ABDOMINAL AORTIC ANEURYSM
(Dilated main artery of the abdomen)

CRL VASCULAR ASSOCIATES

Lewis V. Owens, M.D., Latham B. Murray, M.D.,
Anthony W. Spinelli, M.D., Pradeep Rajagopalan, M.D.

TABLE OF CONTENTS

Introduction
Smoking
High blood pressure
High cholesterol or triglycerides
Diabetes mellitus
Exercise
Drug therapy for patients with arteriosclerosis:

•Pletal
•Trental
•Vitamin E
•Aspirin
•Hormone replacement in postmenopausal women.

INTRODUCTION
Abdominal aortic aneurysms are frequently associated with arteriosclerosis or hardening of the arteries. The normal relationship of the arteries of the trunk is depicted in Figure 1; the arteries of the abdomen are seen in Figure 2. An abdominal aortic aneurysm which is a dilatation of the aorta is seen in Figure 3. Special tests (sonogram, CT scan, or MRI) are used to determine an aneurysm's size, extent, and location. If an operation is planned, you will probably need an arteriogram to show the status of the arteries in your abdomen and to your legs.

Though the degree of arteriosclerosis that a patient may have may be modest, a number of measures are known to slow the progression of arteriosclerosis and are probably appropriate in any event for most people on an American diet, whether they have an aneurysm or not. Arteriosclerosis has a number of causes. Chief among them are smoking, high blood pressure, high cholesterol, and diabetes mellitus.

SMOKING
Smoking is simply the worst thing you can do as far as arterial disease is concerned. It causes heart attacks, disease in the arteries to your legs and, if you are or have been a smoker, disease in the arteries to your brain. In addition, of course, smoking is well known to cause lung disease including cancer of the lung. If you are still smoking, please quit immediately as it will markedly help your lung function. If you are unable to quit ask your personal physician for advice about how to quit.

HIGH BLOOD PRESSURE
High blood pressure or hypertension (they are the same thing) accelerates the development of arteriosclerosis. If you have high blood pressure, it is important that this be controlled with diet and medication. You should have your blood pressure checked regularly by your physician (remember high blood pressure itself produces no symptoms so there is no way for you to know whether you have it except by getting it checked regularly, preferably by your personal physician since the blood pressure machines available in drug stores and the like are not highly reliable).

HIGH CHOLESTEROL OR TRIGLYCERIDES
You should have your blood levels of cholesterol and triglycerides checked once a year by your personal physician (a blood test done after you have not eaten for 12 hours). Though no data exist to support the concept that a rigid low cholesterol diet helps someone with a normal blood cholesterol level (see # 3 under WHEN YOU GO HOME), strong data do exist that suggest that lowering the part of the cholesterol called the low density lipoprotein (LDL) to under 100 mg/dl can cause regression of arteriosclerosis (that is the arteriosclerotic plaques that are already present can become smaller). Since people with carotid artery disease have associated arteriosclerosis, you should employ every reasonable effort to reduce the progression of arteriosclerosis. This includes careful monitoring of your cholesterol and, if it is elevated, lowering it into the normal range.

If you have an elevated total cholesterol (one that is greater than 200 mg/dl) or an elevated LDL cholesterol (one that is greater than 130 mg/dl), it should be reduced to normal by diet or by diet combined with medication. You should see your physician about how to proceed. We believe strongly in patients with vascular disease making sure their cholesterol is in the normal range. Be sure to follow up on this with your personal physician and, if you have questions or doubts, discuss this with us.

DIABETES MELLITUS
Diabetes mellitus is known to accelerate the development of arteriosclerosis. Careful monitoring and treatment of diabetes by your personal physician can slow the progression of arteriosclerosis as well as many of the other adverse consequences of diabetes.

EXERCISE
Exercise, primarily in the form of walking, is highly beneficial. If you develop chest, jaw, left shoulder, or left arm pain while exercising, you should immediately stop and consult your personal physician to see if this type of pain is caused by a heart problem.

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DRUG THERAPY FOR PATIENTS WITH ARTERIOSCLEROSIS

PLETAL
Pletal is a drug whose mechanism of action is unclear but, in several studies, it seems to provide some benefit in increasing the distance patients can walk who have poor blood supply to the legs. It also has some beneficial effect on lipid levels. In most studies the onset of action occurred within a month in many patients with walking distance doubling.

