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Chapter 34
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Abdominal Aortic Aneurysms (AAA):
Actual Approach
Ionel Droc1, Gabriela Droc2, Cosmin Buzila1, Francisca Blanca Calinescu
1
Army’s Center for Cardiovascular diseases, Bucharest, Romania; 2University of Medicine “Carol Davila”, Bucharest, Romania; 3University of
Medicine “Vasile Goldis”, Arad, Romania
Chapter Outline
Introduction 393
Open Repair of AAA 393
The Endovascular Repair 395
Follow-Up of EVAR 397
Anesthetic Considerations for AAA 397
Therapeutic Strategies for rAAA 400
Complications After Ruptured AAA Treated Endovascularly 400
Conclusions 400
References 401
3
INTRODUCTION
Abdominal aortic aneurysm (AAA) represents a major health problem in developed countries. It affects between 2% and 8%
of males over the age of 60 [1] and 1% of women older than 64 years [2]. The natural evolution of AAA is without symptoms
leading to the need for screening of population at risk. The incidence of rupture is between 5.6 and 17.5/100,000 persons/year.
The overall mortality rate of ruptured AAA (rAAA) is 80%–90% [2]. A lot of patients with AAA remain asymptomatic until
rupture occurs. Usually, rapid rising in diameter of the aneurysm is associated with rupture, more than 0.5 cm in 6 months [3].
In studies of natural history of AAA, the rate of rupture and death could exceed 60% within 3 years of the initial diagnosis [4].
Early diagnostic and prophylactic surgical intervention (open or endovascular) are essential to prevent rupture.
In the United States, more than 15,000 deaths/year are caused by aneurysm rupture [5].
The open repair (OR) of the AAA, pioneered in the 1950s, still remains the most durable intervention. Improvements in
patient selection, preoperative preparations, anesthesia, and postoperative care have made this intervention a safe surgical
option for most patients. The mortality ranges between 3% and 5% for uncomplicated cases in centers with high volume
of activity [5]. But patients are older and with a lot of comorbidities particularly with coronary artery disease, extracranial
carotid disease, peripheral artery disease, renal failure, or chronic obstructive pulmonary disease. In this high-risk group of
patients, the mortality rate is higher and the therapeutic strategy should be individualized [6,7].
Endovascular aneurysm repair (EVAR), first done by Parodi in Brasil and Volodos in Ukraine in 1991, has changed the
way of treatment of AAAs, decreasing dramatically the risk related to the intervention. In addition, patients with extensive
comorbidities in whom OR is contraindicated may be successfully treated using endovascular procedures.
OPEN REPAIR OF AAA
Management of AAA is dictated mostly by the risk of rupture associated to life expectancy and perioperative mortality
risk. The risk of rupture is 1%–3% per year for aneurysm between 4 and 5 cm in transversal diameter and rises to 6%–11%
per year when the aneurysm reaches 5–7 cm and can be as high as 20% per year for diameters larger than 7 cm. They are
subject to surgical treatment aneurysms that cause symptoms or have a rapid growth and generally prophylactic repair for
aneurysms of 4.5–5 cm of transversal diameter in women and 5–5.5 cm in men [3,4].
Surgical intervention will allow the replacement of the affected segment of the aorta with a synthetic graft. This type of
surgery is a high-risk procedure. Once the indication is established, the specific approach is individualized according to the
anatomic suitability, the relationship with the renal arteries, and the involvement of the iliac arteries.
New Approaches to Aortic Diseases from Valve to Abdominal Bifurcation. http://dx.doi.org/10.1016/B978-0-12-809979-7.00034-1
Copyright © 2018 Elsevier Inc. All rights reserved.
393
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FIGURE 34.1 Open repair of infrarenal abdominal aortic aneurysm (AAA): standard procedure with median laparotomy. (A) Xifopubian midline incision; (B) Retroperitoneal dissection of the aneurysm and clamping of the aorta and iliac arteries; (C) Proximal anastomosis: suturing the aorta to the graft
starting the suture from the posterior; (D) Tube graft replacement (aorto-aortic). Drawing by B. F. Calinescu.
The most utilized in open surgery is midline transperitoneal approach (Fig. 34.1).
