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• W2012611439 abstract "The Clinical Practice Council of the Society for Vascular Surgery charged a writing committee with the task of updating practice guidelines, initally published in 2003, for surgeons and physicians who are involved in the preoperative, operative, and postoperative care of patients with abdominal aortic aneurysms (AAA).1Brewster D.C. Cronenwett J.L. Hallett Jr, J.W. Johnston K.W. Krupski W.C. Matsumura J.S. Guidelines for the treatment of abdominal aortic aneurysms Report of a subcommittee of the Joint Council of the American Association for Vascular Surgery and Society for Vascular Surgery.J Vasc Surg. 2003; 37: 1106-1117Abstract Full Text Full Text PDF PubMed Scopus (603) Google Scholar This article is an executive summary of the main practice guidelines document and provides recommendations for evaluating the patient, including risk of aneurysm rupture and associated medical co-morbidities, guidelines for selecting surgical or endovascular intervention, intraoperative strategies, perioperative care, long-term follow-up, and treatment of late complications.2Chaikof E.L. Brewster D.C. Dalman R.L. Makaroun M.S. Illig K.A. Sicard G.A. et al.The care of patients with an abdominal aortic aneurysm: The Society for Vascular Surgery practice guidelines.J Vasc Surg. 2009; 50: 2S-49SAbstract Full Text Full Text PDF PubMed Scopus (536) Google Scholar Decision making related to the care of patients with AAA is complex. Aneurysms present with varying risks of rupture, and patient-specific factors influence anticipated life expectancy, operative risk, and the need to intervene. Careful attention to the choice of operative strategy, as influenced by anatomic features of the AAA, along with optimal treatment of medical co-morbidities is critical to achieving excellent outcomes. Moreover, appropriate postoperative patient surveillance and timely intervention in the case of a late complication is necessary to minimize subsequent aneurysm-related death or morbidity. All of these clinical decisions are determined in an environment where cost-effectiveness will ultimately dictate the ability to provide optimal care to the largest possible segment of the population. Currently available clinical data sets have been reviewed in formulating these recommendations. However, an important goal of this document is to clearly identify those areas where further clinical research is necessary. A comprehensive review of the available clinical evidence in the literature was conducted in order to generate a concise set of recommendations. The strength of any given recommendation and the quality of evidence was scored based on the GRADE system (Table).3Guyatt G. Gutterman D. Baumann M.H. Addrizzo-Harris D. Hylek E.M. Phillips B. et al.Grading strength of recommendations and quality of evidence in clinical guidelines.Chest. 2006; 129: 174-181Crossref PubMed Scopus (989) Google Scholar When the benefits of an intervention outweighed its risks, or, alternatively, risks outweighed benefits, a strong recommendation was noted. However, if benefits and risks were less certain, either because of low quality evidence or because high quality evidence suggests benefits and risks are closely balanced, a weak recommendation was recorded. The quality of evidence that formed the basis of these recommendations was scored as high, moderate, or low. Not all randomized controlled trials are alike and limitations may compromise the quality of their evidence. In addition, if there is a large magnitude of effect, the quality of evidence derived from observational studies may be high. Thus, quality of evidence was scored as high when additional research is considered very unlikely to change confidence in the estimate of effect; moderate when further research is likely to have an important impact on in the estimate of effect; or low when further research is very likely to change the estimate of the effect.TableCriteria for strength of a recommendation and grading quality of evidenceStrength of a Recommendation StrongBenefits > RisksRisks > Benefits WeakBenefits ∼ RisksQuality of evidence precludes accurate assessment of risks