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TRENTAL
Trental is a drug that alters the conformability of the red blood cell. The theory is that these red cells can then slip by small obstructed areas and supply more oxygen to the tissues than they normally receive. We have consistently been impressed with the lack of benefit from Trental perceived by our patients. Moreover, when the need to take yet another pill and to pay a lot of money to do so are added to the lack of apparent benefit, we have little enthusiasm for this drug. If you want to try it, we will be happy to give you a prescription, but we see little advantage in taking it.

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VITAMIN E
As those who believe vitamin supplements are beneficial already know, the medical profession is generally poorly informed about the effects and benefits of vitamins. This comes from two beliefs: 1. Americans already receive adequate vitamin intake (there are few cases of overt vitamin deficiency) and 2. Convincing scientific data showing benefit of vitamin supplementation are sparse - primarily because the studies necessary to prove effectiveness require many patients and much money. Nonetheless, there is increased interest in this subject. Much more solid information about vitamin therapy, especially as it relates to cancer and arteriosclerosis (which causes heart and vascular disease) should emerge over the next decade. Antioxidants, such as Vitamin C (water soluble), carotine, and Vitamin E (both fat soluble) have been postulated to inhibit the development of arteriosclerosis. At one point it seemed that Vitamin E was effective in reducing the incidence of arteriosclerosis in the arteries supplying blood flow to the heart (those responsible for heart attacks). Unfortunately, a careful article in the New England Journal of Medicine in late 1999 or early 2000 could find no persuasive evidence that this was so. As a consequence, we no longer recommend Vitamin E. Carotine has been effective in men who smoked but not in non-smokers or women, and Vitamin C was not found to be effective in women or men.

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ASPIRIN
Aspirin has been shown to provide a modest benefit in reducing the incidence of heart attack in men but not women. Aspirin has also shown a very slight beneficial effect in reducing stroke in men. Once again it has shown no benefit in women. The dose of aspirin used in these studies has been between two and four regular aspirin tablets (325mg each) per day. There are experimental data that suggest that lower dose aspirin may be equally effective, though there are no clinical studies to our knowledge that confirm this hypothesis. We recommend that men take one to four buffered aspirin tablets a day. If aspirin bothers them but they can take a baby aspirin (80mg), they probably should take that.

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HORMONE REPLACEMENT IN POSTMENOPAUSAL WOMEN
Estrogen replacement in postmenopausal women is associated with a lower incidence of osteoporosis, a lower incidence of coronary artery disease, a higher incidence of cancer of the uterus, and a slightly higher incidence of breast cancer (but there doesn't seem to be a higher incidence of breast cancer if the total time of taking hormones is less than five years) (See footnotes 1-4). The higher incidence of cancer of the uterus is negated by adding progestins in women who have not had their uterus removed (hysterectomy). Therefore, the trade-off seems to be to accept a slightly higher incidence of breast cancer in exchange for a lower incidence of osteoporosis (bone wasting) and heart disease if you take hormone replacement. Because (by the fact that you have come to specialists in vascular diseases) you probably have at least a moderate amount of arteriosclerosis, it may be to your advantage to try to gain the significant reduction in both heart disease and the incidence of osteoporosis by taking replacement therapy, even though we now know there is an increased incidence of breast cancer with this approach. This subject, however, is not within our field of expertise and advice will be changing as newer studies of this important topic are published. We recommend, therefore, that you consult your gynecologist and follow his or her advice about replacement therapy.

SUMMARY OF NON INVASIVE THERAPY FOR ARTERIOSCLEROSIS WOMEN and MEN

1. No smoking
2. Control of hypertension if present
3. Control of diabetes if present
4. Control of elevated cholesterol if present
5. Daily exercise (primarily walking)
6. Vitamin E supplement - 500 to 1000 units per day
7. Coumadin if appropriate

Probably no need for Trental or Persantine.

• In addition for WOMEN: Hormone replacement therapy for those who are post menopausal (discuss this recommendation with your gynecologist).
• In addition for MEN: Aspirin one to four pills (325mg each) a day

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RISK OF RUPTURE OF AN ABDOMINAL AORTIC ANEURYSM
There is no activity that increases the likelihood of rupture (or bursting) of an abdominal aortic aneurysm nor is there any activity that will help to prevent rupture. If your blood pressure is too high this will increase the risk of rupture so it is important that you get your blood pressure under control with diet and medicine as prescribed by your personal physician. If your aneurysm ruptures it will likely rupture into a closed space near the back. If this occurs you will have a fairly sudden onset of severe back or flank pain with a drop in your blood pressure. This is rarely a subtle event, you will know almost immediately that a major ominous abdominal event has occurred. You should have an ambulance called so that you can be brought to an emergency room immediately. A ruptured aneurysm is not always fatal, but the mortality rate of those who do make it to the hospital is nonetheless quite high (about 50%-70%).

