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Open Abdominal Aortic Surgery: Principles and Anesthetic Considerations

Open abdominal aortic procedures are performed for occlusive or aneurysmal aortic disease. Over the last several decades the overall prevalence of ruptured and nonruptured aortic aneurysm surgery has increased. Contributing factors include the aging population, imaging technology allowing for more incidental findings of aortic pathology, and the advent of endovascular aneurysm repair (EVAR). Because of the increasing trend toward EVAR interventions, those patients presenting to the operating room (OR) will almost inevitably have complex aortic anatomy and/or comorbidities that preclude them from being candidates for EVAR, suggesting increased complexity of surgery. As a result, both the operating and anesthesia times associated with open aortic surgery are increasing. Outcomes after open aortic repair (OAR) are related to many factors, including patient comorbidities, individual vascular anatomy and morphology of aortic disease, surgeon expertise, overall duration of surgery and aortic cross-clamp time, and hospital-related factors. Analysis of morbidity and mortality rates over the most recent decade reveals that hospitals completing <5 OARs or <8 EVARs per year have a significantly higher mortality than their counterparts that perform these interventions more often. This may create a trend of referring patients for elective abdominal aortic aneurysm (AAA) surgery to regional or high-volume aortic surgery hospitals. In addition, there is concern over the training and competency of new vascular surgeons to safely and