The patient is placed in a supine position, prepared, and draped from his nipples to his knees. A long xifopubian midline
incision is done. After entering the abdominal cavity, a full exploration of all the intra-abdominal organs is a rule in order
not to pass near other pathologies not seen to preoperative CT scan. It is not recommended to combine an aseptic vascular
procedure with a potentially contaminated gastrointestinal time. After retracting superiorly, the greater omentum and the
transverse colon, putting the small bowel to the right side of the abdomen, the base of the mesenterium is exposed and we
enter through the posterior peritoneum in the retroperitoneal space, exposing the aneurysmal infrarenal aorta from the left
renal vein to the left and right iliac arteries [8].
In rare cases of juxtarenal aneurysms, the left renal vein is divided close to the inferior vena cava, ligated or clamped to
have access to the neck of the aneurysm and reestablish the vein continuity end to end or by interposition of a short polytetrafluoroethylene (PTFE) graft (Fig. 34.2).
Distally, the common iliac arteries should be exposed for clamping. If the aneurysm involves one or both common iliac
arteries, the dissection should descend to the bifurcation of the iliac arteries to have control of both external and internal
iliac arteries. Circumferential aortic or iliac dissection if not done carefully may lead to venous injuries, which are not easy
to repair, due to their posterior position.
General heparinization should be done before clamping. To achieve this goal, effective team work and communication are essential. The proximal aortic cross-clamping should be done first and then the two iliac arteries.
The aneurysm is then opened longitudinally and the mural thrombus is removed. Any bleeding from the lumbar
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FIGURE 34.2 Operative image of abdominal aortic aneurysm (AAA) with left renal vein reconstruction.
arteries should be sutured. If the inferior mesenteric artery (IMA) has a good flow, it can be anastomosed to the
graft at the end of the procedure, with lateral clamping of the graft. But usually IMA could be ligated without
any ischemic consequences.
If the aneurysm does not involve the iliac arteries, we can use a tube graft, Dacron made (aorto aortic bypass). If we
have good iliac artery for the distal anastomosis, we can perform an aorto biiliac bypass for the exclusion of the AAA. If
the iliac arteries are heavily calcified, stenosed, or occluded, an aorto bifemoral bypass should be done, using a bifurcated
Dacron graft, usually 16/8 mm in diameter.
Sometimes, the aneurysmal illness involves also the common femoral arteries. In this situation, we should treat all the
aneurysms at the same time, doing an aorto bifemoral bypass (Fig. 34.3).
Taking into account the hypogastric arteries, at least one should be kept in circulation whenever possible, to avoid buttock claudication or pelvic ischemia.
The aneurysmal sac should be sutured over the graft and the posterior peritoneum should be sutured with separate
stitches to avoid the direct contact of the duodenum and the bowel with the prosthesis.
The left retropritoneal approach is less used. It is recommended in juxtarenal aneurysms and has better respiratory
recovery in postoperative period. In adjunction with left kidney elevation, we can have excellent exposure of the juxta and
suprarenal aorta for appropriate cross-clamping without dividing the left renal vein.
Perioperative complications include hemorrhage, renal injury, lower extremity embolization, and colonic ischemia.
The postoperative complications of OR can be classified in early and late complications.
In the first 30 days postoperatively, we can deal with respiratory complications (8%–16%), major cardiac (3%–8%),
renal (2%–10%), bowel ischemia (1%–3%), and sexual (erectile dysfunction and retrograde ejaculation, due to sympathetic
nerve dissection around iliac arteries) [9].
The late complications are less common. They may include graft infection (0.3%–1.3%), aortoenteric fistula (0.3%–
1.6%), anastomotic pseudoaneurysm (proximal:1%–3%, distal 8%–9%), or limb occlusion (1.6%–5.3%). Other complications that could necessitate intervention are ventral hernia, bowel stenosis, or obstruction and ischemic colitis.
Another possible complication following open AAA repair is chylous ascites due to cisterna chyli injured during the
surgical dissection [10].
THE ENDOVASCULAR REPAIR
As with open surgery, the objective of endovascular management is to provide a durable repair maintaining flow in the graft
while excluding flow in the aneurysm and so preventing rupture.
Multicenter trials and large prospective registries have shown in the past 25 years that EVAR reduces mortality rate in
these high-risk patients [2].
Technological evolution of EVAR has been rapid in comparison to the time required for the development of successful
open aneurysm repair. EVAR is nowadays considered the technique of first choice for infrarenal AAAs with suitable aortic
anatomy. More than two-thirds of all AAA repairs are done endovascularly [3,11,12].
