Abdominal aortic aneurysms still require open repair despite the advances that endovascular aneurysm repair has made in treating patients with significant operative risk. Older patients with significant comorbidities require open repair of their complex aneurysms when they fail to meet anatomic criteria for endovascular aneurysm repair. This review discusses the physiologic insult of abdominal aortic surgery. It aims to address which patients are the highest risk of postoperative morbidity, and advances in their intensive care unit management to reduce such morbidity.
Advanced age, chronic health dysfunction, emergency surgery, and multiple organ failure are independent predictors of postoperative mortality. Myocardial ischemia is the largest contributor to patient morbidity, with any rise in postoperative cardiac troponin I predicting increased in-hospital myocardial infarction and mortality. Highest-risk patients benefit most from optimizing perioperative cardiac status with β-blockade. Perioperative treatment with fenoldopam may improve renal outcome. Tracheostomy to aid in weaning is associated with increased mortality but may improve outcome in patients with preoperative chronic obstructive pulmonary disease.
Demographic trends indicate that open aortic surgery will continue to be performed on older patients with complex aneurysms. Identifying patients at risk and optimizing their postoperative risk factors will improve outcomes.
aDepartment of Critical Care Medicine, University of Toronto
bDivision of Vascular Surgery, University Health Network, University of Toronto
cDepartment of Medicine, St. Michael's Hospital, Ontario, Canada
Correspondence to Giuseppe Papia, MD, FRCS, University of Toronto, Toronto General Hospital, EN 5-306, 200 Elizabeth Street, Toronto, Ontario M5G 2C4, Canada Tel: +1 416 340 4620; fax: +1 416 340 5029; e-mail: firstname.lastname@example.org