- Symptomatic or ruptured abdominal aortic aneurysm (AAA) of any size.
- Asymptomatic AAA ≥ 5.5 cm or > 0.8-cm growth in 12 months.
- Malignancy with limited life expectancy.
- Prohibitive medical comorbidities.
- Infrarenal AAA may be treated by open or endovascular repair.
- Perioperative mortality:
- Open repair: 2–5%.
- Endovascular repair: 1.2–1.6%.
- Repair of ruptured AAA: 50–75%.
- Exclusion of the aneurysm wall from the systemic circulation and associated pressure, thereby preventing its rupture.
- The established treatment option for AAA for > 50 years.
- Associated with excellent long-term outcomes and fewer subsequent aneurysm-related procedures than endovascular repair.
- Limited by comorbidities.
- Can treat all aneurysms with no anatomic restraints.
- Involves longer hospital and ICU stays, results in more postoperative pain, and is associated with a higher 30-day mortality rate than endovascular repair.
- Complications include but are not limited to:
- Surgical site infections and incisional hernias.
- Myocardial infarction.
- Renal or respiratory failure.
- Retrograde ejaculation.
- Colonic ischemia.
- Embolization of clot to the legs.
- Well established for patients who are not surgical candidates and increasingly being used for all anatomically favorable aneurysms.
- Has specific anatomic requirements.
- Rate of aneurysm-related reintervention is higher than for open repair.
- Patients require lifelong follow-up with serial imaging.
- Is associated with a lower 30-day mortality rate than open repair.
- Complications following endovascular repair are similar to those for open repair, excluding retrograde ejaculation and incisional hernia. In addition, approximately 15% of patients treated with an endovascular approach will need at least one additional procedure to better seal the aneurysm from an endoleak or to fix a complication (eg, graft migration, stent fracture, graft material fatigue).
- Vascular surgery instrument tray.
- Bookwalter or Omni retractor for abdominal exposure.
- Graft material (Dacron or polytetrafluoroethylene [PTFE] of various sizes, 12–36 mm).
- Vascular surgery instrument tray.
- Sterile angiographic capabilities with a full compliment of catheters and wires.
- A portable C-arm may be used, but a fixed fluoroscopic unit gives better images.
- The procedure should be done in a room with operative capabilities (eg, suction, electrocautery, good lighting, etc).
- An angiogram table that permits fluoroscopic imaging of the abdomen is required.
- The arterial anatomy needs to be defined clearly.
- CT angiogram or MR angiogram may provide sufficient detail for operative planning.
- Preoperative stratification with a full history and physical examination is required.
- Eagle criteria or another cardiac risk stratification algorithm can be used to calculate the patient's perioperative risk for coronary events and need for further workup.
- All patients should receive optimal medical therapy in the perioperative period, including:
- Statin therapy, with a goal low-density lipoprotein (LDL) cholesterol of < 100 mg/dL.
- Tight blood glucose control, with ...
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