Open AAA Repair
What the Examiner Expects
Open surgical repair of an abdominal aortic aneurysm through a transperitoneal (midline) or retroperitoneal (left flank) approach. The examiner expects you to know the size criteria for repair (≥ 5.5 cm, or ≥ 5.0 cm in women), describe the approach (proximal and distal aortic control, opening the aneurysm sac, sewing a prosthetic graft — tube or bifurcated — from within the sac, closing the sac over the graft), and understand the hemodynamic management during aortic cross-clamping. For ruptured AAA, the examiner will test your ability to manage hemorrhagic shock, obtain rapid supraceliac aortic control, and perform the repair expeditiously.
Key Examiner Focus Points
- Indicated for AAA ≥ 5.5 cm, rapid growth (> 0.5 cm/6 months), or symptomatic
- Ruptured AAA: emergent repair — permissive hypotension until aortic control
- Tube graft (infrarenal) for aortic disease; bifurcated graft if iliac disease present
- Reimplant IMA if back-bleeding is poor or sigmoid appears ischemic
- Postop complications: MI (most common cause of death), renal failure, colonic ischemia, spinal cord ischemia
Common Curveballs
After unclamping, the sigmoid colon appears dusky and cyanotic
Colonic ischemia from loss of IMA flow. Check for IMA back-bleeding and Doppler signals in the marginal artery. If the colon appears ischemic, reimplant the IMA into the graft. If colonic ischemia persists, sigmoid resection may be necessary. Postop flexible sigmoidoscopy at 24 hours can confirm mucosal viability.
Patient develops paraplegia postoperatively
Spinal cord ischemia from disruption of the artery of Adamkiewicz (usually arises T9-T12). More common with suprarenal clamping. Management: CSF drainage (lumbar drain to reduce CSF pressure to 10–12 mmHg), augment spinal cord perfusion pressure with MAP > 90 mmHg. Prevention includes limiting cross-clamp time.
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