Introduction
Since its inception in 2001 the Scottish National Thoraco-Abdominal Aortic Aneurysm (TAAA) Service is located in the Royal Infirmary of Edinburgh, NHS Lothian.
The aim and purpose of the Service is to provide comprehensive and effective care for patients in Scotland requiring assessment and treatment for disease of the aortic arch, thoracic, thoraco-abdominal or supra-renal abdominal aorta and other complex aortic conditions.
The service is managed and funded by the NHS National Services Division.
- Thoraco-abdominal Aortic Aneurysm
- Thoraco-abdominal Aortic Dissection
- Aortic conditions relating to connective tissue disorders
Staff
Surgeons
- Mr Orwa Falah Consultant Vascular Surgeon (Clinical Director)
- Mr Vincenzo Giordano Consultant Cardio-Thoracic Surgeon
- Mr Russell Jamieson Consultant Vascular Surgeon
Consultant Anaesthetists
- Dr Stephen Biggart
- Dr Euan McGregor
- Dr Alasdair Ruthven
Consultant Interventional Radiologists
- Dr Neil Masson
- Dr Andrew Walker
Specialist Nurse
- Mrs Luann Randall
Services
Referral and Multi-disciplinary Team Opinion
Referrals to the National Thoraco-Abdominal Anuerysm and Complex Aortic service are accepted from medical professionals from across Scotland. This is often the patient’s local Consultant Vascular Surgeon, or Consultant from another speciality, or family doctor. For advice and guidance on the management of complex aortic disease cases are discussed at a multipdisciplinary team (MDT) meeting where patients’ case histories and available imaging are reviewed. The MDT consists of Consultant Vascular Surgeons, Consultant Cardio-Thoracic Surgeons, Consultant Vascular Anaesthetists, Consultant Vascular Interventional Radiologists and Vascular Nurse Specialists from the service.
Assessment for intervention
Out-patient clinic appointment
Patients may be invited to attend an initial out-patient appointment, in order to explain the condition, to broadly explain the range of treatments available for each particular condition and how the process of assessment and selection for treatment is carried out. If this discussion has happened previously, for instance, with your local Consultant patients may instead be invited to attend the preoperative assessment clinic as a first point of contact.
Preoperative assessment
Before an aortic aneurysm repair is recommended a thorough assessment of the person’s health and fitness is conducted. Tests, in particular, of the heart and lungs, and blood tests and x-ray examinations are conducted to form an accurate picture of the patient’s current state of health. This assessment is usually conducted as an out-patient, over 2 days of tests and consultations. Typically the tests include;
- CT angiography including CT coronary angiography
- Echocardiogram including dobutamine stress echo
- Electrocardiogram
- Lung functions tests
- Cardio-pulmonary exercise testing (static bicycle test)
- Blood tests
- Chest x-ray
A report of the findings of these tests is made by a Consultant Anaesthetist based on the results of the tests, the persons past medical history and age. This can be considered a personalised ‘risk assessment’ for each individual patient, and guides the surgeons as to whether it is safe and beneficial to recommend treatment.
The outcome of this assessment is discussed at a team meeting of surgeons, anaesthetists, radiologists and nursing staff (multi-disciplinary team meeting, or MDT) and an explanation of the discussion is given to the patient and their local Consultant and family doctor. Sometimes the initial assessment gives rise to other questions about the patient’s health and further tests, or referral to another specialist doctor may be advised. The explanation of the results of the assessment and the recommendation of the team is usually given at a further out-patient appointment, or can sometimes be arranged with your local Vascular Consultant.
Open Surgical RepairAll operations of the thoracic aortic are major surgery.
The type of operation required depends on where on the aorta the aneurysm occurs and how much of the aorta is affected. The aneurysm is replaced with a tube-shaped graft. Grafts can be thought of as an artificial replacement aorta. In order to replace the aorta the blood flow within the aorta has to be temporarily stopped using clamps. Often smaller arteries that come from the aorta need to be bypassed or re-routed to allow continued blood supply to organs and other parts of the body during the operation, and once the graft is in place. Some aneurysm repairs are possible in a single operation, but some need to be done in stages, with time to recuperate between each stage. Some aneurysm repairs involve a combination of a traditional operation and an endovascular stent (see below). Operations involve a cut across the tummy (laparotomy) or a cut from the tummy, across the front of the left ribs to the shoulder blade at the back (thoracotomy), or sometimes a cut down the middle of the ribs (sternotomy). Sometimes small cuts at the groin are also required.
Thoracic aortic repairs are, on the whole, only conducted as planned procedures, as they are long operations and require a large team of operating theatre specialists.
These types of operations require some time in the Intensive Care unit immediately after the operation. We plan for patients to be in hospital for 10-14 days after their operation, but sometimes the hospital stay can be significantly longer. Most of the recovery from a thoracic aneurysm repair happens at home. We estimate that patients would not feel fully recovered, in regards to their exercise tolerance and energy levels, for around 3-6 months, but can sometimes take longer. Sometimes, if further hospital rehabilitation, convalescence, or home support packages are necessary, patients may be transferred to a local, or specialist rehabilitation hospital before returning home. This is more likely if you live outside of the Edinburgh area, in order for local home support to arranged prior to returning home, if necessary.
Endovascular and Complex Endovascular Repair
Endovascular Repair
An endovascular aneurysm repair uses a tube like device (stent) to create a new channel within the aorta for the blood to be carried. This is referred to as a Thoracic Endovascular Aneurysm Repair or TEVAR and can be thought of as a relining and internal re-enforcement of the aorta. The stent is placed through a small cut, usually at the groin. This avoids the need for the large cut required in a traditional operation, but it is not always possible, or the best solution, to use a stent. This can be due to the shape of the aneurysm, its position and the location of the many smaller arteries that come from the aorta. Stents require a portion of good aorta, above and below the aneurysm to ensure the aneurysm is sealed off and no significant blood flow remains in the bulge. If the seal is not entirely successful this is called an endoleak. Most endoleaks do not require further treatment, but all endovascular repairs requirement life-long follow-up scans to ensure they are still working safely and effectively.
Complex Endovascular Repair (custom stenting)
This category of endovascular stent repair requires a made-to-measure stent, custom made for the patient. This is usually to allow for the important smaller arteries that come from the aorta, to avoid these arteries being blocked off by the stent. The stent is made with to align exactly with the points where there are branches from the aorta. These are commonly the important arteries supply blood to the kidneys, intestines and other organs. This type of repair is referred to as a Branched or Fenestrated Endovascular repair (BEVAR or FEVAR) depending on the type of stent required. Complex endovascular stent repairs can be a single operation, or sometimes in stages, with time to recover between stages. The planning and manufacturing of custom made stents can take several weeks or months, including an application for funding from the Scottish Government. This often lengthy process does not make this type of treatment ideal in urgent situations.
Hybrid Open and Endovascular Repair
Hybrid procedures involve a combination of open surgery and endovascular repair. Most commonly these procedures are carried out in stages with time to recover between each procedure.
Contact
Scottish National Thoraco-Abdominal Aortic Service
c/o Department of Vascular Surgery
Royal Infirmary of Edinburgh
51 Little France Crescent
Old Dalkeith Road
Edinburgh
