𝗖𝗔𝗦𝗘 04
𝗨𝗿𝗴𝗲𝗻𝘁 𝗢𝗽𝗲𝗻 𝗥𝗲𝗽𝗮𝗶𝗿 𝗼𝗳 𝗮 𝗟𝗮𝗿𝗴𝗲 𝗦𝘆𝗺𝗽𝘁𝗼𝗺𝗮𝘁𝗶𝗰 𝗜𝗻𝗳𝗿𝗮𝗿𝗲𝗻𝗮𝗹 𝗔𝗯𝗱𝗼𝗺𝗶𝗻𝗮𝗹 𝗔𝗼𝗿𝘁𝗶𝗰 𝗔𝗻𝗲𝘂𝗿𝘆𝘀𝗺
A 65-year-old gentleman presented with abdominal pain. Clinical examination revealed abdominal tenderness, raising concern for a symptomatic abdominal aortic aneurysm.
Urgent CT angiography demonstrated a large fusiform infrarenal abdominal aortic aneurysm extending into both common iliac arteries.
Key imaging findings included:
• Infrarenal abdominal aortic aneurysm extending to both common iliac arteries
• Aneurysm length approximately 8.2 cm
• Maximum diameter approximately 6 × 6 cm
• Significant mural thrombus with anterior thickness of 19 mm and posterior thickness of 26 mm
• No evidence of active leak or peri-aortic hematoma
• No aortic dissection
• Patent visceral and renal vessels
Although there was no radiological evidence of rupture, the presence of abdominal pain and tenderness in a patient with a large aneurysm represented a symptomatic AAA and a potential precursor to impending rupture.
Following assessment and optimization, the patient was taken urgently to theatre for open aneurysm repair.
A standard midline laparotomy was performed, providing exposure of the abdominal aorta and iliac vessels. The bowel was carefully packed and retracted to allow safe access to the retroperitoneal structures.
Following meticulous dissection, proximal control was obtained below the renal arteries at a suitable infrarenal neck.
The aneurysm demonstrated a favorable long proximal neck, facilitating secure infrarenal aortic clamping.
Distal control was established bilaterally at the iliac bifurcations beyond the aneurysmal common iliac segments.
Following systemic heparinization, vascular clamps were applied and the aneurysm sac was opened. The mural thrombus was evacuated and definitive aneurysm repair performed.
Particular attention was paid to maintaining hemodynamic stability during aortic cross-clamping and unclamping, minimizing blood loss, and achieving meticulous hemostasis throughout the procedure.
Following completion of the repair, restoration of flow demonstrated satisfactory distal perfusion to both lower limbs with no evidence of technical complications.
Hemostasis was secured and the abdomen closed in standard fashion.
The patient was transferred to the intensive care unit for close postoperative monitoring and recovered without immediate complications.
𝗞𝗲𝘆 𝗟𝗲𝗮𝗿𝗻𝗶𝗻𝗴 𝗣𝗼𝗶𝗻𝘁𝘀
Symptomatic abdominal aortic aneurysms should be considered surgical emergencies even in the absence of radiological rupture.
Abdominal pain and aneurysm tenderness may represent impending rupture and should never be underestimated.
Careful preoperative CT planning remains fundamental to successful aneurysm repair.
Identification of an adequate proximal neck is essential for safe aortic control.
Selection of appropriate proximal and distal clamping zones significantly influences operative safety and outcomes.
Aortic cross-clamping and unclamping require meticulous anesthetic and hemodynamic management.
Meticulous hemostasis remains one of the most important determinants of successful open aneurysm surgery.
Successful AAA repair is the result of coordinated teamwork between vascular surgeons, anesthetists, intensivists, nursing staff, and blood bank services.
𝗞𝗘𝗬 𝗠𝗘𝗦𝗦𝗔𝗚𝗘
In abdominal aortic aneurysm surgery, the operation often begins long before entering the operating theatre. Careful interpretation of imaging, correct timing of intervention, precise selection of clamping zones, meticulous hemostasis, and strict perioperative blood pressure control are the foundations of a successful repair.
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