye is released, you may feel a sensation of spreading warmth. Although the arteriogram may be uncomfortable, do your best to keep still during the procedure, which usually takes an hour or less.

After the Arteriogram

Following the arteriogram, you’ll b asked to lie quietly. You can usually go home in several hours if your blood pressure is normal and the needle insertion site is not bleeding.

Your Treatment Plan

After your medical evaluation, your doctor will discuss a treatment plan with you. In almost every case, treatment is likely to include reducing your risk factors. If your circulation is severely impaired, procedures such as angioplasty or bypass surgery may be recommended.

Angioplasty

our doctor may recommend angioplasty to widen a narrowed artery or to open a small blockage by pressing the plaque against the artery wall. Following angioplasty, your doctor will see you to make sure the artery is still open. Blood flow in the artery may remain improved for a few years. If the artery becomes blocked again, this procedure may be repeated.

Your Angioplasty Experience

Angioplasty usually takes 1 to 2 hours to perform. Before the procedure actually begins, an IV (intravenous) line may be started in your arm. The skin where the catheters are inserted will be numbered. You'll be awake, but you will be given medications to help you relax. You may feel discomfort, but do your best to stay still. If you feel dizzy or nauseated at any time, tell your doctor.

What is Renal Artery Disease?

Renal artery disease may be defined as a narrowing of the blood supply to the kidneys. When the kidneys have a normal blood supply, they filter toxins from the blood and help to keep blood pressure in the normal range. Some patients with renal artery disease have no symptoms or mild symptoms, while in others it leads to severe high blood pressure (hypertension), poor kidney function or even kidney failure and dialysis.



Other terms used to describe renal artery disease include:

Renovascular Disease
Renovascular Hypertension
Ischemic nephropathy
Renal Artery Stenosis

Renal Artery Disease is most often caused by either atherosclerosis (also called "hardening of the arteries") or fibromuscular dysplasia (FMD). When atherosclerosis or FMD affects the kidney, it can cause uncontrolled high blood pressure. The condition is known as renovascular hypertension. Renovascular hypertension develops as a result of decreased blood flow to the kidney. This decreased blood flow can also cause a change in kidney function that worsens over time. Four out of every 10,000 people have renal artery disease. It is most common in men over the age of 60.

The clinical clues to suggest renal vascular disease include the following:

Onset of high blood pressure before the age of 30 or after the age of 55

High blood pressure that was controlled and now has become difficult to control

Blood pressure that becomes out of control in a very rapid fashion or to a very severe level

Blood pressure that is very resistant to therapy

An abnormal vascular sound known as a bruit when a stethoscope is placed on the abdominal wall over the renal artery

An imaging study that suggest a difference in size between the two kidneys
Abnormal renal function while receiving a medication called an angiotensin converting enzyme inhibitor

Abnormal renal function in an elderly patient with generalized vascular disease

Any patient with generalized vascular disease.

The primary goals of renal artery revascularization are to preserve or restore renal function, improve control of hypertension, and eliminate congestive heart failure. Associated secondary benefits can include reduction in anti-hypertensive medications, the potential to retard progression of vascular disease because of a reduction in blood pressure, and occasionally, elimination of the need for dialysis. For patients with chronic congestive heart failure, correction of renal artery stenosis may allow safe institution of an important medication known as a angiotensin converting enzyme inhibitor.

If You are Diagnosed with Renal Artery Disease

Your physician may recommend angioplasty with or without placement of a stent in the diseased renal artery. During these procedures, the narrowed renal artery is made wider, so blood can flow more easily to the kidney. During an angioplasty, a catheter (or tube) with a small balloon on the tip is inserted into the artery and guided to the area where the artery has narrowed. The radiologist then inflates and deflates the balloon several times to crack the plaque and press it against the artery wall. Once the blockage has been flattened and the artery is open, the balloon is deflated and the catheter is removed. Specially designed stents can also be placed in the artery to hold the walls open.

The Procedure

If a patient is found to have one of the clinical clues listed above which suggests the possibility of renal vascular disease, a duplex ultrasound of the renal arteries would be indicated. This is a non-invasive test that uses ultrasound technology to determine the velocity of blood flow through the renal artery. If the ultrasound confirms the diagnosis, and/or the clinical suspicion remains high should the ultrasound findings be indeterminate, the next procedure would be a renal angiogram. A renal angiogram is when a catheter is placed inside of the renal artery to measure blood pressure and then inject contrast to determine the degree of narrowing of the renal artery. If significant narrowing of the renal artery is found, and one of the clinical clues to suggest renal vascular disease is present, a renal artery angioplasty and stent procedure would then be indicated. An angioplasty is when a balloon catheter is placed inside the renal artery at the site of narrowing and inflated to expand the area of blockage. Next, a renal artery stent is placed inside the renal artery to scaffold the narrowing open, and increase the likelihood for a more durable treatment outcome long-term. There is an approximately 15-20 % chance for restenosis to occur. Restenosis is the healing response of the artery wall to the angioplasty and stent procedure which can present itself as a recurrent narrowing in the renal artery. This can again be treated with a subsequent renal artery angioplasty. The whole process takes about one to two hours. The hospital stay is usually one day. If the blockage in your kidney cannot be treated with angioplasty or stenting, you may need to undergo renal artery bypass surgery. In this surgical procedure, a graft usually made of leg vein is used to create a new path around the blocked renal artery. The hospital stay is five to seven days, and the total recovery time is six to eight weeks.

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