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DIAGNOSTIC STUDIES: CT SCAN, MRI, or SONOGRAM
You will be having a Computed Tomogram (CT scan), a Magnetic Resonance Image (MRI), or a sonogram (you may already have had one or more of these before you were referred to us) to evaluate the size and location of your aneurysm. These are non-invasive tests with minimal risk (a CT scan exposes you to a very small amount of radiation and the radiologist may give a small amount of iodinated contrast with the CT scan - if you have questions or concerns, ask the radiologist at the time of your study).

DECISION TO OPERATE (Figure 8)

Small Aneurysm (less than 4cm)
If your aorta is dilated but the transverse diameter is less than 4 centimeters, (the normal diameter of an aorta is usually less than 2 centimeters [less than an inch]), it is generally considered that the safest approach is to get repeat CT scans, MRIs (most expensive) or sonograms (cheapest and plenty accurate) every 6-12 months for the rest of your life and to operate on the aneurysm if it gets larger.

Aneurysm (between 4-5 cm)
If your aorta is dilated and the transverse diameter is between 4 and 5 centimeters it is a difficult risk-benefit decision. The risk of rupture (and probable death) is in the range of 2%-4% per year (that's each year so that risk of rupture over 5 years is 10%-20%). The risk of death from the operation is 2-4%. Advantage to you in the form of prolonged survival is conveyed after one to two years (the mortality rate from the operation is equal to the mortality rate from rupture the first year or two so that 2 years after the operation the survival statistics favor the person who had the operation since they now have a lowered risk of rupture - if you don't understand this analysis please ask us to explain). A number of vascular surgeons recommend operation for aneurysms 4cm or more in diameter based on decision-modeling (See footnote 5) and others because it has been found that 74% of patients under age 69 with aneurysms more than 4cm in diameter eventually were operated upon for their aneurysm (See footnote 6); thus most patients at good risk will eventually require operation. As a consequence, if you are otherwise in reasonably good health, we sometimes recommend an operation when an aorta is dilated and the transverse diameter is between 4 and 5 centimeters. The pros and cons as to whether or not to operate on a 4cm - 5cm abdominal aortic aneurysm are probably sufficiently equal so that the final decision whether to operate will depend on which you fear more - a possible rupture of a small aneurysm or the certain inconvenience and pain associated with a major abdominal operation.

Larger Aneurysm (greater than 5 cm.)
If your aorta is dilated and the transverse diameter is five centimeters (5cm) or more, we recommend an operation unless your general health makes the risks too high. The risk of rupture (and probable death) is in the range of 4-15% per year depending on the size (Figure 8) - the larger the aneurysm the greater the likelihood of rupture - (that's each year so that risk of rupture over 5 years is 20-80%). The risk of death from the operation is about 2-4% (the risk of the operation is not increased by the size of the aneurysm). Advantage to you in the form of prolonged survival is conveyed rather quickly since the risk of rupture in the first year exceeds the operative risks. This operation is one of the few vascular operations (Figure 9) that has been consistently shown to prolong life (the other vascular operations we do enhance [we hope] the quality of life but not the length of survival).

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ENDOVASCULAR APPROACHES
It is possible to insert a bypass graft (called an endograft) through the groin artery. This approach is referred to as an endovascular approach. The magnitude of the procedure is much less than the open operative procedure. Two different devices are currently available (FDA approved). One (AnCure®) is bulky and is appropriate for only about 20% of those with abdominal aneurysms. It does incorporate some design features that we think are important. It is unsupported just like the grafts we currently use in the open procedure (and this graft type has a long history of good durability) and it attempts to have more secure attachment to the aortic neck. Its primary disadvantage is that it is bulky and people without large arteries in the pelvis are usually not candidates for this device. The other FDA approved device is the AneuRx®. This is smaller and easier to insert. The disadvantages are that it is stiff and it probably doesn't have a highly secure attachment mechanism. It is also a supported graft (metal struts support the graft) and the interface between the struts and the graft material may prove to be a problem with fraying over time. Also the stiffness may cause problems if the bypassed aneurysm shortens and the graft has to bend.

