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Open surgical repair of abdominal aortic aneurysm

John F Eidt, MD
Section Editor
Joseph L Mills, Sr, MD
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


Replacement of the abdominal aorta for the repair of abdominal aortic aneurysm has been performed since it was first described in 1952 [1]. Prosthetic materials have since replaced the arterial homografts that were originally used and open surgical repair has proven to be a durable procedure [2]. Open repair of abdominal aortic aneurysm is performed under general anesthesia with appropriate monitoring of volume status and fluid administration and transfusion, as needed. Repair of the aorta is carried out in a systematic fashion that involves opening the aneurysm, removing thrombus and debris from within the aorta, suturing a graft into the aorta proximally, and distally at the aortic bifurcation or the iliac or femoral vessels, whichever is deemed appropriate.

The preoperative evaluation and preparation, operative technique, and postoperative care and follow-up of patients undergoing AAA repair is reviewed here. General issues regarding management of AAA and the surgical and endovascular management of ruptured AAA are discussed elsewhere. (See "Management of asymptomatic abdominal aortic aneurysm" and "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm" and "Surgical and endovascular repair of ruptured abdominal aortic aneurysm".)


The indications for repair of abdominal aortic aneurysm (AAA) are discussed in detail elsewhere and include symptomatic aneurysm of any size (eg, abdominal, back or flank pain, evidence of embolization, frank rupture), asymptomatic aneurysm ≥5.5 cm [3,4], rapidly expanding AAA, AAA associated with other arterial disease, infected AAA, and complications following endovascular repair necessitating early or late conversion to an open AAA repair [5]. The clinical evaluation and management of AAA are discussed separately. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Summary of indications for elective AAA repair' and "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm", section on 'Approach to AAA associated with symptoms'.)

Contraindications — Open repair of abdominal aortic aneurysm is contraindicated in patients with a prohibitive risk for perioperative mortality and morbidity. These risk factors are discussed below. (See 'Medical risk assessment' below.)

Relative contraindications to open surgical repair of AAA in the era of endovascular aneurysm repair may include the following: hostile abdomen, obesity, major cardiac or pulmonary comorbidities, and limited life expectancy. (See "Management of asymptomatic abdominal aortic aneurysm", section on 'Open versus endovascular aneurysm repair' and "Management of symptomatic (non-ruptured) and ruptured abdominal aortic aneurysm".)

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Literature review current through: Nov 2017. | This topic last updated: Jul 18, 2017.
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  1. Dubost, C, Allary, et al. Resection of an aneurysm of the abdominal aorta: Reestablishement of the continuity by a preserved arterial graft, with result after five months. Arch Surg 1952; 64:405.
  2. Becquemin JP, Pillet JC, Lescalie F, et al. A randomized controlled trial of endovascular aneurysm repair versus open surgery for abdominal aortic aneurysms in low- to moderate-risk patients. J Vasc Surg 2011; 53:1167.
  3. Moll FL, Powell JT, Fraedrich G, et al. Management of abdominal aortic aneurysms clinical practice guidelines of the European society for vascular surgery. Eur J Vasc Endovasc Surg 2011; 41 Suppl 1:S1.
  4. Chaikof EL, Brewster DC, Dalman RL, et al. SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: executive summary. J Vasc Surg 2009; 50:880.
  5. Sampram ES, Karafa MT, Mascha EJ, et al. Nature, frequency, and predictors of secondary procedures after endovascular repair of abdominal aortic aneurysm. J Vasc Surg 2003; 37:930.
  6. Johnston KW, Rutherford RB, Tilson MD, et al. Suggested standards for reporting on arterial aneurysms. Subcommittee on Reporting Standards for Arterial Aneurysms, Ad Hoc Committee on Reporting Standards, Society for Vascular Surgery and North American Chapter, International Society for Cardiovascular Surgery. J Vasc Surg 1991; 13:452.
