Before the procedure, it is important to obtain a careful history and perform a physical examination and laboratory assessment. These basic evaluations provide the information that allows the treating physician to estimate perioperative risk and life expectancy after the proposed procedure.
Careful consideration should be given to the issue of whether the patient’s current quality of life is sufficient to justify the operative intervention. In the case of elderly persons who may be debilitated or may have mental deterioration, this decision is made in conjunction with the patient and family.
Once the decision in favor of surgical treatment is made, the next step is to identify any comorbid conditions or risk factors that may increase operative risk or decrease the chances of survival. To this end, the patient’s activity level, stamina, and stability of health are evaluated, and a thorough cardiac assessment is performed that is tailored to the patient’s history, symptoms, and results from preliminary screening tests (eg, ECG and stress testing).
Because COPD is an independent predictor of operative mortality, lung function should be assessed by performing room-air arterial blood gas measurement and pulmonary function tests. In patients with abnormal test results, preoperative intervention in the form of bronchodilators and pulmonary toilet often can reduce operative risks and postoperative complications.
Antibiotics (usually a cephalosporin, such as cefazolin, 1 g IV piggyback) are administered to reduce the risk of infection. Arranging for appropriate IV access to accommodate blood loss, arterial pressure monitoring through an arterial line, and Foley catheter placement to monitor urine output are routine preparations for surgery.
For patients at high risk because of cardiac compromise, a Swan-Ganz catheter is placed to assist with cardiac monitoring and volume assessment. Transesophageal echocardiography can be useful for monitoring ventricular volume and cardiac wall motion and for helping guide fluid replacement and pressor use.
Preparations are made for blood replacement. The patient should have blood available for transfusion. Intraoperative use of a cell salvage machine and preoperative autologous blood donation have become popular.
The patient’s body temperature should be kept at a normal level during the operative intervention to prevent coagulopathy and maintain normal metabolic function. To prevent hypothermia, a recirculating, warm forced-air blanket should be placed on the patient, and any IV fluids and blood should be warmed before being administered.
The skin is prepared from the nipples to the midthigh. General anesthesia is administered, with or without epidural anesthesia.
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Radiograph shows calcification of abdominal aorta. Left wall is clearly depicted and appears aneurysmal; however, right wall overlies spine.
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On radiography, lateral view clearly shows calcification of both walls of abdominal aortic aneurysm, allowing diagnosis to be made with certainty.
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CT demonstrates abdominal aortic aneurysm (AAA). Aneurysm was noted during workup for back pain, and CT was ordered after AAA was identified on radiography. No evidence of rupture is seen.
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Arteriography demonstrates infrarenal abdominal aortic aneurysm. This arteriogram was obtained in preparation for endovascular repair of aneurysm.
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Lateral arteriogram demonstrates infrarenal abdominal aortic aneurysm. Demonstration of superior mesenteric artery, inferior mesenteric artery, and celiac artery on lateral arteriogram is important for complete evaluation of extent of aneurysm.
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Arteriogram after successful endovascular repair of abdominal aortic aneurysm.
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Ultrasonogram from patient with abdominal aortic aneurysm (AAA). This aneurysm was best visualized on transverse or axial image. Patient underwent conventional AAA repair.
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MRI of 77-year-old man with leg pain believed to be secondary to degenerative disk disease. During evaluation, abdominal aortic aneurysm was discovered.
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Age is risk factor for development of aneurysm.
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Inflammation, thinning of media, and marked loss of elastin.
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Pulsatile abdominal mass.
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Aneurysm with retroperitoneal fibrosis and adhesion of duodenum.
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Aortic endoprosthesis (Cook aortic and aortobi-iliac endograft).
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Endoaneurysmorrhaphy
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Endovascular grafts.
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Atheroemboli from small abdominal aortic aneurysms produce livedo reticularis of feet (ie, blue toe syndrome).
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Enhanced spiral CT scans with multiplanar reconstruction and CT angiogram.
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Angiography is used to diagnose renal area. In this instance, endoleak represented continued pressurization of sac.