and benefitsGrading Quality of Evidence HighAdditional research is considered very unlikely to change confidence in the estimate of effect ModerateFurther research is likely to have an important impact on the estimate of effect LowFurther research is very likely to change the estimate of the effectAdapted from Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006;129:174-81. Open table in a new tab Adapted from Guyatt G, Gutterman D, Baumann MH, Addrizzo-Harris D, Hylek EM, Phillips B, et al. Grading strength of recommendations and quality of evidence in clinical guidelines. Chest 2006;129:174-81. The medical history is helpful in determining the patient's risk of developing an AAA. Even in the absence of clinical symptoms, knowledge of the risk factors for developing an AAA may facilitate early diagnosis. The Aneurysm Detection and Management Veterans Affairs Cooperative Study Group (ADAM) trial found a number of factors to be associated with increased risk for AAA: advanced age, greater height, coronary artery disease (CAD), atherosclerosis, high cholesterol levels, hypertension, and, in particular, smoking.4Lederle F.A. Johnson G.R. Wilson S.E. Chute E.P. Hye R.J. Makaroun M.S. et al.The aneurysm detection and management study screening program: validation cohort and final results Aneurysm Detection and Management Veterans Affairs Cooperative Study Investigators.Arch Intern Med. 2000; 160: 1425-1430Crossref PubMed Scopus (512) Google Scholar An AAA is over seven times more likely to develop in a smoker than a nonsmoker, with the duration of smoking, rather than total number of cigarettes smoked, being the key variable.5Wilmink T.B. Quick C.R. Day N.E. The association between cigarette smoking and abdominal aortic aneurysms.J Vasc Surg. 1999; 30: 1099-1105Abstract Full Text Full Text PDF PubMed Scopus (168) Google Scholar Family members are also at significant risk with 12% to 19% of those undergoing aneurysm repair having a first-degree relative with an AAA.6van Vlijmen-van Keulen C.J. Pals F. Rauwerda J.A. Familial abdominal aortic aneurysm: A systematic review of a genetic background.Eur J Vasc Endovasc Surg. 2002; 24: 105-116Abstract Full Text PDF PubMed Scopus (68) Google Scholar The risk for developing an AAA is lower in women, African Americans, and diabetic patients. Risk factors for rupture have also been identified, including female gender, large initial aneurysm diameter, low forced expiratory volume in one second (FEV1), current smoking history, and elevated mean blood pressure. Only 30% to 40% of aneurysms are noted on physical examination, with detection dependant on aneurysm size and limited by truncal obesity. An abdominal aneurysm may be present in up to 85% of patients with a femoral artery aneurysm and in up to 60% of those with a popliteal aneurysm. In contrast, approximately 15% patients with an abdominal aneurysm have either a femoral or a popliteal artery aneurysm. Tabled 1Physical examination should include an assessment of femoral and popliteal arteries in all patients with a suspected abdominal aortic aneurysm.Level of recommendation:StrongQuality of evidence:High Open table in a new tab Coronary artery disease (CAD) is the leading cause of early and late mortality after AAA repair. Chronic kidney disease, chronic obstructive pulmonary disease (COPD), and diabetes mellitus may also influence morbidity and mortality. Accordingly, further evaluation is warranted and optimization of perioperative status beneficial when any of these conditions are present. A substantial portion of patients with AAA have underlying CAD and postoperative myocardial infarction (MI) carries with it a substantially increased risk of death, as well as a high risk for later cardiovascular events and death. Indeed, while elective open surgical repair (OSR) can generally be considered to carry a higher risk for a perioperative cardiovascular event than endovascular aortic aneurysm repair (EVAR), the latter is associated with intermediate to high cardiac risk in the range of 3% to 7%. Thus, it is critical to minimize the risk of cardiac morbidity during the course of OSR or EVAR for AAA. In the absence of an active cardiac condition (unstable