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FIGURE 34.3 Abdominal aortic aneurysm with aneurysmal common femoral arteries—the reconstruction: Ao-bifemoral bypass. (A) Femoral aneurysm; (B) Right leg of the aorto-bifemoral prosthesis.
Benefits of endovascular treatment are no large abdominal incision, lower bleeding risk, less postoperative pain and
complications, faster recovery, shorter intensive care unit, and in-hospital stay. However, as any other intervention or technique besides advantages EVAR also has limitations.
The technique of introduction and deployment of standard modular endograft is shortly described. The access sites are the
two common femoral arteries through a short cut down. Two introducer sheaths are placed in each femoral artery. A pigtail
catheter is placed into the suprarenal aorta for angiographic purposes. At the intraoperative angiogram the position of the renal
arteries, aortic bifurcation and internal iliac arteries are noted. Measurements are checked and compared with the preoperative
data on the computed tomography angiogram (CTA). The appropriate endograft is selected. The main body is introduced on a
superstiff guide wire taking care of the tortuosity of the iliac arteries. After positioning the device under the origin of the renals,
the graft is deployed. The contralateral leg is engaged from the contralateral side after the guide wire enters the main body
and a pigtail is rotating to be sure that we are inside the graft [13]. All overlapping segments are dilated by balloon as are the
proximal sealing zone and the distal sealing zone. At the end, an angiography is performed to rule out endoleaks.
Endovascular grafts may be bifurcated or tubular unibody grafts, modular multicomponent grafts, or aorto-unilateral
grafts with a contralateral iliac occluder (followed by surgical femoro-femoral cross over bypass). The unibody prosthesis
(Powerlink Endologix) builds up the endoluminal channel from the aortic bifurcation to the renals preventing distal migration of the endoprosthesis.
As stent technologies evolve we have to deal with fenestrated, branched, snorkel stent grafts allowing treatment for dif-
ficult anatomies.
For the treatment of juxtarenal aortic aneurysms, we can use fenestrated stent grafts (if the length of the neck does not provide
a sufficient sealing zone). If the renal arteries originates from the aneurysmal sac a branched stent graft is a better choice [13].
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Parallel stents or chimneys comprise stents that are placed parallel to the aortic stent graft to maintain perfusion into
the aortic vessels.
Endovascular aortic sealing (EVAS) is a novel treatment using a polymer within the endobags in order to diminish
the endoleaks, especially type II. EVAS in conjunction with parallel stents may potentially be an alternative for fenestrated EVAR. This new technique has gained European Community (CE) mark in 2013 with the Nellix endoprothethis
(Endologix). It consists of two balloon expandable cobalt–chromium stents surrounded by PTFE grafts. The endobags are
of polyurethane. They are filled with a polyethylene glycol-based hydrogel and extents the anatomical fixation from the
proximal and distal end also to the aneurysmal sac. This technology may reduce the incidence of type II endoleaks and may
treat a wider range of unfavorable morphologies [14].
The outcome of EVAR is highly dependent on the morphological suitability of the AAA. The morphological criteria
of the AAA are the one that can establish or exclude the indication of EVAR. The failure to comply with these criteria,
requested also in the instruction manuals of the endoprostheses currently on the market, may lead to the increase of the
peri- and postoperative complications, reinterventions, and post-EVAR mortality rate [15,16]. Preoperative evaluation of
the patients includes a CTA of the abdomen and pelvis, completed by chest if we plan a brachial access. This investigation
will give us information about the size and the shape of the aorta and visceral vessels, iliac and femoral arteries, tortuosity,
degree of calcification or stenosis, as well as angulations [17].
The specific complications of EVAR are endoleaks meaning the presence of blood flow outside the graft but within
the aneurysm sac. They can cause the aneurysm enlargement and increase the risk of rupture. The incidence is about 14%.
The endoleaks are classified from type I to V; type I and III should be treated when detected; type II are more frequent and
generally considered benign [18].
Percutaneous EVAR (pEVAR) is more and more used to avoid the local complications of the exposure of the
common femoral arteries. There are specific devices such as Perclose ProGlide (Abbott Vascular) for this method.
This technique is not to be used when there is severe femoral artery calcification, scarred groins, or femoral artery
aneurysm [19].
