Chapter 34. Management of Infrarenal Abdominal Aortic Aneurysm

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

Absolute

• None.

Relative

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

Open Repair

• Anterior approach: the patient should be supine, with a lumbar roll placed to allow for better aortic exposure and arms extended on arm boards.
• Retroperitoneal approach: the patient should be in left lateral decubitus position.

Endovascular Repair

• The patient should be supine on the angiotable, with both arms tucked or extended.

Both Procedures

• A nasogastric tube is inserted.
• A Foley catheter is placed.
• Distal pulses are marked.
• Two large-bore intravenous lines are placed to provide for rapid infusion.
• A radial arterial line is placed for hemodynamic monitoring.

Open Repair

• Patients usually are extubated in the operating room or within the first 12 hours and out of bed by postoperative day (POD) 1.
• The typical patient requires up to 2 days in the ICU.
• During the first 24–48 hours, patients require adequate fluid resuscitation.
• We recommend aggressive diuresis of uncomplicated patients starting on POD 3 to prevent cardiac and pulmonary complications.
• All central venous lines and arterial catheters should be removed as early as possible to decrease the risks of catheter-related infections.
• The nasogastric tube may be removed on POD 1 or according to physician preference.
• Most patients who have uncomplicated procedures are ready for discharge home by POD 7.

Endovascular Repair

• Patients are extubated in the operating room.
• Patients should be assigned to a telemetry floor bed.
• Most patients with uncomplicated procedures are ready for discharge by POD 1 or 2.

Open Repair

Intraoperative Complications

• Injury to the small bowel, colon, ureter, or major venous structures.

Postoperative Complications

• Myocardial infarction.
• Bleeding.
• Infections, including urinary tract or wound complications.
• Pneumonia.
• Bowel ischemia (particularly of the descending and sigmoid colon).
• Lower extremity ischemia from distal embolization, thrombosis, or clamp injuries.
• Renal failure.

Endovascular Repair

Intraoperative Complications

• Malposition of the graft.
• Arterial dissection or rupture.
• Avulsion of iliac arteries.
• Endoleaks.

Postoperative Complications

• Myocardial infarction.
• Infections, including urinary tract or wound complications.
• Pneumonia.
• Bowel ischemia (particularly of the descending and sigmoid colon).
• Lower extremity ischemia from distal embolization, thrombosis, or clamp injuries.
• Renal failure.