Ruptured abdominal aortic aneurysm

. Management of ruptured abdominal aortic aneurysm

  • Preoperative management  of ruptured abdominal aortic aneurysm . Unstable patients with a presumed diagnosis of a ruptured aneurysm (hypotension, abdominal or back pain, and a pulsatile abdominal mass or history of aneurysmal disease) are gently resuscitated with fluids (crystalloid, colloid, or blood) to maintain organ perfusion pressure. Hypertension is avoided to lessen further bleeding. Unstable patients are transferred immediately to the operating room for exploration, whereas those who are stable should undergo emergency CT scanning to confirm the diagnosis.
  • Operative management   of ruptured abdominal aortic aneurysm is aimed at rapidly controlling the aorta. Anesthetic induction is delayed until the surgeon is ready to make the abdominal incision. Through a midline incision, the aorta is cross-clamped or compressed at the diaphragmatic hiatus. The retroperitoneal hematoma is opened, and the proximal neck of the aneurysm is identified and cross-clamped. Distal vessel dissection continues, and management is similar to repair of an elective Abdominal Aortic Aneurysms. Bifurcation grafts should be avoided in favor of the more expeditious tube graft techniques if possible. Heparin should also be avoided in these patients due to the high risk of intraoperative and postoperative bleeding. Some centers are now approaching ruptured Abdominal Aortic Aneurysmss with endovascular techniques by deploying an occlusive balloon inserted through the femoral artery as a means of controlling the aorta above the aneurysm.

. Complications

  • Complications from open Management of ruptured abdominal aortic aneurysm Abdominal Aortic Aneurysms repair
  • Arrhythmia, myocardial ischemia, or infarction may occur after Management of ruptured abdominal aortic aneurysm.
  • Intraoperative hemorrhage Management of ruptured abdominal aortic aneurysm can be reduced by clamping the aorta proximal to the aneurysm and the iliac arteries distally. Once the aneurysm is opened, retrograde bleeding from lumbar arteries must be controlled rapidly with transfixing ligatures. Blood should be salvaged in the operating room and autotransfused to the patient.
  • Aortic cross-clamping shock, which may occur on release of the aortic cross-clamp, may be obviated by adequate hydration and slow release of the aortic cross-clamp.
  • Renal insufficiency may be related to intravenous contrast, inadequate hydration, hypotension, a period of aortic clamping above the renal arteries, or embolization of the renal arteries.
  • Lower-extremity ischemia may result from embolism or thrombosis, especially in emergency operations for which heparin might not be used. Embolism to the lower extremities can be prevented by minimizing manipulation of the aneurysm prior to clamping and by perfusing the hypogastric arteries before perfusing the external iliac arteries at the time of unclamping. Use of a Fogarty catheter to remove a clot from lower-extremity vessels is indicated when leg ischemia is identified in the operating room.
  • Microemboli arising from atherosclerotic debris can cause cutaneous ischemia (“trash foot”), which is usually treated expectantly as long as the major vessels are patent. Amputation may be required if significant necrosis results.
  • Gastrointestinal complications consist of prolonged paralytic ileus, anorexia, periodic constipation, or diarrhea. This problem is diminished by using the left retroperitoneal approach. A more serious complication, ischemic colitis of the sigmoid colon, is related to ligation of the inferior mesenteric artery in the absence of adequate collateral circulation. Symptoms include leukocytosis, significant fluid requirement in the first 8 to 12 postoperative hours, fever, and peritoneal irritation. Diagnosis is made by sigmoidoscopy to 20 cm above the anal verge. Necrosis that is limited to the mucosa may be treated expectantly with antibiotics and bowel rest. Necrosis of the muscularis causes segmental strictures, which may require delayed segmental resection. Transmural necrosis requires immediate resection of necrotic colon and construction of an end colostomy.
  • Paraplegia, a rare complication of infrarenal aneurysm surgery, may occur after repair of a ruptured Abdominal Aortic Aneurysms due to spinal cord ischemia. Supraceliac cross-clamping and prolonged hypotension increase the risk of paraplegia. Obliteration or embolization of important spinal artery collateral flow via the internal iliac arteries or an abnormally low origin of the accessory spinal artery (artery of Adamkiewicz) can result in paraplegia.
  • Sexual dysfunction and retrograde ejaculation result from damage to the sympathetic plexus during dissection near the aortic bifurcation, especially around the proximal left common iliac artery.