From the Guidelines
Advanced age, pre-existing renal insufficiency, chronic obstructive pulmonary disease (COPD), and previous stroke are significant factors that increase morbidity from abdominal aortic aneurysm (AAA) repair, as evidenced by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1.
Key Factors Increasing Morbidity
- Advanced age, particularly ≥75 years, is associated with increased perioperative morbidity and mortality after open and endovascular repair of descending thoracic aortic aneurysms (TAA) 1.
- Preoperative renal insufficiency (stage 3 or greater chronic kidney disease (CKD)) or hemodialysis increases the risk of adverse outcomes after open surgical repair 1.
- COPD with forced expiratory volume in 1 second (FEV1) ≤50% predicted is a significant risk factor for increased morbidity after open surgical repair 1.
- Previous stroke is also associated with increased risk of death, perioperative morbidity, or both after open surgical repair 1.
Additional Considerations
- The type of repair, whether open surgical or endovascular, influences morbidity, with open surgical repair generally associated with higher complication rates than endovascular approaches (EVAR) 1.
- Anatomical factors such as aneurysm size, location, and complex morphology can increase surgical difficulty and complications 1.
- Patient-specific factors like functional dependence, pulmonary disease, and need for iliac access can further elevate risk, particularly for endovascular repair 1.
Recommendations for Practice
Given the evidence, it is crucial to carefully evaluate patients for these risk factors before proceeding with AAA repair, considering the benefits and risks of intervention, especially in high-risk patients 1.
- Preoperative optimization and informed consent discussions are essential to potentially reduce morbidity associated with AAA repair.
- The choice between open surgical and endovascular repair should be tailored to the individual patient's risk profile and anatomical considerations.
- High-volume centers with experienced surgeons are likely to demonstrate better outcomes, emphasizing the importance of referral to specialized care when possible.
From the Research
Factors Increasing Morbidity from Abdominal Aortic Aneurysm (AAA) Repair
- Chronic kidney disease 2
- Peripheral artery disease 2, 3
- Existence of three or more co-morbidities 2
- Older age 3, 4, 5
- Hypertension 3
- Congestive heart failure 3, 4
- Urgent procedures 3
- Prior open thoracoabdominal aortic aneurysm (TAAA) repair 4
- Aortic cross-clamping (ACC) time 4
- Intraoperative volume of red blood cell (RBC) and use of epinephrine 4
- Dependent functional status 5
- Presence of a major complication 5
- Chronic obstructive pulmonary disease (COPD) 5