  7. Norman PE, Powell JT. Abdominal aortic aneurysm: the prognosis in women is worse than in men. Circulation 2007; 115:2865.
  8. Dawson J, Vig S, Choke E, et al. Medical optimisation can reduce morbidity and mortality associated with elective aortic aneurysm repair. Eur J Vasc Endovasc Surg 2007; 33:100.
  9. Faggiano P, Bonardelli S, De Feo S, et al. Preoperative cardiac evaluation and perioperative cardiac therapy in patients undergoing open surgery for abdominal aortic aneurysms: effects on cardiovascular outcome. Ann Vasc Surg 2012; 26:156.
  10. Prinssen M, Verhoeven EL, Buth J, et al. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 2004; 351:1607.
  11. Prinssen M, Buskens E, Nolthenius RP, et al. Sexual dysfunction after conventional and endovascular AAA repair: results of the DREAM trial. J Endovasc Ther 2004; 11:613.
  12. Martin MC, Giles KA, Pomposelli FB, et al. National outcomes after open repair of abdominal aortic aneurysms with visceral or renal bypass. Ann Vasc Surg 2010; 24:106.
  13. Landry GJ, Lau IH, Liem TK, et al. Adjunctive renal artery revascularization during juxtarenal and suprarenal abdominal aortic aneurysm repairs. Am J Surg 2010; 199:641.
  14. Patel R, Conrad MF, Paruchuri V, et al. Balloon expandable stents facilitate right renal artery reconstruction during complex open aortic aneurysm repair. J Vasc Surg 2010; 51:310.
  15. Pennell RC, Hollier LH, Lie JT, et al. Inflammatory abdominal aortic aneurysms: a thirty-year review. J Vasc Surg 1985; 2:859.
  16. Rasmussen TE, Hallett JW Jr. Inflammatory aortic aneurysms. A clinical review with new perspectives in pathogenesis. Ann Surg 1997; 225:155.
  17. Bajardi G, Pecoraro F, Mirabella D, Bellisi MG. Inflammatory abdominal aortic aneurysm (IAAA). Ann Ital Chir 2009; 80:171.
  18. McKenna AJ, O'Donnell ME, Collins A, Harkin DW. Endovascular repair of an inflammatory abdominal aortic aneurysm causing bilateral ureteric obstruction. Ir J Med Sci 2012; 181:415.
  19. Pang YC, Chan YC, Ting AC, Cheng SW. Tender inflammatory infrarenal aortic aneurysm simulating acute rupture. Asian Cardiovasc Thorac Ann 2010; 18:180.
  20. Paravastu SC, Ghosh J, Murray D, et al. A systematic review of open versus endovascular repair of inflammatory abdominal aortic aneurysms. Eur J Vasc Endovasc Surg 2009; 38:291.
  21. Khan S, Lombardi JV, Carpenter JP, et al. Open abdominal aortic aneurysm repair is still necessary in an era of advanced endovascular repair. J Vasc Surg 2016; 64:333.
  22. Osborne Z, Hanson K, Brooke BS, et al. Variation in Transfusion Practices and the Association with Perioperative Adverse Events in Patients Undergoing Open Abdominal Aortic Aneurysm Repair and Lower Extremity Arterial Bypass in the Vascular Quality Initiative. Ann Vasc Surg 2018; 46:1.
  23. Shantikumar S, Patel S, Handa A. The role of cell salvage autotransfusion in abdominal aortic aneurysm surgery. Eur J Vasc Endovasc Surg 2011; 42:577.
  24. Vogel TR, Symons R, Flum DR. The incidence and factors associated with graft infection after aortic aneurysm repair. J Vasc Surg 2008; 47:264.
  25. de Maistre E, Terriat B, Lesne-Padieu AS, et al. High incidence of venous thrombosis after surgery for abdominal aortic aneurysm. J Vasc Surg 2009; 49:596.