or severe angina, recent MI <1 month, decompensated heart failure, significant arrhythmia, or severe valvular heart disease), further non-invasive testing is only indicated if it will change management. Asymptomatic patients capable of a moderate or high activity level (metabolic equivalent unit [MET] ≥ 4), such as climbing stairs or a short run, generally do not benefit from further testing. However, those patients who present with three or more cardiac risk factors (history of heart disease, congestive heart failure, cerebral vascular disease, diabetes, creatinine > 2 mg/dL) and have an unknown or low activity level (MET < 4) may benefit from stress testing. Routine coronary revascularization by coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) prior to elective vascular surgery in patients with stable cardiac symptoms does not appear to significantly alter the risk of postoperative MI or death or long-term outcome. However, it bears emphasis that coronary revascularization is indicated for those patients who present with acute ST elevation MI, unstable angina, or stable angina with left main coronary artery or three-vessel disease, as well as those patients with two-vessel disease that includes the proximal left anterior descending artery and either ischemia on non-invasive testing or an ejection fraction of less than 0.50. Perioperative heart rate control with beta blockade appears appropriate for patients with known cardiovascular disease or at least one clinical risk factor, but should be started days to weeks before elective surgery with a target heart rate of less than 65 beats per minute.7Feringa H.H. Bax J.J. Boersma E. Kertai M.D. Meij S.H. Galal W. et al.High-dose beta-blockers and tight heart rate control reduce myocardial ischemia and troponin T release in vascular surgery patients.Circulation. 2006; 114: I344-I349Crossref PubMed Scopus (151) Google Scholar Recent clinical data also supports the notion that statins, alpha-2 agonists for perioperative control of hypertension, and calcium channel blockers reduce perioperative cardiac morbidity and death. Between 7% and 11% of patients with chronic obstructive pulmonary disease (COPD) have an aneurysm and failure to optimize COPD management is associated with increased morbidity and mortality. If COPD is severe, formal pulmonary consultation is recommended for prediction of short- and long-term prognosis and optimization of medical therapy. In general, smoking cessation for at least two weeks prior to aneurysm repair can be beneficial and administration of pulmonary bronchodilators for at least two weeks prior to aneurysm repair is recommended for patients with a history of symptomatic COPD or abnormal pulmonary function studies. Preoperative renal insufficiency is known to be a risk factor for a poor outcome after open aneurysm repair. To minimize deterioration in renal function among these patients, preoperative intravenous hydration is recommended and angiotensin-converting enzyme inhibitors and angiotensin receptor antagonists should be held the morning of surgery and restarted only after the patient is euvolemic.8Bertrand M. Godet G. Meersschaert K. Brun L. Salcedo E. Coriat P. Should the angiotensin II antagonists be discontinued before surgery?.Anesth Analg. 2001; 92: 26-30Crossref PubMed Scopus (211) Google Scholar Recent meta-analyses have not identified a significant benefit from intraoperative use of mannitol alone,9Hersey P. Poullis M. Does the administration of mannitol prevent renal failure in open abdominal aortic aneurysm surgery?.Interact Cardiovasc Thorac Surg. 2008; 7: 906-909Crossref PubMed Scopus (27) Google Scholar but have found beneficial effects from fenoldopam, particularly when administered at ∼0.1 μg/kg/min beginning at the initiation of surgery.10Landoni G. Biondi-Zoccai G.G. Tumlin J.A. Bove T. De Luca M. Calabro M.G. et al.Beneficial impact of fenoldopam in critically ill patients with or at risk for acute renal failure: A meta-analysis of randomized clinical trials.Am J Kidney Dis. 2007; 49: 56-68Abstract Full Text Full Text PDF PubMed Scopus (176) Google Scholar Likewise, patients at increased risk for contrast-induced nephropathy (CIN) should