The rates of endovascular treatment are quite different among countries all around the world. For example, in Germany
and Australia more than 70% of the procedures are endovascular in comparison with Denmark where only one-third is
done by EVAR. The 2013 EVAR rates show a clear shift toward the endovascular treatment in developed countries, and a
significant increase in the less developed ones [20].
There are several types of endografts commonly in use today. The main features and differences are shown in
Table 34.1. The choice of the endograft should be done individually related to the anatomy of the aorta and the experi-
ence of the team.
FOLLOW-UP OF EVAR
Although multiple imaging modalities are available for AAA monitoring following EVAR, CT has been the most com-
monly used modality and it remains the gold standard (Fig. 34.4). However, given the need for lifelong surveillance, the
cumulative exposure to ionizing radiation is a concern, particularly for younger patients. As a consequence, other methods
to explore the aorta and the graft are more and more used: ultrasound, contrast-enhanced ultrasound, magnetic resonance
angiography, and implantable pressure sensors [21,22].
The aneurysmal sac enlargement in the follow-up of EVAR indicates a high risk of rupture and needs surgical explantation of the endoprosthesis (Fig. 34.5).
Total laparoscopic aortic surgery aims to achieve similar results to those of open aortic surgery while avoiding the
physiological stress associated with laparotomy. Centers from Europe and Canada have developed the laparoscopic aortic surgery (Dion et al. in 1993 and Coggia in France demonstrated its feasibility) [23]. This technique could be offered
in centers well trained in laparoscopic surgery. It has his indication in patients unfit for EVAR but where the open surgery
is too hazardous due to the comorbidities of the patient. Rouhani in UK reported a 30-day mortality between 0% and
6% similar with OR [24]. Reviewing the perioperative outcomes, he concluded that this technique is feasible and safe
in comparison to OR.
ANESTHETIC CONSIDERATIONS FOR AAA
Patients presenting for AAA repair are generally old and with extensive comorbidities and are real challenges for anesthesiologists. Risk assessment is established at the preanesthetic visit and is discussed with the whole team to establish best
therapeutic approach on a case-to-case basis.
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tem; magnet accelerated cannulation
introducer sheath
Lowest profile system I7F
mechanism
hydrogel
Polyester Nitinol Self-expanding 21–34 120–210 Fully repositionable deployment sys-
Polyester Nitinol Self-expanding 22–36 112–116
Polyester Nitinol Self-expanding 23–36 90–200 “tip capture” mechanism
Polyester Nitinol Self-expanding 22–35 100–212 C3 delivery system
Polyester Nitinol Self-expanding 22–36 112–179 Hydrophilic kink-resistant Flexor
TABLE 34.1 Current Abdominal Aortic Stent Grafts in Use
Type of Device Graft Material Stent Material Deployment Diameter (mm) Length (mm) Remarks
Anaconda (Vascutek Terumo
Group)
Talent AAA device (Medtronic,
Inc. Minneapolis, MN)
Endurant II (Medtronic, Inc.
Minneapolis, MN)
Excluder (Gore & Associates,
Flagstaff, AZ),
Zenith Flex AAA endovas-
cular graft (Cook Medical
Bloomington, IN)
ePTFE Nitinol Self-expanding 22–34 120–207 Unibody
Polyester Nitinol Self-expanding 24–34 130–230 Squeeze-to-Release deployment
AFX endovascular system
(Endologix, Inc., Irvine, CA)
E-vita ABDOMINAL XT Stent
Polyester Nitinol Self-expanding 23–36 130–170
Graft System (Jotec Gmbh,
Germany)
E-tegra Stent Graft System (Jotec
Gmbh, Germany)
ePTFE Nitinol Self-expanding 20–34 130–190 Lowest profile endograft system
Ovation PRIME abdominal stent
graft system (TriVascular, Inc.,
Santa Rosa, CA)
Nellix (Endologix) ePTFE Cobalt Chrome Balloon expanding 18–32 100–200 Endobag field with glycol-based
ePTFE, expanded polytetrafluoroethylene.
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FIGURE 34.4 Multislice computed tomography with three-dimensional reconstruction of a patient treated with a Jotec endoprosthesis with a branched
right leg for the right hypogastric artery.
FIGURE 34.5 Explantation of an endoprosthesis for sac enlargement and aorto biiliac bypass using the two legs of the endoprosthesis.
