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Each individual considering open surgical repair must be evaluated carefully to determine if they have a high risk profile for mortality, including:

• Cardiovascular disease
• Abnormal electrocardiogram
• Chronic Obstructive Pulmonary Disease (COPD) or other pulmonary involvement
• Elevated creatinine levels (indicative of renal impairment)
• Older age
• Gender - estimates are that women may be at 1.5 times greater risk of perioperative mortality than men

• Anatomical features of the aneurysm and aorta are important since they can effect several technical issues, including:

  • the implantation of the stent-graft (e.g., sealing, risk of slippage)
  • if the aneurysm is close to the renal arteries, more clamping of those arteries may be required during surgery potentially elevating the time of renal ischemia (lack of oxygen) and stress on the vascular system
  • clot formation or calcification can effect clamping as well as placement of stent
  • if the aneurysm is stuck to adjacent structures (e.g., veins, ureters, or bowel) this can increase the level of risk for surgical complications.

Surgical Approaches

There are two surgical approaches with which the surgeon can expose the aorta for repair:

• Transperitoneal approach which involves gaining access to the AAA via a midline abdominal incision.

• Left retroperitoneal approach where the incision to gain access to the AAA is towards the left side of the abdomen. This type of incision has gained acceptance due to several advantages, including:

  • improved pulmonary function
  • less post-operative pain
  • fewer gastrointestinal complications
  • shorter postoperative time in the intensive care unit
  • shorter hospital stay

The left retroperitoneal incision is also beneficial for people with underlying medical conditions, including:

• Prior abdominal or pelvic radiation
• Dialysis
• Obesity
• Aneurysms close to the renal arteries

Advantages of Open Surgical Repair

Advantages of open repair of abdominal aortic aneurysm include:

• Low rate of surgical reintervention (second operation required to correct a problem arising from the initial surgery).
• Low rate of complications due to endoleaks or other graft related problems. An "endoleak" is persistent blood flow into the aneurysm. There are several types of endoleaks, but the most common include a leak resulting from an incomplete seal of the stent-graft to the aortic wall or resulting from opposing blood flow from collateral vessels.
• Long-term success rates

Risks of Open Surgical Repair

Postoperative complications of open repair for abdominal aortic aneurysm include:

• Cardiac events - More than one half of complications that occur postoperatively are cardiac in nature and they account for up to 60% of postoperative deaths, the majority due to heart attack.

• Hemorrhage - This is the second most common complication and is often due to technical difficulties or errors.

• Pulmonary insufficiency - Since abdominal aortic aneurysms are so closely associated with smoking and chronic obstructive pulmonary disease (COPD), pulmonary insufficiency is a common complication for those patients. This risk factor can be somewhat reduced if patients stop smoking several weeks prior to surgery. Individuals who are at high risk for developing this complication include:

  • smokers
  • patients with COPD
  • patients over the age of 70
  • obese patients

• Renal (kidney) failure - Although renal failure may occur in up to 8% of patients who undergo open repair, only a small percentage requires dialysis. Renal failure is related primarily to procedures during surgery (e.g., clamping of the renal arteries during surgery, use of radiographic contrast dyes).