be hydrated both prior (normal saline 1 ml/kg/h for six to 12 hours or D5W/sodium bicarbonate 154 meq/L, 3 mL/kg for one hour) and after (normal saline 1 ml/kg/h for six to 12 hours or D5W/sodium bicarbonate 154 meq/L, 1 mL/kg for six hours) receipt of a contrast dye load as in EVAR. While fenoldapam, dopamine, theophylline, or calcium channel blockers do not appear to be beneficial in preventing CIN, N-acetylcysteine and ascorbic acid may be of benefit.11Pannu N. Wiebe N. Tonelli M. Prophylaxis strategies for contrast-induced nephropathy.JAMA. 2006; 295: 2765-2779Crossref PubMed Scopus (321) Google Scholar The incidence of CIN appears to be lower with iodixanol (Visipaque) and iopamidol (Isovue-370) than with iohexol (Omnipaque). Use of CO2 gas as an alternate imaging agent may be considered. Gadolinium-based contrast agents carry an increased risk of nephrogenic systemic fibrosis among patients with severe renal insufficiency. A number of studies have documented that even in the elective setting, anemia or a low hemoglobin level is associated with increased mortality following OSR. Ho and colleagues12Ho P. Ting A.C. Cheng S.W. Blood loss and transfusion in elective abdominal aortic aneurysm surgery.ANZ J Surg. 2004; 74: 631-634Crossref PubMed Scopus (14) Google Scholar documented that a hemoglobin level of less than 10.5 g/dL was an independent determinant of blood loss. A hematocrit less than 28% has also been associated with an increased incidence of postoperative MI in patients undergoing vascular surgery. Therefore, we recommend perioperative blood transfusion if the preoperative hematocrit is less than 28%. Ho et al have also documented that a platelet count of 130,000 platelets/μL or less was associated with increased risk of bleeding among patients undergoing OSR,12Ho P. Ting A.C. Cheng S.W. Blood loss and transfusion in elective abdominal aortic aneurysm surgery.ANZ J Surg. 2004; 74: 631-634Crossref PubMed Scopus (14) Google Scholar and Matsumura and colleagues noted that a lower preoperative platelet count was an independent predictor of two-year mortality among patients undergoing OSR and EVAR (P = .012).13Matsumura J.S. Katzen B.T. Sullivan T.M. Dake M.D. Naftel D.C. Predictors of survival following open and endovascular repair of abdominal aortic aneurysms.Ann Vasc Surg. 2009; 23: 153-158Abstract Full Text Full Text PDF PubMed Scopus (14) Google Scholar Thus, further hematologic assessment is recommended if the preoperative platelet count is less than 130,000 platelets/μL. Genetic abnormalities associated with AAA, include Ehlers-Danlos type IV (COL3A1), an autosomal dominant defect in the type-III collagen synthesis. Isolated AAA, unrelated to a prior aortic dissection, is uncommonly associated with Marfan syndrome. Population screening for single nucleotide polymorphisms (SNPs) to identify patients at risk for AAA have identified a number of genetic variants proposed to be associated with AAA, but few, if any, of these findings have been reproduced in more than one independent research group. A recent large study has suggested that a common sequence variant on 9p21, rs10757278-G, is associated with a 31% increased risk of abdominal aortic aneurysm.14Helgadottir A. Thorleifsson G. Magnusson K.P. Gretarsdottir S. Steinthorsdottir V. Manolescu A. et al.The same sequence variant on 9p21 associates with myocardial infarction, abdominal aortic aneurysm and intracranial aneurysm.Nat Genet. 2008; 40: 217-224Crossref PubMed Scopus (578) Google Scholar Maximum AAA diameter remains the most widespread criterion to predict risk of AAA rupture, but a variety of alternate parameters have been proposed as more sensitve predictors of rupture risk including AAA expansion rate, increase in intraluminal thrombus thickness, wall stiffness, wall tension, and peak AAA wall stress.15Fillinger M.F. Marra S.P. Raghavan M.L. Kennedy F.E. Prediction of rupture risk in abdominal aortic aneurysm during observation: wall stress versus diameter.J Vasc Surg. 2003; 37: 724-732Abstract Full Text Full Text PDF PubMed Scopus (541) Google Scholar As an enlarging AAA is accompanied both by an increase in wall stress and a decrease in wall strength, recent efforts