How is open surgery performed on a patient with abdominal aortic aneurysm (AAA)?

Updated: Jan 08, 2019
  • Author: Saum A Rahimi, MD, FACS; Chief Editor: Vincent Lopez Rowe, MD  more...
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Answer

The aorta may be approached either transabdominally or through the retroperitoneal space. Juxtarenal and suprarenal aortic aneurysms are approached from the left retroperitoneal space. Self-retaining retractors are used. The bowel is kept warm and, if possible, is not exteriorized. The abdomen is explored for abnormalities (eg, gallstones or associated intestinal or pancreatic malignancy). Depending on the anatomy, the aorta can be reconstructed with a tube graft, an aortic iliac bifurcation graft, or an aortofemoral bypass.

For proximal infrarenal control, the first step is to identify the left renal vein. Occasionally (<5% of cases), patients may have a retroaortic vein. In this situation, care must be taken in placing the proximal clamp. Division of the left renal vein is usually required for clamping above the renal arteries.

Before aortic cross-clamping, the patient is heparinized (5000 U IV). If significant intraluminal debris, juxtarenal thrombus, or prior peripheral embolization is present, the distal arteries are clamped first, followed by aortic clamping.

With respect to pelvic outflow, the inferior mesenteric artery is sacrificed in most instances. Therefore, to prevent colon ischemia, every attempt must be made to restore perfusion from at least one hypogastric (internal iliac) artery. If the hypogastric arteries are sacrificed (eg, because of associated aneurysms), the inferior mesenteric artery should be reimplanted.

For supraceliac aortic control, the ligaments are first divided to the left lateral section of the liver, which is then retracted. The crura of the diaphragm are separated, and the aorta is bluntly dissected.

Supraceliac control is recommended for inflammatory aneurysms, along with minimal dissection of the duodenum and balloon occlusion of the iliac arteries. In patients with inflammatory aneurysms or large iliac artery aneurysms, the ureters should be identified; occasionally, ureteral stents are recommended in patients with inflammatory aneurysms.

The aorta is reconstructed from within by using a polytetrafluoroethylene (PTFE) or Dacron graft. The aneurysm sac is closed, and the graft is put into the duodenum to prevent erosion. Before restoration of lower-extremity blood flow, both forward flow (aortic) and backflow (iliac) are allowed to remove debris. The graft is also irrigated to flush out debris.

Before closure, the colon is inspected, and the femoral arteries are palpated. Before the patient leaves the operating room, the status of the lower-extremity circulation must be determined. If a clot was dislodged at the time of aortic clamping, it can be removed with a Fogarty embolectomy catheter. Heparin reversal usually is not required.


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