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Open Surgical Treatment of Ruptured Infrarenal Aortic Aneurysms
Despite numerous medical and surgical technological advances in the past decade, rupture of an abdominal aortic aneurysm (AAA) still portends an exceedingly poor prognosis, with mortality rates greater than 90%, including patients who do not survive long enough to undergo medical evaluation. Reports from national data indicate that with the recent endovascular revolution, the annual number of patients experiencing ruptured AAA has slightly diminished as the numbers of elective endovascular aneurysm repair (EVAR) have increased nationally. This effect is more pronounced for men than for women, who continue to experience aneurysm rupture at an unchanged rate. To what extent newly supported AAA screening efforts for men older than 65 years could further decrease these rupture rates remains to be seen.
Diagnosis
The approach to the suspected AAA rupture has markedly changed in recent years as the availability of rapid diagnostic modalities has become more commonplace. The traditional surgical teaching that a patient with hypotension, back pain, and a pulsatile abdominal mass should be taken directly to the operating room still has value as a tenet; however, it is not universally applicable. Many centers now have a protocol-driven approach to suspected aneurysm rupture whereby a stance of permissive hypotension is maintained. This strategy is derived from the trauma literature and entails limiting volume resuscitation to the extent that the patient maintains consciousness and a detectable blood pressure to limit over-resuscitation and promote ongoing uncontrolled hemorrhage. If these tenets are met, many centers simultaneously ready the hybrid operating room for both open and endovascular repair while expeditiously performing a 64-slice computed tomography angiogram (CTA) of the abdomen and pelvis. Many trauma and referral centers can perform these studies within the emergency department and have three-dimensional reconstructions available to view in a matter of minutes.
In a patient who is truly hemodynamically unstable, only two things prevent the patient’s imminent demise: proximal control of the aorta and intravenous access to allow volume and blood-product resuscitation. With this scenario, it is appropriate to follow the time-tested principle of rapid transit to the operating room, pausing only to send a blood sample to the blood bank with the intent of having six units of blood immediately available, as well as having other products including fresh frozen plasma (FFP), platelets, and cryoprecipitate sent to the operating room to limit the unavoidable dilutional coagulopathy that will ensue.
In patients who are systemically anticoagulated on warfarin for other medical reasons, anticoagulation should be rapidly reversed. This reversal is traditionally performed with a combination of vitamin K and FFP. Anticoagulation should not delay the transfer process. Newer agents are available, such as prothrombin complex concentrates (PCCs) and recombinant activated factor VII (rFVIIa), that can allow a rapid reversal of warfarin-induced coagulopathy with a small volume of fluid. Enthusiasm for the ease and rapidity of the administration of these products must be tempered by the unmeasured potential for thrombotic complications, as well as the exorbitant health care costs associated with their use. The cell-saver autotransfusion device should be used if it is available because it can decrease the requirement for banked blood to some degree.
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