have also been directed to accurately map the pointwise distribution of AAA wall stress and strength as a more accurate determinant of rupture risk. Further validation of these tools, however, will be required before they can be applied with confidence in clinical practice. Four randomized clinical trials that included 127,891 men and 9,342 women between the ages of 65 and 79 years have provided evidence that ultrasound screening is effective in reducing AAA-related mortality.16Scott R.A. Bridgewater S.G. Ashton H.A. Randomized clinical trial of screening for abdominal aortic aneurysm in women.Br J Surg. 2002; 89: 283-285Crossref PubMed Scopus (253) Google Scholar, 17Lindholt J.S. Juul S. Fasting H. Henneberg E.W. Hospital costs and benefits of screening for abdominal aortic aneurysms Results from a randomised population screening trial.Eur J Vasc Endovasc Surg. 2002; 23: 55-60Abstract Full Text PDF PubMed Scopus (144) Google Scholar, 18Ashton H.A. Buxton M.J. Day N.E. Kim L.G. Marteau T.M. Scott R.A. et al.The Multicentre Aneurysm Screening Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: A randomised controlled trial.Lancet. 2002; 360: 1531-1539Abstract Full Text Full Text PDF PubMed Scopus (955) Google Scholar, 19Scott R.A. Wilson N.M. Ashton H.A. Kay D.N. Influence of screening on the incidence of ruptured abdominal aortic aneurysm: 5-year results of a randomized controlled study.Br J Surg. 1995; 82: 1066-1070Crossref PubMed Scopus (401) Google Scholar, 20Vardulaki K.A. Walker N.M. Couto E. Day N.E. Thompson S.G. Ashton H.A. Scott R.A. Late results concerning feasibility and compliance from a randomized trial of ultrasonographic screening for abdominal aortic aneurysm.Br J Surg. 2002; 89: 861-864Crossref PubMed Scopus (79) Google Scholar, 21Norman P.E. Jamrozik K. Lawrence-Brown M.M. Le M.T. Spencer C.A. Tuohy R.J. et al.Population based randomised controlled trial on impact of screening on mortality from abdominal aortic aneurysm.BMJ. 2004; 329: 1259Crossref PubMed Scopus (430) Google Scholar Thus, we recommend one-time ultrasound screening for AAA for all men at or older than age 65, or as early as age 55 for those with a family history of AAA. Ultrasound screening should also be performed for women at or older than age 65 who have smoked or have a family history. If an AAA is identified, we recommend follow-up imaging at 12-month intervals for patients with an AAA of 3.5 cm to 4.4 cm in diamater and at six-month intervals for patients with an AAA diameter between 4.5 cm and 5.4 cm. For otherwise healthy patients, imaging is recommended at three-year intervals for those between 3.0 cm and 3.4 cm in diameter and at five-year intervals if the aortic diameter measures between 2.6 cm and 2.9 cm. It bears noting that these recommendations are based upon maximum external aortic diameter. Patients that present with an AAA and abdominal or back pain, even of an atypical nature, are at increased risk of rupture and intervention is recommended. For those who present with an asymptomatic AAA, management is dependant on the size of the aneurysm. There is general agreement that small fusiform aneurysms, less than 4.0 cm maximum diameter, are at low risk of rupture and should be monitored and a fusiform aneurysm greater than 5.4 cm in maximum diameter should be repaired in a healthy patient. Elective repair is also reasonable for patients that present with a sacular aneurysm. Debate remains for patients presenting with AAAs between 4.0 cm and 5.4 cm regarding the most appropriate role for either immediate treatment or surveillance and selective repair for those aneurysms that subsequently enlarge beyond 5.4 cm. Long-term survival was equivalent in the United Kingdom Small Aneurysm Trial (UKSAT)22United Kingdom Small Aneurysm Trial ParticipantsLong-term outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms.N Engl J Med. 2002; 346: 1445-1452Crossref PubMed Scopus (512) Google Scholar and the Aneurysm Detection and Management (ADAM) Trial23Lederle F.A. Wilson S.E. Johnson G.R. Reinke D.B. Littooy F.N. Acher C.W. et al.Immediate repair compared with surveillance of small abdominal aortic aneurysms.N Engl J Med. 2002; 346: 1437-1444Crossref PubMed