Abdominal aortic aneurysm surgery

Abdominal Aortic Aneurysm Microchapters
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]

Surgery

Indications for repair

• Symptomatic
• Rupture/ contained rupture
• Diameter > 5.5 cm
• Expansion > 1.0 cm in 1 year
• Inflammatory or infectious etiology

Pre-Operative Assessment

• The ADAM trial suggested that the "biological age," as reflected by the condition of the vital organs such as the lungs, kidneys, heart was more important than the chronological age as a determinant of operative outcome. ADAMref4
• Patients with poor renal and pulmonary function have worse operative outcomes

  • Chronic obstructive pulmonary disease
  • Elevated creatinine concentrations
  • Electrocardiographic evidence of ischemia

• Aortic factors implicated in postoperative morbidity and mortality include:

  • Extensive atheromatous disease
  • Mural calcification
  • Thrombosis
  • Juxtarenal extension of aneurysm
  • Inflammatory aortic aneurysms
  • The increased risk resulted from:

    • Longer suprapenal clamping time
    • Need for complex dissection
    • Increased hemodynamic stresses

Surgery options

The treatment options for asymptomatic AAA are immediate repair, surveillance with a view to eventual repair, and conservative. There are currently two modes of repair available for an AAA: open aneurysm repair (OR), and endovascular aneurysm repair (EVAR).

• Conservative treatment
  • Smoking cessation
  • Blood pressure control.
  • Indicated when repair carries a high risk of mortality and is unlikely to improve life expectancy.

• Surveillance
  • Surveillance is indicated when the risk of repair exceeds the risk of rupture.
  • Although some controversies exists around the world, most vascular surgeons would not consider repair until the aneurysm reached a diameter of 5cm.
  • The threshold for repair varies slightly from individual to individual, depending on the balance of risks and benefits when considering repair versus ongoing surveillance.
  • The size of an individual's native aorta may influence this, along with the presence of comorbitities that increase operative risk or decrease life expectancy.

• Open repair (operation):
  • Indicated in -
    • Young patients as an elective procedure
    • Growing
    • Symptomatic
    • Ruptured aneurysms

• Endovascular repair:
  • Indicated in older, high risk patients or those unfit for open repair.
  • Advantages over open repair:
    • The peri-operative period has less impact on the patient

1. Less time in intensive care unit,
2. Less time in hospital overall, and
3. Earlier return to normal activity.*** Lower mortality compared to open repair

• • Disadvantages:
    • Endovascular repair requires more frequent ongoing hospital reviews and a higher chance of further procedure being required
    • It does not offer any survival benefit.
    • Although it has a lower mortality compared to open repair, it has unknown long term mortality

Complications of EVAR

Endoleaks

• Incomplete seal at proximal or distal stent attachment
• Leaking into the sac from branch vessels
• Failure of anastomosis between stent components
• Leakage through graft material

Surgery and Device Based Therapy

2011 ACCF/AHA Focused Update of the Guideline for the Management of Patients With Peripheral Artery Disease (Updating the 2005 Guideline) - Recommendations for Management of Abdominal Aortic Aneurysm (DO NOT EDIT)

Class I

1. Open or endovascular repair of infrarenal AAAs and/or common iliac aneurysms is indicated in patients who are good surgical candidates. (Level of Evidence: A)

2. Periodic long-term surveillance imaging should be performed to monitor for endoleak, confirm graft position, document shrinkage or stability of the excluded aneurysm sac, and determine the need for further intervention in patients who have undergone endovascular repair of infrarenal aortic and/or iliac aneurysms. (Level of Evidence: A)

Class IIa

1.Open aneurysm repair is reasonable to perform in patients who are good surgical candidates but who cannot comply with the periodic long-term surveillance required after endovascular repair. (Level of Evidence:C)

Class IIb

1.Endovascular repair of infrarenal aortic aneurysms in patients who are at high surgical or anesthetic risk as determined by the presence of coexisting severe cardiac, pulmonary, and/or renal disease is of uncertain effectiveness. (Level of Evidence:B)

ACC/ AHA Guidelines - Recommendations for surgery of Abdomino-thoracic surgery (DO NOT EDIT)

Class I

1. For patients with chronic dissection, particularly if associated with a connective tissue disorder, but without significant comorbid disease, and a descending thoracic aortic diameter exceeding 5.5 cm, open repair is recommended (Level of Evidence: B)

2. For patients with degenerative or traumatic aneurysms of the descending thoracic aorta exceeding 5.5 cm, saccular aneurysms, or postoperative pseudoaneurysms, endovascular stent grafting should be strongly considered when feasible(Level of Evidence: B)

3.For patients with thoracoabdominal aneurysms, in whom endovascular stent graft options are limited and surgical morbidity is elevated, elective surgery is recommended if the aortic diameter exceeds 6.0 cm, or less if a connective tissue disorder such as Marfan or Loeys-Dietz syndrome is present (Level of Evidence: C)

4. For patients with thoracoabdominal aneurysms and with end-organ ischemia or significant stenosis from atherosclerotic visceral artery disease, an additional revascularization procedure is recommended(Level of Evidence:B)

References

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