  26. Scarborough JE, Cox MW, Mureebe L, et al. A novel scoring system for predicting postoperative venous thromboembolic complications in patients after open aortic surgery. J Am Coll Surg 2012; 214:620.
  27. Killewich LA, Aswad MA, Sandager GP, et al. A randomized, prospective trial of deep venous thrombosis prophylaxis in aortic surgery. Arch Surg 1997; 132:499.
  28. Farkas JC, Chapuis C, Combe S, et al. A randomised controlled trial of a low-molecular-weight heparin (Enoxaparin) to prevent deep-vein thrombosis in patients undergoing vascular surgery. Eur J Vasc Surg 1993; 7:554.
  29. Chaikof EL, Brewster DC, Dalman RL, et al. The care of patients with an abdominal aortic aneurysm: the Society for Vascular Surgery practice guidelines. J Vasc Surg 2009; 50:S2.
  30. Gould MK, Garcia DA, Wren SM, et al. Prevention of VTE in nonorthopedic surgical patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest 2012; 141:e227S.
  31. Moussa O, Jonker L, Joseph T. Marked variation in venous thromboprophylaxis management for abdominal aortic aneurysm repair; results of survey amongst vascular surgeons in the United kingdom. Eur J Vasc Endovasc Surg 2011; 42:591.
  32. Belch JJ, Lowe GD, Pollock JG, et al. Low dose heparin in the prevention of deep-vein thrombosis after aortic bifurcation graft surgery. Thromb Haemost 1980; 42:1429.
  33. Muehling B, Schelzig H, Steffen P, et al. A prospective randomized trial comparing traditional and fast-track patient care in elective open infrarenal aneurysm repair. World J Surg 2009; 33:577.
  34. Muehling BM, Ortlieb L, Oberhuber A, Orend KH. Fast track management reduces the systemic inflammatory response and organ failure following elective infrarenal aortic aneurysm repair. Interact Cardiovasc Thorac Surg 2011; 12:784.
  35. Kusaka J, Matsumoto S, Hagiwara S, et al. Use of perioperative ureteral stent in abdominal aortic aneurysm with retroperitoneal fibrosis - A report of two cases -. Korean J Anesthesiol 2012; 63:76.
  36. Dorweiler B, Neufang A, Schmiedt W, Oelert H. Autogenous reconstruction of infected arterial prosthetic grafts utilizing the superficial femoral vein. Thorac Cardiovasc Surg 2001; 49:107.
  37. Grass F, Deglise S, Corpataux JM, Saucy F. In situ aortobiiliac reconstruction of infected aneurysm using a single superficial femoral vein. Vasc Endovascular Surg 2013; 47:390.
  38. Darling RC 3rd, Shah DM, McClellan WR, et al. Decreased morbidity associated with retroperitoneal exclusion treatment for abdominal aortic aneurysm. J Cardiovasc Surg (Torino) 1992; 33:65.
  39. Borkon MJ, Zaydfudim V, Carey CD, et al. Retroperitoneal repair of abdominal aortic aneurysms offers postoperative benefits to male patients in the Veterans Affairs Health System. Ann Vasc Surg 2010; 24:728.
  40. Twine CP, Humphreys AK, Williams IM. Systematic review and meta-analysis of the retroperitoneal versus the transperitoneal approach to the abdominal aorta. Eur J Vasc Endovasc Surg 2013; 46:36.
  41. Twine CP, Lane IF, Williams IM. The retroperitoneal approach to the abdominal aorta in the endovascular era. J Vasc Surg 2012; 56:834.
  42. Laohapensang K, Rerkasem K, Chotirosniramit N. Mini-laparotomy for repair of infrarenal abdominal aortic aneurysm. Int Angiol 2005; 24:238.
  43. Endo M, Kobayashi K, Tsubota M, et al. Advantages of using the midline incision right retroperitoneal approach for abdominal aortic aneurysm repair. Surg Today 1996; 26:1.