Patients who receive either device will probably need to have imaging studies of some sort at six month intervals for the rest of their lives because the likelihood of continued problems with inserted endografts is likely to continue until some of the design issues are worked out. In brief, we believe this endovascular approach holds excellent promise for use in the future as the devices available improve. We also think someone with a reasonably damaged heart and a 6 centimeter or larger aneurysm should strongly consider this approach. For most others we continue to favor the open operative approach because the complications more than 30 days after the operation are quite rare.

This view, we believe, will change as the devices available become better and more likely to provide a durable benefit. The endovascular approach is one that we should review with you. Please feel free to bring it up so we can discuss the state of the art and what our views are at the time since this is a fairly rapidly changing method of treatment.

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ARTERIOGRAM
If you decide to have your aneurysm operated upon, we sometimes (though not usually) will order an arteriogram (also called an "angiogram" or "aortogram"). This is a study in which the radiologist will inject contrast material (a clear fluid that shows up on an X-ray as white) into your aorta or main artery of the abdomen. X-ray pictures will then be taken of your abdomen, pelvis, thighs and legs at the time of the injection. The catheter (or tube delivering the contrast material) is usually inserted through the groin artery. There is some mild discomfort with this but it isn't too painful as the radiologist will usually give some intravenous medicine that will reduce anxiety and will numb the skin by injection with a local anesthetic before inserting the catheter. At the time of the injection of the contrast material you will probably feel a very warm or even hot burning sensation. It clears completely after 10 to 20 seconds and you should have few if any pains or problems associated with the injection. The catheter is then removed from the groin and pressure is applied to the area where you were stuck so as to get the hole to seal. You will then go back to your room. The entire arteriogram usually takes about an hour.

Before the arteriogram you will be asked not to eat any solids for 5-8 hours but you should continue to drink fluids, especially water. You don't need to have a full bladder so you can urinate as often as you like but you should have drunk plenty of fluid. This increases the amount of fluid your kidneys filter and reduces the likelihood of kidney damage caused by the arteriogram.

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RISKS OF THE ARTERIOGRAM
The major risk is an allergic reaction to the contrast agent used. These agents almost all have iodine in them so, if you have had a previous reaction to an injection of contrast (for an IVP for instance) or you know you are allergic to iodine, you should let the radiologist know. Other risks include damaging the kidneys with the contrast (this is minimized by drinking large quantities of water prior to the arteriogram) and damage to the artery where the catheter is inserted. If necessary, damage to the artery can usually be fixed by a small groin operation. After the arteriogram you may find that you have swelling or a hard lump in the groin. This is from a small amount of blood that almost invariably leaks out around the catheter during the procedure or out the small hole in the artery immediately after the catheter is removed. This may cause bruising and mild discomfort for a few days but will usually improve without problems. The lump may persist for 1-3 months as it takes time for the blood to be broken down and reabsorbed. This clot, however, is not risky - it is not within a blood vessel so it can't break off and go to your leg or heart. In general, arteriograms are safe and have a major complication rate of 1% or less. The radiologist is the expert in this field and you should be sure to discuss with him or her any concerns or questions you might have.

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LASER
Use of the laser has no role in the treatment of abdominal aortic aneurysms.

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TIMING OF THE OPERATION
Obviously the day to do the operation is the day before it is to rupture. Unfortunately it is impossible to predict when this might occur. As a consequence you should proceed with the operation as soon as you have evaluated the advantages and disadvantages and have been evaluated by your personal physician and a cardiologist.

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AORTO-AORTO or AORTOBIILIAC BYPASS
THE OPERATIVE PROCEDURE

ANESTHESIA
You will have an anesthesiologist in charge of your anesthesia. He or she will see you before the operation and review with you the risks and approaches that will be employed when you have your anesthesia.

For an abdominal aortic aneurysm repair the anesthesiologist may choose a general anesthetic which will consist of putting you to sleep through an IV injection and then keeping you asleep with gasses delivered through a tube in your windpipe (that is put in after you are asleep). Or the anesthesiologist may choose to give you a spinal or epidural anesthetic whereby you will have medicine injected near your spinal cord that will numb up your legs and you will then be heavily sedated. Or, finally, the anesthesiologist may choose a combination of these techniques. If the anesthesiologist inserts an epidural catheter, it is likely we will leave it in for 2-3 days so that we can continue to give you pain medicine through it in order to reduce the amount of pain you have.

