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  • Symptomatic or ruptured abdominal aortic aneurysm (AAA) of any size.
  • Asymptomatic AAA ≥ 5.5 cm or > 0.8-cm growth in 12 months.

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Absolute

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  • None.

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Relative

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  • Malignancy with limited life expectancy.
  • Prohibitive medical comorbidities.

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  • 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%.

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Expected Benefits

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  • Exclusion of the aneurysm wall from the systemic circulation and associated pressure, thereby preventing its rupture.

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Potential Risks

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Open Repair

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  • 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.

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Endovascular Repair

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  • 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).

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Open Repair

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  • Vascular surgery instrument tray.
  • Bookwalter or Omni retractor for abdominal exposure.
  • Graft material (Dacron or polytetrafluoroethylene [PTFE] of various sizes, 12–36 mm).

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Endovascular Repair

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  • 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.

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  • 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:
    • β-Blockers.
    • Statin therapy, with a goal low-density lipoprotein (LDL) cholesterol of < 100 mg/dL.
    • Tight blood glucose control, with ...

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