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Retroperitoneal Approach for Elective Abdominal Aortic Aneurysmectomy

The abdominal aorta, located posterior to the parietal peritoneum and adjacent to the spine, is by definition a retroperitoneal structure. The ease of aortic exposure from the supradiaphragmatic level to the iliac bifurcation makes a retroperitoneal approach an ideal option for both routine and complex aortic reconstruction. Techniques and appropriate indications vary for left-sided and right-sided retroperitoneal approaches in treating abdominal aortic aneurysms (AAA). Indications and…

Open Surgical Treatment of Pararenal and Suprarenal Abdominal Aortic Aneurysms

Pararenal abdominal aortic aneurysms (AAAs) are an uncommon but important category of aortic disease. Pararenal AAAs are classified as being juxtarenal ( Figure 1 A) or suprarenal ( Figure 1 B) in location. Juxtarenal AAAs extend superiorly to just below the renal arteries such that no normal aorta exists between the aneurysm and the renal arteries. Suprarenal AAAs extend superiorly to include the orifices of the…

Surgical Treatment of Infected Abdominal Aortic Aneurysms

Infected abdominal aortic aneurysms (AAAs) are very unusual, extremely challenging, and associated with high rates of morbidity and mortality. There are several mechanisms whereby the abdominal aorta can become infected, and this has led to several classification schemes. The first reported was septic embolization from cardiac valve vegetations. Described by Osler and originally called mycotic , because of the gross appearance of the vegetations, this is…

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…

Open Transperitoneal Surgical Treatment of Nonruptured Infrarenal Aortic Aneurysms

Open repair of an abdominal aortic aneurysm (AAA) had been the standard treatment for these lesions prior to the wide adoption of endovascular aneurysm repair (EVAR). Currently, in most developed countries, open repair of infrarenal AAAs is primarily performed in patients who do not fit the anatomic criteria for EVAR. In addition, some patients who may be good anatomic candidates for EVAR opt for open AAA…

Treatment of Aortic Endograft Migration

Caudal movement of the proximal aspect of an aortic endograft is a significant late failure of endovascular aneurysm repair (EVAR). This endograft migration can cause type Ia endoleak and enlargement and rupture of an abdominal aortic aneurysm (AAA). Thus, surveillance for and timely treatment of significant endograft migration is important in maximizing the long-term safety of EVAR. Definition Caudal movement of 10 mm or more, or…

Postoperative Surveillance of Thoracic and Abdominal Aortic Endografts

Postoperative surveillance is an integral part of the overall treatment strategy after endovascular aortic repair, and failure of surveillance can be considered tantamount to no treatment at all. Indeed, suspected noncompliance to follow-up during preoperative evaluation of a potential endovascular candidate can even be construed as a relative contraindication to the therapy. Lifelong follow-up after endovascular repair is one of the necessary burdens that the patient…

Neurologic Complications after Open and Endovascular Aortic Surgery

Neurologic complications after aortic surgery can range from minor irritants to life-threatening problems. It is important to recognize that the majority, but certainly not all, can be avoided by careful preoperative planning and meticulous intraoperative technique. Spinal Cord Injury The devastating neurologic injury following aortic surgery is spinal cord ischemia (SCI). This is true for open and endovascular procedures on the abdominal or thoracic aorta. Much…

Intestinal and Renal Ischemia Complicating Open and Endovascular Abdominal Aortic Reconstructions

Death, myocardial infarction, and bleeding are the complications most discussed with patients before aortic surgery, but kidney failure and intestinal injuries can be the most devastating and lead to a dramatically higher morbidity and mortality. This chapter reviews the etiology for the majority of these complications and describes how to recognize and avoid them. Renal Complications Postoperative acute kidney failure is the second most common cause…

Management of Acute Limb Ischemia Complicating Aortic Reconstruction

Scope of the Problem Historical reports documented acute limb ischemia in up to 25% of patients undergoing abdominal aortic surgery. With refinement of operative technique and the use of local and systemic anticoagulation, the incidence of this complication has decreased significantly, but it has not been eliminated. Data from the randomized aneurysm trials and large retrospective database analyses report perioperative thromboembolic complication rates between 1% and…

Treatment of Endovascular Leaks After Aortic Endografting

Endovascular abdominal aortic aneurysm repair (EVAR) is predicated on complete exclusion of the aneurysm from the arterial circulation. An endoleak, or continued arterial perfusion of the aneurysm sac after endovascular treatment, can compromise the effectiveness of EVAR. There are five major categories of endoleaks ( Table 1 ). Some appear to be an unavoidable consequence of placing a stent graft inside an aneurysm sac with patent…

Conversion to Open Surgical Treatment After Failed Endovascular Aortic Aneurysm Repair

Endovascular aneurysm repair (EVAR) has proved to be safe and effective for the primary treatment of aortic aneurysms. However, endoleaks, endotension, migration, and stent fracture can lead to aneurysm growth and rupture if not treated in a timely fashion. Although transition to newer-generation material and technology has improved the durability of EVAR, complications still occur. Despite the success rate of secondary interventions, patients who are not…

Endovascular Iliac Branch Devices for Iliac Aneurysms

Endovascular aneurysm repair (EVAR) offers significant benefits to many patients, yet the applicability of EVAR has been challenged in patients with unfavorable proximal necks or aneurysmal involvement of the iliac arteries. The latter situation occurs in 12% to 40% of patients. Standard therapy involves embolization or coverage of the internal iliac artery, which often results in buttock and thigh claudication and on rare occasion spinal cord…

Internal Iliac Artery Embolization as an Adjunct to Endovascular Aneurysm Repair

An important requirement for endovascular aortic or iliac aneurysm repair is the presence of an adequate distal landing zone in the common iliac artery. Aneurysmal aortas are associated with dilated common iliac arteries in about 20% of patients, making patients ineligible for standard endovascular repair. Because of the limit of a maximum diameter of commercially available iliac limbs, patients with large-diameter common iliac arteries do not…

Endovascular Treatment of Ruptured Infrarenal Aortic Aneurysms

Endovascular repair of a ruptured abdominal aortic aneurysm (rAAA) was first performed successfully by Marin and colleagues on April 21, 1994. A second case was reported by Yusuf and coworkers in 1994. Since then, many centers have employed endovascular aneurysm repair (EVAR) to treat rAAAs with varying results. Several groups have developed standardized systems of management for rAAAs, have used EVAR whenever possible, and have achieved…

Endovascular Treatment of Inflammatory Abdominal Aortic Aneurysms

Inflammatory abdominal aortic aneurysms (iAAAs) represent a small but challenging proportion of all AAAs. The evidence base for the management of iAAAs is sparse, particularly with respect to endovascular aneurysm repair (EVAR). iAAAs have historically been treated by a variety of open approaches with increased technical difficulty, but mortality is comparable to that of open repair of noninflammatory AAAs. Few data exist regarding iAAA repair in…

Endovascular Treatment of Pararenal and Suprarenal Abdominal Aortic Aneurysms

Endovascular aortic aneurysm repair (EVAR) is now entering its third decade and has matured into a viable alternative to open repair. The mandatory need for a suitable proximal landing zone (also referred to as “the proximal neck”) was overcome about a decade ago with the introduction of fenestrated grafts. Vital branches, such as the celiac axis, superior mesenteric artery, and renal arteries cannot be sacrificed without…