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Chapter 90. Open AAA Surgery

Megan Graybill Anders, MD; Harendra Arora, MD

  • Large intra-abdominal surgery with rapid hemodynamic changes and potential for high blood loss
  • Goal is to maintain intravascular volume and perfusion to brain, myocardium, kidneys, and central nervous system while controlling hemodynamics to prevent rupture
  • Indications for repair include size >5.5 cm (>4.5 cm in women), expansion >0.5 cm in 6 months, or presence of symptoms
  • Common comorbidities include CAD, PVD, chronic obstructive pulmonary disease (COPD), and HTN
  • Mortality from elective repair <5% (outcomes better with vascular surgeons at high-volume centers), mortality from emergent repair of rupture >50%
  • Endovascular repair has short-term mortality benefit for high-risk surgical candidates (e.g., severe CAD or COPD), although studies suggest equivalent long-term survival

  • Evaluate and optimize coexisting disease to define and minimize risk
  • Continue β-blocker therapy; if initiating therapy, titrate dose gently, to HR <70 while avoiding hypotension
  • Continue or consider initiating statin therapy, which may reduce perioperative cardiovascular complications by reducing inflammation and stabilizing plaques
  • Noninvasive evaluation of left ventricular (LV) function (e.g., echocardiogram) may be considered for patients with dyspnea of unknown origin or history of heart failure with worsening clinical status and no evaluation within 12 months
  • Cardiac testing is recommended if it will change management; however, prophylactic coronary artery revascularization via percutaneous coronary intervention (PCI) or CABG before vascular surgery has not been shown to improve short- or long-term survival. (CARP trial, 2004)
  • Brief list of equipment and drugs to prepare besides usual GA setup:
    • Possibly DL ETT if TAAA, with fiberoptic scope to check placement
    • Lumbar drain kit, if CSF drainage intended (discuss with surgeon)
    • A-line, CVL/Cordis, ± pulmonary artery catheter (PAC)
    • Transesophageal echo (TEE) if possible
    • Epidural kit
    • Cell saver
    • Rapid infuser device
    • Upper-body warming device only (do not rewarm ischemic lower extremities)
    • Nitroprusside (50 mg in 250 mL: 200 μg/mL; 0.5–10 μg/kg/min)
    • Nitroglycerin (50 mg in 250 mL: 200 μg/mL; 0.5–10 μg/kg/min)
    • Esmolol (2,500 mg in 250 mL: 10 mg/mL; 50–200 μg/kg/min)
    • Norepinephrine (4 mg in 250 mL: 16 μg/mL; 1–10 μg/min)
    • Phenylephrine (20 mg in 250 mL: 80 μg/mL; 0.2–1 μg/kg/min)

  • Per ASA standards, plus preinduction arterial line (side with highest NIBP) and central venous line 8.5 Fr. at least
  • Consider PAC for patients with systolic dysfunction (may help guide intra- and postoperative fluid therapy)
  • Consider TEE for patients with at-risk myocardium on preop stress test (may help identify evolving wall motion abnormality) or severe LV dysfunction
  • SSEP monitoring may help diagnose evolving spinal cord ischemia (especially with supraceliac cross-clamp, prolonged hypotension, known low origin of spinal accessory artery) and can help advise need for bypass or arterial reimplantation during procedure

  • Consider placing mid-thoracic (T8-9) epidural preop for postop pain control. Usually, epidural not used until after unclamping because of risk of extreme hypotension. Many vascular patients are on antiplatelet medications that will preclude neuraxial anesthesia
  • Lumbar drain may be placed for patients at higher risk for paraplegia (Crawford type I or II aneurysm; see Chapter 91)
  • Select induction agent appropriate for patient’s ...

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