Scopus (947) Google Scholar for both immediate surgery and surveillance groups. Nonetheless, a trend towards a beneficial effect of early surgery was observed in both studies in the younger patient and for those with larger aneurysms. Uncertainty regarding the potential benefit of early repair in selected patients with small AAA is further magnified by the demonstration that EVAR is associated with reduced perioperative mortality. The Comparison of surveillance vs endografting for small aneurysm repair (CAESAR)24Cao P. Comparison of surveillance vs Aortic Endografting for Small Aneurysm Repair (CAESAR) trial: study design and progress.Eur J Vasc Endovasc Surg. 2005; 30: 245-251Abstract Full Text Full Text PDF PubMed Scopus (80) Google Scholar and Positive impact of endovascular options for treating aneurysm early (PIVOTAL) trials compare immediate EVAR with surveillance and selective EVAR, but neither trial has been designed to determine whether immediate EVAR might be beneficial or harmful for specific AAA size ranges or age subgroups. Patients need to appreciate the therapeutic uncertainty for AAA in the range of 4.0 cm to 5.4 cm. At present, surveillance with selective repair is most appropriate for older male patients with significant co-moribidities. Young, healthy patients, and especially women, with AAA between 5.0 cm and 5.4 cm may benefit from early repair. Tabled 1Repair is recommended for patients that present with an AAA and abdominal or back pain.Level of recommendation:StrongQuality of evidence:HighElective repair is recommended for patients that present with a fusiform AAA ≥ 5.5 cm in maximum diameter, in the absence of significant co-morbidities.Level of recommendation:StrongQuality of evidence:HighElective repair should be considered for patients that present with a saccular aneurysm.Level of recommendation:WeakQuality of evidence:LowSurveillance is recommended for most patients with a fusiform AAA in the range of 4.0 cm to 5.4 cm in maximum diameter.Level of recommendation:StrongQuality of evidence:Moderate Open table in a new tab Tabled 1Areas in Need of Further Research•Management recommendations for EVAR versus surveillance and selective treatment for AAA <5.5 cm.•Examination of the survival effect of immediate treatment versus surveillance and selective treatment for specific AAA size (4.0 cm to 4.4 cm, 4.5 cm to 4.9 cm, and 5.0 cm to 5.5 cm), age, gender, and fitness subgroups.•Scales of fitness for surgical or endovascular intervention.•Management recommendations for AAA in women and minorities. Open table in a new tab During the surveillance period, patients should be counseled to cease smoking if tobacco products are being utilized and encouraged to seek appropriate management for hypertension, hyperlipidemia, diabetes, and other atherosclerotic risk factors. A statin and angiotensin-converting enzyme (ACE) inhibitor should be initiated given their broad potential benefits and acceptable safety profile. Insufficient data exists to recommend use of doxycycline or roxithromycin. Likewise, although animal studies have suggested that beta blockade protects against aneurysm expansion and rupture, the evidence in clinical trials has generally not supported this view.25Propanolol Aneurysm Trial InvestigatorsPropanolol for small abdominal aortic aneurysms: Results of a randomized trial.J Vasc Surg. 2002; 35: 72-79Abstract Full Text Full Text PDF PubMed Scopus (178) Google Scholar, 26Lindholt J.S. Henneberg E.W. Juul S. Fasting H. Impaired results of a randomised double blinded clinical trial of propranolol versus placebo on the expansion rate of small abdominal aortic aneurysms.Int Angiol. 