Ruptured abdominal aortic aneurysm (AAA) is a common cause of death. Abdominal aortic aneurysms tend to be asymptomatic until the time of rupture, which has a mortality rate of greater than 80%. Therefore, elective repair prior to rupture is preferred if life expectancy is reasonable and the risk of rupture outweighs the risk of repair. Mr F, a 66-year-old man with a 5.2-cm AAA, illustrates the issues surrounding monitoring and treating AAA. Risk factors for AAA include older age, male sex, smoking history, and a family history of AAA. Screening for AAA with ultrasound has been shown to prevent rupture, prevent AAA-related death, and be cost-effective. Risk factors for rupture include larger diameter, female sex, and smoking history. Endovascular repair has lower operative mortality and complications and has replaced standard open surgery in more than half of patients. However, long-term survival is similar after endovascular and open surgical repair. Those at risk of AAA who would benefit from repair should undergo screening.
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A, The ultrasound shows the diameter of the infrarenal abdominal aortic aneurysm. B, Left slice shows the aneurysm and thrombus involving the infrarenal aorta. The aneurysm extends up to and possibly involves the main renal artery origins. The left slice illustrates the importance of appropriate plane when assessing diameter in the presence of angulation or tortuosity of the aorta. The horizontal line shows Mr F's aorta measurement as 5.2 cm, whereas the diagonal line shows the more accurate measurement, perpendicular to the center line of the aorta, as 4.6 cm. In both slices, a large accessory left renal artery arising from lower aorta involved in the aneurysm can be seen (yellow arrowheads). Note also the presence of 2 right renal arteries (black arrowhead). See interactive Figure of the computed tomographic angiogram here.
A, With open repair, the abdomen is opened anteriorly (as shown) or from a lateral retroperitoneal approach. The aorta is clamped, preferably below the renal arteries, and the common iliac arteries are both clamped. The aneurysm sac is opened longitudinally; backbleeding lumbar arteries and the inferior mesenteric artery are typically suture-ligated. A prosthetic graft is then sutured in place proximally and distally. A bifurcated graft (shown) is used in more than half of cases with the distal anastomoses to the common iliac or, rarely, the common femoral arteries, as opposed to a straight tube graft sewn to the aortic bifurcation. The aneurysm sac is then closed over the graft to provide separation of the graft from the intestines. B, With endovascular repair, stiff wires are introduced through the common femoral arteries over which a fabric covered stent (stent-graft) is introduced. The proximal graft is positioned just below the renal arteries. The stent-graft is initially constrained in a low-profile state until deployment. A modular device is depicted in which a separate component for the left iliac limb is inserted through and overlaps with a docking limb on the main device. Ultimately, there is a seal zone in the normal infrarenal aorta and bilateral iliac arteries, thereby excluding the abdominal aortic aneurysm. See animation of surgical procedures here.
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Open and Endovascular Repair of Abdominal Aortic Aneurysm
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