Open Abdominal Aortic Aneurysm Repair

An abdominal aortic aneurysm (AAA) is a bulge in the wall of the aorta below the kidneys, where the wall has stretched and weakened. Most are found before they cause symptoms, often on imaging done for something else. The danger is rupture, which causes massive internal bleeding and is often fatal, so a large or growing aneurysm is repaired on purpose before that happens. Today many AAAs are repaired from inside the artery with a stent graft (endovascular repair, EVAR). The open repair is used when the anatomy is not right for a stent graft, when an endovascular repair has failed, and sometimes for a rupture. Through a long midline incision, the aorta is clamped above and below the aneurysm, the aneurysm is opened, and a synthetic graft (Dacron or PTFE) is sewn inside it: a straight tube graft when the aneurysm ends above the aortic bifurcation, or a bifurcated (Y) graft when the iliac arteries are involved. The old aneurysm wall is then closed over the graft to protect it. This is a long, high-blood-loss case on a heparinized patient with the aorta clamped, so preparation and speed matter: blood should be available before the incision, the circulator times the clamps, and the scrub needs every suture loaded before the aorta is clamped.