1999; 18: 52-57PubMed Google Scholar Patients should be counseled that moderate physical activity does not precipitate rupture and may limit AAA growth rate. Screening of family members should be recommended. Tabled 1Smoking cessation is recommended to reduce the risk of AAA growth and rupture.Level of recommendation:StrongQuality of evidence:HighStatins may be considered to reduce the risk of AAA growth.Level of recommendation:WeakQuality of evidence:LowDoxycycline, roxithromycin, ACE inhibitors, and angiotensin receptor blockers are of uncertain benefit in reducing the risk of AAA expansion and rupture.Level of recommendation:WeakQuality of evidence:LowThe use of beta blockers to reduce the risk of AAA expansion and rupture is not recommended.Level of recommendation:StrongQuality of evidence:ModerateScreening for AAA is recommended for first degree relatives of patients presenting with an AAA.Level of recommendation:StrongQuality of evidence:High Open table in a new tab Tabled 1Areas in Need of Further Research•Therapeutic strategies directed at reduction in AAA growth rate or rupture risk, including clarification of the potential role of doxycycline, roxithromycin, and statin therapy in the progression of aneurysmal disease.•Therapeutic strategies directed at regression of AAA size.•Biomarkers and genetic polymorphisms that identify new avenues for pharmacotherapy. Open table in a new tab Because many infrarenal AAA with favorable neck anatomy are currently repaired with endovascular stent grafts, in contemporary practice, all vascular surgeons recognize that the technical complexity and challenges of OSR have increased since only aneurysms with adverse neck anatomy not felt to be suitable for EVAR undergo standard OSR. It is clear, therefore, that a vascular surgeon should be familiar and experienced with both an anterior transperitoneal (TP) and left-flank retroperitoneal (RP) approaches, utilizing each as determined by patient anatomy and clinical needs. Although advocates of a RP approach claim various physiologic benefits, including reductions in fluid losses, cardiac stress, postoperative pulmonary complications, and severity of ileus, randomized prospective studies have generated conflicting results.27Cambria R.P. Brewster D.C. Abbott W.M. Freehan M. Megerman J. LaMuraglia G. et al.Transperitoneal versus retroperitoneal approach for aortic reconstruction: a randomized prospective study.J Vasc Surg. 1990; 11: 314-324PubMed Scopus (190) Google Scholar, 28Sicard G.A. Reilly J.M. Rubin B.G. Thompson R.W. Allen B.T. Flye M.W. et al.Transabdominal versus retroperitoneal incision for abdominal aortic surgery: report of a prospective randomized trial.J Vasc Surg. 1995; 21: 174-181Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar A RP approach is generally preferable for patients with a “hostile abdomen” secondary to multiple prior intra-abdominal operations, a history of irradiation, or stoma, or for repair of inflammatory aneurysms or AAA associated with a horseshoe kidney. Perhaps the clearest indication for a RP approach is extension of aneurysmal disease to the juxtarenal or visceral aortic segment. Exposure and control of the aorta in this region, as well as the left renal and visceral branches, are facilitated by a left lateral RP approach and opening of the left diaphragmatic crura. Tabled 1A retroperitoneal approach should be considered for patients in which aneurysmal disease extends to the juxtarenal and/or visceral aortic segment, or in the presence of an inflammatory aneurysm, horseshoe kidney or hostile abdomen.Level of recommendation:StrongQuality of evidence:ModerateDivision of the left renal vein may be considered to gain suprarenal aortic exposure.Level of recommendation:StrongQuality of evidence:High Open table in a new tab The proximal extent of aneurysmal disease and quality of the aorta at the anticipated clamp site are best determined by careful examination of a high-quality fine-cut abdominal CT scan, both with and without contrast to allow accurate identification of aortic wall calcification and the extent of atheromatous debris and the length and diameter of the aneurysm neck. If extensive calcification or intraluminal atheromatous disease is noted, or the aneurysm extends very close to the renal arteries, a decision to clamp at a higher level becomes advisable to minimize the risk of atheromatous embolization into the renal arteries or clamp injury to the aortic wall. Although suprarenal clampin" @default.
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• W2012611439 title "SVS practice guidelines for the care of patients with an abdominal aortic aneurysm: Executive summary" @default.
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