The anesthesiologists we use are excellent. The risks of anesthesia are small, but nonetheless should not be dismissed. One of the great advances in anesthesia over the last 20 years has been the development of oxygen saturation monitors. These are devices that are put on the fingers during the operation and monitor the oxygenation of your blood. This works by shining a light through your finger and detecting color changes if you are not being adequately oxygenated. Alarms go off if your oxygen saturation drops slightly. This gives the anesthesiologist lots of time to make the necessary adjustments and tends to reduce the anesthetic complications due to anesthetic error down to an extremely small number. Anesthesia is an important aspect of your care and you should be sure to ask the anesthesiologist any questions you may have.

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OPERATION
This is a bypass replacing the dilated (aneurysmal) portion of your aorta (main arterial blood vessel in the abdomen - see Figure 3). The graft is made of Dacron® or Teflon (Gore-Tex®) and is shaped like a tube (Figure 4) or an upside down Y (Figure 5) (the choice of which configuration to be used is usually made during the operation once the extent of the dilatation is precisely determined). The graft is usually inserted just below the take off from the aorta of the kidney (renal) arteries and bypasses down to where the artery is not so dilated (Figure 6) and (Figure 7). Though it is a big operation the results are, in general, excellent. These bypasses tend to stay open for a long term and prevention of blood vessel rupture is excellent.

After you have been put to sleep, a tube will be inserted through your nose into your stomach and another tube will be inserted into your bladder through your urethra (the tube you urinate through). These will be left in place for 2-3 days after the operation to make sure we prevent your stomach from becoming distended and to allow us to measure the amount of urine you produce (a good measure of kidney function and adequate fluid balance). Though we will remove the tube in your nose as soon as possible, it will be annoying and may give you a sore throat.

You may also wake up with a tube in your windpipe that allows the ventilator to breathe for you. This will prevent you from speaking and may cause you some anxiety (you can communicate by writing - the nurses will provide you with a writing pad). The best approach is to relax as much as possible and we will remove the tube as soon as breathing and blood tests indicate you can get an adequate amount of oxygen when you are breathing without ventilator assistance.

Though you will gain weight with the operation because of extra fluid we give you through your vein (intravenous or IV line), you will feel dry and thirsty during the first 3 days after your operation. This is normal. Though you can wash your mouth out with ice chips or glycerin swabs, do not drink water as it will not be absorbed (your gastrointestinal tract will not yet be working properly). Drinking water will only distend your abdomen which will be painful or it will stimulate and washout important secretions in your stomach (by the suction in the tube - called NG or Nasogastric tube - in your stomach).

This operation is painful and the incision will hurt, though probably not greatly if you have an epidural catheter in place (put in by the anesthesiologist just before the operation - we can give you pain killer through this catheter and control postoperative pain much better than we can with pain shots). This pain steadily lessens over the subsequent few days so that by the time you leave the hospital you will be able to control it easily with pain pills. At first, though, you will need narcotic injections and we will order these for you - all you will need to do is ask the nurse for a pain shot. If you aren't getting them frequently enough or getting adequate relief, let us know and we will increase the frequency or amount. You will not become addicted and we are not concerned about it so be sure to take your shots frequently at first. There is no virtue in suffering and the pain shots will allow you to be more active - an important part of recovery. After the first couple of days, however, you should try to reduce the number of pain shots you ask for (you do this - we won't cut you back) since this will allow your gastrointestinal tract to function better and sooner (i.e. narcotic use slows bowel motility and causes constipation).

We will remove the tube from your nose 3 or 4 days after the operation but we won't feed you liquids or solids for another 2 or 3 days after that. You need to be passing gas through your anus (flatus) and you need to be hungry. It is best if you have had a bowel movement (this will occur despite your not having eaten - half of each bowel movement is made up of bacteria and your own cells that normally slough off). If we don't feed you until you are really ready, you recover quickly; if we feed you too early you can become distended, and then we may have to put the NG tube back down, and you may require an additional 3-10 days in the hospital.