  44. Kawaharada N, Morishita K, Fukada J, et al. Minilaparotomy abdominal aortic aneurysm repair versus the retroperitoneal approach and standard open surgery. Surg Today 2004; 34:837.
  45. Nakajima T, Kawazoe K, Komoda K, et al. Midline retroperitoneal versus midline transperitoneal approach for abdominal aortic aneurysm repair. J Vasc Surg 2000; 32:219.
  46. Wirth G, Moccia R, Clement Darling R 3rd, et al. Aortoiliac reconstruction: the retroperitoneal approach and splenic injury. Ann Vasc Surg 2003; 17:604.
  47. Kunihara T, Adachi A, Akimaro Kudo F, et al. The less incisional retroperitoneal approach for abdominal aortic aneurysm repair to prevent postoperative flank bulge. J Cardiovasc Surg (Torino) 2005; 46:527.
  48. Hafez H, Makhosini M, Abbassi-Ghadi N, et al. Transverse minilaparotomy for open abdominal aortic aneurysm repair. J Vasc Surg 2011; 53:1514.
  49. Shortell CK, Welch EL, Ouriel K, et al. Operative management of coexistent aortic disease and horseshoe kidney. Ann Vasc Surg 1995; 9:123.
  50. Barshes NR, McPhee J, Ozaki CK, et al. Increasing complexity in the open surgical repair of abdominal aortic aneurysms. Ann Vasc Surg 2012; 26:10.
  51. Mehta T, Wade RG, Clarke JM. Is it safe to ligate the left renal vein during open abdominal aortic aneurysm repair? Ann Vasc Surg 2010; 24:758.
  52. Chinien G, Waltham M, Abisi S, et al. Systemic administration of heparin intraoperatively in patients undergoing open repair of leaking abdominal aortic aneurysm may be beneficial and does not cause problems. Vascular 2008; 16:189.
  53. Gold MS. The effect of epidural/general and cervical plexus block anesthesia on activated clotting time in patients undergoing vascular surgery. Anesth Analg 1993; 76:701.
  54. Imparato AM. Abdominal aortic surgery: prevention of lower limb ischemia. Surgery 1983; 93:112.
  55. Thompson JF, Mullee MA, Bell PR, et al. Intraoperative heparinisation, blood loss and myocardial infarction during aortic aneurysm surgery: a Joint Vascular Research Group study. Eur J Vasc Endovasc Surg 1996; 12:86.
  56. Lindblad B, Bergqvist D, Wakefield TW, Stanley JC. Time-related anticoagulation after regional and systemic administration of heparin in patients undergoing aortoiliac surgery. Eur J Vasc Surg 1994; 8:574.
  57. Wakefield TW, Hantler CB, Lindblad B, et al. Protamine pretreatment attenuation of hemodynamic and hematologic effects of heparin-protamine interaction. A prospective randomized study in human beings undergoing aortic reconstructive surgery. J Vasc Surg 1986; 3:885.
  58. Wakefield TW, Hantler CB, Wrobleski SK, et al. Effects of differing rates of protamine reversal of heparin anticoagulation. Surgery 1996; 119:123.
  59. Bevis PM, Windhaber RA, Lear PA, et al. Randomized clinical trial of mesh versus sutured wound closure after open abdominal aortic aneurysm surgery. Br J Surg 2010; 97:1497.
  60. Piotrowski JJ, Ripepi AJ, Yuhas JP, et al. Colonic ischemia: the Achilles heel of ruptured aortic aneurysm repair. Am Surg 1996; 62:557.
  61. Eliason JL, Wainess RM, Dimick JB, et al. The effect of secondary operations on mortality following abdominal aortic aneurysm repair in the United States: 1988-2001. Vasc Endovascular Surg 2005; 39:465.