Preoperative assessment is important not only in evaluating risks for this procedure but also in determining strategies to
minimize that risk whenever possible.
Techniques for anesthesia management may differ if we are talking of OR or endovascular approach. Whenever EVAR
is possible, the intervention is considered of intermediate risk as opposed to OR, which is a high-risk procedure according
to the American College of Cardiology/American Heart Association guidelines [25].
When talking about an OR, general anesthesia (GA) is of choice; epidural analgesia both for intraoperative and
postoperative purpose can be proposed, it will also help in the rapid recovery of bowel function postintervention [26].
EVAR is less invasive and anesthesia will be the same. Regional or local monitored anesthesia care is of choice; it can
range from full neuraxial blockade to local infiltrations associated with sedation. Advantages of this type of management
are a shorter length of stay in hospital and fewer postoperative complications [27]. But sometimes the hemodynamic status
of the patient, the presence of heavy comorbidities (chronic obstructive pulmonary disease, congestive heart failure), the
presence of antiplatelet drugs and/or anticoagulation, the estimation of a lengthy procedure may dictate the need for GA.
GA will allow easier hemodynamic management, blood loss control ,and offer the whole team the comfort of a secure
airway.
Monitoring for OR or for EVAR should be invasive. Standard monitoring will be with pulseoximetry, capnography, continuous electrocardiogram, urine output, and temperature measurement associated with at least an invasive blood pressure
monitoring. Venous access is obtained with large bore catheters to be able to quickly compensate any blood loss. Central
venous access is not routinely used but in some cases can be considered useful.
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After the intervention, patients need to be placed in a postanesthesia care unit for analgesia and proper
surveillance. The length of stay depends on the type of procedure chosen, which is shorter for the less invasive
techniques [3].
THERAPEUTIC STRATEGIES FOR RAAA
In the present, the outcome after rAAA repair has significantly improved. Nevertheless, even after the development
of the EVAR techniques, the rAAA repair is very challenging and is associated with a high postoperative mortality
rate [28].
In the rAAA patients, preoperative management it is very important to obtain the hemodynamic stability (supporting the vital organs perfusion) and to prevent (if possible) the shock state occurrence [28]. On the other hand, the
excessive fluid administration should be avoided before obtaining control on the aorta to avoid further hemorrhaging
[28]. The concept of “permissive hypotension” suggests to maintain the systolic blood pressure at 70–80 mmHg and
the fluid resuscitation must be performed avoiding blood pressure over 100 mmHg [29].
COMPLICATIONS AFTER RUPTURED AAA TREATED ENDOVASCULARLY
One of the most serious complications following EVAR in rAAA patients is represented by the abdominal compartment
syndrome [30,31]. In this case, the factors leading to intra-abdominal hypertension and subsequent abdominal compartment
syndrome may be hematomas in the retroperitoneum, bleeding (lumbar arteries, IMA), coagulopathies, or tissue edema
occurring due to a shock state [28,32].
CONCLUSIONS
Patient selection is crucial in the successful treatment of AAA. We should carefully investigate and consider the anatomy
of the abdominal aorta but also the comorbidities of the patient when we establish the treatment we propose. We also have
to take into consideration the opinion of the patient. The “aorta team” formed by a vascular surgeon, anesthesiologist, and
a cardiologist will individualize the treatment. The clinical practice guidelines of the European Society of vascular surgery
(2011) set out a series of recommendations, modified by us (Fig. 34.6)
Knowing that 5 years ago 20%–40% of AAAs were unfit for EVAR, the development of the new devices, with
lowest profile introduction systems and techniques have to face difficult anatomies to treat most of the AAAs
[4,23].
Endovascular aortic repair has demonstrated good results in both acute and chronic pathology. Branched or fenestrated graft technologies will develop and allow complete endovascular aortic procedures, which can compare with
open surgery.
Consideration of
AAA repair
AAA morphology
assessment
Fit forEVAR
Standard
endoprosthesis
Custom made
endoprosthesis
Unfit for EVAR
Open
surgery
Laparoscopic
surgery
FIGURE 34.6 Management of abdominal aortic aneurysm (AAA) with surgical indication. EVAR, endovascular aneurysm repair. Modified after Moll [33].
Transabdominal
approach
Retroperitoneal
approach
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