Normally all of us sigh or take an extra large breath several times a minute. This sighing expands our lungs and prevents tiny areas of collapse called "atelectasis". After your operation you will not sigh since bigger breaths will cause your abdomen to hurt. As a consequence, you will probably have a fever (atelectasis causes a fever) for a couple of days. In order to prevent or reduce this you should concentrate on taking deep breaths as often as you can think of it. If you do this fairly frequently, it will improve your lung function. We will also order a blowing instrument (called an incentive spirometer) to help you with this activity.

We will encourage you to get out of bed and start walking quite early. Though you won't like it at first, you will find that it will hasten your recovery and also lessen the likelihood you will develop clots in the veins of your legs. Also, again to reduce the likelihood of clots in the leg veins, you should move your feet and contract the muscles of your calves starting when you wakeup. We may order compression cuffs that we can put around your calves in the early post operative period in order to aid in the prevention of these clots. When you first start to walk be sure to have the nurses help you - you won't be as strong as you think and you certainly don't want to fall and break a bone.

In summary, the things you need to remember to do starting as soon as you wake up from the operation are:

• Breathe deeply fairly frequently. Use the incentive spirometer to aid you in this.
• Move your feet and calves frequently. Try to push yourself to be more and more active as this will prevent vein clots and will cause your gastrointestinal tract to start working sooner.

This recovery period passes relatively quickly and, though you certainly wouldn't want to volunteer for this kind of operation on a frequent basis, it is likely you will find that the anticipation will turn out to have been worse than the actual event. If you have problems, the nurses and we will help as soon and as effectively as we can.

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COMPLICATIONS OF AORTO-AORTO or AORTOBIILIAC BYPASS

The major risk associated with entering a hospital or having any procedure performed, no matter how minor, is death; this unassailable fact must always be kept in mind. The major risks of aorto-aorto or aortobiiliac bypass (the operation described in this handout) are death, stroke, heart attack, lung or kidney damage, bleeding, loss of one or both legs, hepatitis, infection either of the graft or throughout your body, impotence in males, worsening of the blood supply to the legs, and clots forming in the legs and possibly going to the lungs.

If death occurs during the operation, or within a few days afterward, it is usually caused by a heart attack, but can be caused by many other factors as well. The risk of death within 30 days of the operation is 2%-4%. Stroke, bleeding, blood transfusion complications, infection, and impairment of blood supply to the legs are unusual after this operation, but all can and, on very infrequent occasion (major complication rate of 2-4%), do occur. Males may already be impotent since the blood supply to the pelvis and penis can be decreased. Though this operation can occasionally improve the ability to obtain and sustain an erection, it can also interfere with it as well. Moreover, one can end up with a retrograde ejaculation where sperm enters the bladder and later comes out with urination. Clots can form in the legs and cause leg problems later or can break off, go to your lungs, and interfere with your ability to breathe.

This is a short but by no means comprehensive review of some of the complications that can occur. If you have any questions or want a more detailed explanation of any of these or any other complications, please make sure you discuss it with us before you enter the hospital. If you would like a more formal review article about abdominal aortic aneurysms, one is readily available in the medical literature (See footnote 7).

We will certainly try to avoid or minimize the likelihood of operative complications. Nonetheless this operation is not now and never will be risk free. You should feel very comfortable with your understanding - not only of the benefits, but also of the risks.

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WHEN YOU GO HOME:

1. You should resume all the medications you were taking before the operation unless your personal physician has changed them.
2. You should not drive until you are completely confident of your stamina and your ability to suddenly put the brakes on should an emergency arise. This usually take 2-4 weeks.
3. You can resume your normal diet. You will notice that you lost 5-10 lbs. during your hospitalization. If you are overweight you might want to use this opportunity to reach the weight you want by being more moderate in your intake and reducing the fats in your diet. More fish, poultry, vegetables and unsaturated fats; less butter, cheese, pork, eggs, cream etc. A prudent diet is best. A rigid low fat diet, though probably somewhat beneficial, is difficult to comply with and probably doesn't make a great deal of difference unless your cholesterol is elevated. If it is, follow the directions given previously. [Back]
4. You should not smoke again. Ever. Not even a little. Not at all. If you cannot comply with this, ask your doctor for his or her suggestions or we will refer you to someone who will try to help you.
5. You may drink alcohol in moderation.
6. You may take baths or showers and get your incision wet - you don't need to wear bandages over your incisions.
7. You should walk daily and should slowly increase the distance you walk each day.
8. You should see your personal physician within two weeks after you leave the hospital. Bring all your medicines to him or her so they can be checked to make sure you are taking the medicines the way your personal physician wants you to.
9. Return to our office within two weeks. Come back within a week if we didn't take all of your skin sutures or staples out when you were in the hospital.
10. You may resume sexual relations when you feel strong enough. Be aware, however, you may find your desires and abilities diminished for some time.
11. Because arteriosclerosis is a progressive disease, you should return to us at least once a year for repeat vascular evaluation.