  62. Tambyraja AL, Murie JA, Chalmers RT. Prediction of outcome after abdominal aortic aneurysm rupture. J Vasc Surg 2008; 47:222.
  63. Cho JS, Kim JY, Rhee RY, et al. Contemporary results of open repair of ruptured abdominal aortoiliac aneurysms: effect of surgeon volume on mortality. J Vasc Surg 2008; 48:10.
  64. Senekowitsch C, Assadian A, Assadian O, et al. Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair: influence on postoperative colon ischemia. J Vasc Surg 2006; 43:689.
  65. Končar IB, Davidović LB, Savić N, et al. Role of recombinant factor VIIa in the treatment of intractable bleeding in vascular surgery. J Vasc Surg 2011; 53:1032.
  66. Edwards JM, Teefey SA, Zierler RE, Kohler TR. Intraabdominal paraanastomotic aneurysms after aortic bypass grafting. J Vasc Surg 1992; 15:344.
  67. Coscas R, Greenberg RK, Mastracci TM, et al. Associated factors, timing, and technical aspects of late failure following open surgical aneurysm repairs. J Vasc Surg 2010; 52:272.
  68. Dillavou ED, Muluk SC, Makaroun MS. A decade of change in abdominal aortic aneurysm repair in the United States: Have we improved outcomes equally between men and women? J Vasc Surg 2006; 43:230.
  69. McPhee JT, Hill JS, Eslami MH. The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004. J Vasc Surg 2007; 45:891.
  70. Sarac TP, Bannazadeh M, Rowan AF, et al. Comparative predictors of mortality for endovascular and open repair of ruptured infrarenal abdominal aortic aneurysms. Ann Vasc Surg 2011; 25:461.
  71. Pol RA, Reijnen MM, Zeebregts CJ. Outcome after open repair of ruptured abdominal aortic aneurysm in patients >80 years old: a systematic review and meta-analysis. World J Surg 2011; 35:2575.
  72. Biancari F, Leo E, Ylönen K, et al. Value of the Glasgow Aneurysm Score in predicting the immediate and long-term outcome after elective open repair of infrarenal abdominal aortic aneurysm. Br J Surg 2003; 90:838.
  73. Chiesa R, Tshomba Y, Psacharopulo D, et al. Open repair for infrarenal AAA: technical aspects. J Cardiovasc Surg (Torino) 2012; 53:119.
  74. Vega de Céniga M, Estallo L, Barba A, et al. Long-term cardiovascular outcome after elective abdominal aortic aneurysm open repair. Ann Vasc Surg 2010; 24:655.
  75. Kadakol AK, Nypaver TJ, Lin JC, et al. Frequency, risk factors, and management of perigraft seroma after open abdominal aortic aneurysm repair. J Vasc Surg 2011; 54:637.
  76. Chong T, Nguyen L, Owens CD, et al. Suprarenal aortic cross-clamp position: a reappraisal of its effects on outcomes for open abdominal aortic aneurysm repair. J Vasc Surg 2009; 49:873.
  77. Jongkind V, Yeung KK, Akkersdijk GJ, et al. Juxtarenal aortic aneurysm repair. J Vasc Surg 2010; 52:760.
  78. Grant SW, Grayson AD, Grant MJ, et al. What are the risk factors for renal failure following open elective abdominal aortic aneurysm repair? Eur J Vasc Endovasc Surg 2012; 43:182.
  79. Dardik A, Burleyson GP, Bowman H, et al. Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: factors influencing outcome among 527 recent cases. J Vasc Surg 1998; 28:413.
  80. Champagne BJ, Darling RC 3rd, Daneshmand M, et al. Outcome of aggressive surveillance colonoscopy in ruptured abdominal aortic aneurysm. J Vasc Surg 2004; 39:792.
  81. Fassiadis N, Roidl M, Hennig M, et al. Randomized clinical trial of vertical or transverse laparotomy for abdominal aortic aneurysm repair. Br J Surg 2005; 92:1208.