OVERVIEW OF GRAFTING ABDOMINAL AORTIC ANEURYSM

Grafting an abdominal aortic aneurysm is one of the major challenges to the vascular surgeon. The principle is a simple tube problem, where surgery is usually potentially very effective. A plastic tube about 8cm long is stitched into the lining of the aneurysm to carry blood from just below the renal arteries to the bifurcation of the aorta or the common iliac arteries.

In practice, however, there are formidable problems which lead to a 30 day mortality of 2-4% for an elective operation, rising to 40-50% or more for a ruptured aneurysm.

The outcome is influenced very much by factors such as the age of the patient and intercurrent diseases, the anatomy of the aneurysmal process, and the presence of leakage of the aneurysm.

Technically, the operation demands the highest levels of coordination and determination from the whole surgical team. The surgeon, in particular, needs coolness, accuracy, endurance, and above all, the very large amount of relevant information that is usually only acquired by at least ten years of post-graduate experience.

This text endeavours to provide most of the information required by the surgeon. Most of the very large number of variations and surgical scenarios, each with its particular problems and solutions, should be covered. The structure of the program encourages continuous improvement and tuning of this information.

DANGER POINTS IN THE OPERATION

All patients with leaking aneurysms are actively dying.
The patient has a 25% chance of dying in the anaesthetic room or on the operating table.
Danger areas are:
     Moribund patient arriving in the anaesthetic room.
     Deterioration on induction of anaesthesia.
     Deterioration on opening the abdomen.
     Uncontrollable bleeding on dissecting the upper end of the aneurysm.
     Failure to control the upper end of the aneurysm.
     Bleeding from a torn vena cava.
     Bleeding from the lower end of the aneurysm.
     Bleeding from the iliac vessels.
     Bleeding from the upper anastomosis.
     Bleeding from the lower anastomosis.
     Red ink syndrome (Bleeding due to a lack of clotting factors).
     Myocardial failure.

The patient is likely to develop a profound bradycardia with negligible cardiac output
Cardiac massage is a last ditch move
Another 25% of patients will die from one or more of the features below:
     Rebleeding after leaving the operating theatre
     Renal and other systems failures
     Myocardial Infarction
     Pulmonary Infarction
     Cerebral thrombosis and haemorrhage