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A WARNING
This operation is a big one. Patients are understandably focused on two aspects: "Will I die and will I have a major complication"? After the operation when they realize they are doing well, they are obviously pleased and become reasonably happy when they see substantial improvement each day after the operation. After about three weeks, however, they stop noticing daily improvement and observe that they are still weak, fatigue easily, and require daily naps. Frequently, patients then become depressed and irritable - not so nice to be around. This depression will last 3-6 weeks but improves when the patient realizes that he or she is still improving week to week. Recovery from the operation to the point you can get about is relatively quick, but complete recovery to the point where you feel as well or perhaps even better than you did before the operation may take 3-6 months. Be patient and continue to try to walk farther each day.

BEFORE YOU ARE ADMITTED TO THE HOSPITAL
You should call or see your personal physician. We would like him or her to thoroughly evaluate you to make sure you are in optimal condition to have a major operation. Ideally, we would like you to have a complete physical examination and blood tests.

In addition, we would like your physician to send you to a cardiologist to make sure your heart is in reasonable shape. The cardiologist will check your blood pressure, perform an EKG and perhaps do other tests to detect unsuspected heart disease (arteriosclerosis is a systemic disease and, in addition to causing problems in your aorta in your abdomen, it can also cause problems in the arteries supplying your heart). Temporary occlusion of your aorta (necessary in order to put in the prosthetic graft) places a stress on the heart. The normal heart generally tolerates this maneuver well, but the heart with unsuspected compromised blood flow due to coronary artery disease may not. Though you may view this additional testing as inconvenient or unnecessary, in the unlikely event you have a problem, it is reassuring to know that both your personal physician and a cardiologist have recently examined you and are quite familiar with your overall condition.

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BLOOD
You may need blood during or after your operation. We will try to lose as little as possible and will retransfuse your own blood when possible. The risk of transmitting hepatitis or AIDS virus is exceedingly small as our blood supply is carefully checked and monitored. Nonetheless, you may want to donate your own blood in advance and we encourage this. In general, we do not encourage having family members or friends donate blood specifically for you since the methods for doing this are complex and, at least statistically, directed donors probably do not offer an advantage. If, however, you would like more information or would like to explore your or your family's donating blood please ask our office personnel to help you get the appropriate information (the way to achieve this varies from hospital to hospital).

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BILLING
Our charges for the operation include the admission evaluation, the operation, the in hospital postoperative care, and the postoperative visits in our office over the 2-3 months after the operation. You should check with our office personnel for the amount you will be charged and the extent to which your insurance will cover it. You will also receive other related bills - the hospital, radiologists and anesthesiologists all will have separate bills. Be sure to check with our office regarding any questions you have about what your financial obligation is.

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REFERENCES
1. Belchetz, PE. Hormonal treatment of postmenopausal women. N Engl J Med, 1994; 330:1062-71.
2. Golditz, GA et.al. The use of estrogens and progestrins and the risk of breast cancer in postmenopausal women. N Engl J Med, June 15, 1995; 332:1589-93.
3. Martin KA et al. Postmenopausal hormone-replacement therapy. (Editorial) N Engl J Med, April 15, 1993; 328:1115-1117.
4. Davidson NE. Hormone-replacement therapy - breast vs. heart vs. bone. (Editorial). N Engl J Med, June 15, 1995; 332:1638-9.
5.Katz DA, Littenbnberg B, Cronenwett JL. Management of small abdominal aortic aneurysms: early surgery vs. watchful waiting. JAMA 1992; 268:2678-86.
6.Brown PM, Pattenden R, Gutelius JR.  The selective management of small abdominal aortic aneurysms: the Kingston study. J Vasc Surg 1992;15:21-7.
7. Ernst CB. Abdominal aortic aneurysm. N Engl J Med 1993; 328:1167-72.

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