Surgery for aortic aneurysms

Aortic aneurysms, the majority of which affect the infrarenal abdominal portion of the aorta, are responsible for 1–2% of all deaths in men aged over 65 years in the Western world. The disease most commonly represents a multifactorial degenerative process involving both genetic and environmental risk factors and is characterized pathologically by a reduction in elastic lamellae within the aortic wall. The natural history of the condition is one of progressive enlargement with an associated increase risk of aneurysm rupture. Although aneurysm rupture remains a catastrophic event, with an overall mortality of approximately 80%, the majority of patients are asymptomatic. Asymptomatic aneurysms are usually diagnosed as an incidental finding and management relies on an assessment of the risks of future aneurysm rupture weighed against the risks associated with elective surgical repair. Aneurysm repair may be accomplished by traditional open surgery or minimally invasive endovascular repair. Although the latter confers a short-and medium-term survival advantage in selected patients, long-term follow-up data suggest this benefit may not persist. Thoracoabdominal aortic aneurysm disease is considerably more complex, with intervention, even in specialist centres, associated with significant morbidity and mortality. Best medical management of aortic aneurysm disease requires control of blood pressure, smoking cessation together with aspirin and statin therapy. Screening has been introduced in an effort to identify a largely silent killer although with better medical management the overall prevalence may be in decline.