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Vascular Surgery

Abdominal Aortic Aneurysm & Occlusive Disease

An aneurysm is a localized, balloon-like expansion in a blood vessel, caused by weak vessel walls. The abdominal aorta refers to the part of the aorta (the artery that carries oxygen-rich blood from the heart to the legs) between the diaphragm and the legs. Hence, when a bulge occurs in the abdominal aorta, it is called an abdominal aortic aneurysm. Most aortic aneurysms occur in the abdomen, and most abdominal aortic aneurysms occur beneath the kidneys and may continue into the iliac (leg) arteries.

The weakened, bulging vessel walls are susceptible to rupture, a catastrophic event which causes severe bleeding and pain and is often fatal. Half of all untreated abdominal aortic aneurysms end in rupture and death within five years. Leakage rather than rupture may occur, causing blood to flow through the inner lining into the vessel wall, known as aortic dissection. Further, blood clots may form in the aneurysm and travel to other arteries, where they may block blood flow. Other complications are infection and blockage of the aorta.

Atherosclerosis, the hardening and narrowing of arteries due to disease or fatty tissue accumulation, weakens vessel walls and is responsible for about 80% of aortic aneurysms. Other causes include genetics, vessel injury, hypertension, inflammation due to disease, congenital deformity, advanced syphilis and fungal infection. Men are more likely than women to develop abdominal aortic aneurysms. Being over the age of 60 also increases one's chances of developing abdominal aortic aneurysms.

Abdominal aortic aneurysms may occur with no warning signs. Possible symptoms are deep abdominal pain, especially in the lower back, and a pulsing sensation in the abdomen. Secondary symptoms may include paleness, rapid pulse, dry skin/mouth, excessive thirst, anxiety, nausea and vomiting, light-headedness or fainting with upright posture, excessive sweating, clammy skin, fatigue, palpitations, rapid heart rate (tachycardia) when rising to standing position, impaired concentration and shock.

Aortic occlusive disease is a condition in which the artery in the abdominal area or pelvis becomes narrowed, affecting the blood supply to the legs. The symptoms include pain, numbness and fatigue in the hips, thighs or buttocks upon movement. If the disease worsens, the pain may be felt even at rest, loss of muscle tone may occur and ulcers may form on the lower leg or foot.

Abdominal aortic aneurysms, occlusive disease and other forms of peripheral artery disease may be detected by manual examination by a physician, x-rays, ultrasound, CT scans, MR imaging and aortography.

Surgery is recommended for arteries at great risk for rupture: those over six centimeters wide, and those five to six centimeters wide in patients otherwise in good health. Surgery is performed immediately on arteries that threaten imminent rupture or have already ruptured, although success is far less likely once the vessel has burst.

Traditional surgery involves making an incision to open the abdomen, then removing the aneurysm and replacing the excised vessel piece with a synthetic tube. Minimally invasive laparoscopic techniques require only small incisions, typically made in the femoral artery in the thigh, through which fluoroscopy is used.

A stent graft is inserted into one of the small incisions and guided up to the weak area of the artery with a catheter. Stent grafts are six-inch-long metal-mesh cylinders containing synthetic tubes. Once inside the artery they expand to fill the vessel, providing a strong new vessel wall and permitting uninterrupted blood flow. The aneurysm then generally shrinks around the stent graft as time passes.


Management of Acute/Chronic Leg Pain/Ulcers

Claudication is a symptom of pain in the legs caused by too little blood flow and is generally associated with conditions such as peripheral artery disease or atherosclerosis. Patients with this condition often experience pain that worsens while exercising, discolored skin or ulcers, weakness or a burning in the affected area. If left untreated, claudication can lead to serious skin ulcers and other injuries.

To relieve the discomfort of claudication and rest pain as well as slow the progression of peripheral artery disease and prevent tissue loss and swelling, patients can follow certain recommended life changes such as exercising regularly, quitting smoking, lowering cholesterol and wearing shoes that fit properly. If life changes are ineffective, more advanced treatment may include medication, angioplasty, athrectomy, stenting and bypass surgery.

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