Abdominal Aortic Aneurysm (AAR) Repair

Learning objectives

Etiology and complications of abdominal aortic aneurysm (AAA)
Anesthetic management of Abdominal aortic aneurysm (AAR) repair through an open incision or through EndoVascular Aneurysma Repair (EVAR)

Abdominal aortic aneurysm (AAR) repair is a procedure used to treat an aneurysm of the abdominal aorta
An aneurysm is a bulging, weak spot in the aorta that may be at risk for rupturing
- small AAA: 3-4.4 cm across
- medium AAA: 4.5-5.4 cm across
- large AAA: ≥5.5 cm more across
The incidence of AAA increases with age
Repair of an abdominal aortic aneurysm may be performed surgically through an open incision or in a minimally-invasive procedure called endovascular aneurysm repair (EVAR)
In the EVAR procedure, a stent graft is inserted into the aneurysm through small incisions in the groin

Atherosclerosis
Cystic medial necrosis
Connective tissue disorders	Marfan’s syndrome Ehlers Danlos syndrome type IV Turner's syndrome Polycystic kidney disease
Arterirtis	Giant cell arteritis Takayasu's disease Relapsing polychondritis
Infections	Acute: syphilis, salmonella, staphylococcus, brucellosis Chronic: tuberculosis, fungal (mycotic)
Posttraumatic
Inflammatory

Preoperative management

Similar for open repair and EVAR

Start patients on statins and antiplatelet medications
Control arterial pressure
Perform standard investigations: full blood count, electrolytes, ECG, chest X-ray, urinalysis
Assess major cardiac risk factors:
- Decompensated heart failure
- Acute coronary syndrome
- Arrhythmias
- Valvular disease
- Worsening ischemic heart disease
- Recent MI
Consider:
- Diuretics and ACE inhibitors
- Potential for hemorrhage, large fluid shifts & hypothermia

Perioperative management: open incision

Perioperative management: EVAR

Perioperative management: ruptured AAA

Postoperative management: open repair and EVAR

Respiratory complications	Pneumonia Atelectasis Respiratory failure Pulmonary thromboembolism
Cardiovascular complications	Myocardial ischemia Myocardial infarction Dysrhythmias
Cerebrovascular complications	Cerebrovascular disease Carotid insufficiency Postoperative cognitive dysfunction Confusion/delirium
Renal complications	AKI CKD Dialysis acute tubular necrosis Renal vascular injury Ureteral injury
Gastrointestinal complications	Bowel ischemia ACS paralytic ileus
Neurological complications	Spinal cord ischemia Paraplegia
Surgical complications	Bleeding Wound dehiscence Incisional hernia Venous thromboembolism Wound infection Leg ischemia Graft infection Graft thrombosis

Surgical	Medical
Maldeployment of malposition of graft Arterial rupture/arterial dissection Delayed AAA rupture Stent-graft limb thrombosis leading to lower limb ischemia Graft migration Endoleak Rupture of iliac artery Ischemia of spinal cord, kidneys, liver, bowel, legs Graft infection Paralysis	Acute coronary syndromes Acute congestive cardiac failure Acute kidney injury (AKI)/CIN arrhythmia Respiratory infection Venous thromboembolism Cerebovascular accident Postimplantation syndrome