What are the implications of a leaking aortic arch aneurysm (AAA) repair with a diameter of 7.8 centimeters, status post (s/p) repair?

From the Guidelines

The patient with a 7.8cm leak from a previously repaired aortic arch aneurysm requires immediate surgical intervention at a tertiary care center with cardiothoracic surgery capabilities to prevent rupture and reduce mortality risk. This recommendation is based on the high risk of rupture associated with large aortic diameters, as indicated by the 2022 ACC/AHA guideline for the diagnosis and management of aortic disease 1. The guideline suggests that intervention is justified when the diameter is ≥5.5 cm in size, and high-risk features such as rapid aortic growth, symptomatic aneurysms, and underlying connective tissue disorder or HTAD support repair at a smaller diameter threshold.

While awaiting transfer, blood pressure should be strictly controlled with IV beta-blockers such as labetalol (10-20mg IV bolus, followed by 0.5-2mg/min infusion) or esmolol (500mcg/kg loading dose, then 50-200mcg/kg/min) to maintain systolic blood pressure between 100-120mmHg, as recommended by the 2010 ACCF/AHA/AATS/ACR/ASA/SCA/SCAI/SIR/STS/SVM guidelines for the diagnosis and management of patients with thoracic aortic disease 1. Pain should be managed with IV opioids as needed. The patient requires immediate cross-sectional imaging (CT angiography) if not already performed and hemodynamically stable. Type and cross for at least 4 units of packed red blood cells, establish two large-bore IVs, and monitor vital signs continuously.

Key considerations for the surgical intervention include:

• The large size of the leak (7.8cm) indicates a high risk of rupture, which carries a mortality rate exceeding 90% 1
• Endovascular repair may be possible depending on the location and anatomy of the leak, but open surgical repair might be necessary given this is a complication of previous repair
• The patient should be kept nil by mouth in preparation for emergency surgery
• High-risk clinical features such as advanced age, preoperative renal insufficiency, chronic obstructive pulmonary disease, and previous stroke should be considered when evaluating the risks and benefits of intervention 1

The 2022 ACC/AHA guideline provides the most recent and highest-quality evidence for the management of aortic disease, and its recommendations should be prioritized in this case 1. The patient's condition requires immediate attention, and prompt surgical intervention is necessary to prevent rupture and reduce mortality risk.

From the Research

Aortic Arch Aneurysm Repair

• The management of aortic arch aneurysms has evolved over time, with advancements in open surgical techniques, cardiopulmonary bypass, anesthesia, and perioperative care leading to decreased morbidity and mortality associated with repair 2.
• Endovascular technology has also played a significant role in the management of aortic arch aneurysms, offering a less-invasive treatment modality for patients who are at high risk for conventional surgical treatments 3, 4.

Treatment Options

• Open surgical repair remains the gold standard for low and intermediate risk patients, but endovascular repair is becoming increasingly popular, especially for high-risk patients 2, 5.
• Hybrid approaches, which combine open surgical and endovascular techniques, have also been developed to manage aortic arch aneurysms, and have shown promising results in reducing morbidity and mortality 4, 6.
• Endovascular repair techniques, including fenestrated and branched stent-grafts, have been developed to treat aortic arch pathologies, but more data is needed to determine their long-term durability and comparative treatment effect 4, 5.

Complications and Outcomes

• Open surgical repair of aortic arch aneurysms is associated with significant morbidity and mortality, including neurologic injury rates ranging from 4% to 12% 4.
• Endovascular repair of the aortic arch is also associated with complications, including stroke rates as high as 20% and spinal cord ischemia as high as 3.1% 5.
• Hybrid approaches have shown promising results in reducing morbidity and mortality, but more data is needed to determine their long-term outcomes 6.