before the aneurysm repair, the same course should likely be followed although this decision requires a

modicum of clinical judgment. The infectious concerns must be balanced by the fact that the small

bowel contents are sterile, a second procedure will be required to repair the aneurysm, and the small

risk of aneurysm rupture during the intervening delay. Injury to the bowel during or after implantation

of the aortic graft should be treated with repair of the defect, extensive irrigation, and prolonged

antibiotics. Admittedly, these approaches are very conservative and it is noteworthy that multiple

clinical series have attested to the safety of simultaneous aortic and gastrointestinal/urologic

procedures.202–205 The ureter is susceptible to injury at the point where it crosses over the iliac

bifurcation. Injury can be avoided by a heightened awareness of this anatomic location and dissection in

the tissue plane immediately on top of the common iliac vessels. Inadvertent venous injury can be

associated with significant bleeding. This can usually be controlled by direct pressure using sponge

sticks and suture repair. The left renal vein may be transected if necessary. It should be transected near

its juncture with the vena cava, and the gonadal, adrenal, and lumbar branches should be preserved to

maintain venous outflow from the kidney. Although somewhat inelegant, division of the left renal vein

does not appear to affect renal function after AAA repair.206 Transecting the common iliac artery or

infrarenal aorta may facilitate exposure of the common iliac or retroaortic renal veins, respectively.

Excessive intraoperative bleeding may be encountered occasionally. Routine elective aneurysm

repairs are usually associated with moderate intraoperative blood loss with a mean transfusion

requirement of 1 to 2 units of packed red blood cells. Excessive bleeding may be caused by either the

surgical trauma or coagulopathy. Reversal of the heparin with protamine may help correct the

coagulopathic bleeding. Patients with significant bleeding and platelet counts below 50,000/mL should

receive a platelet transfusion, and it should be considered for coagulopathic bleeding and counts below

100,000/mL or for those on preoperative clopidogrel or other equivalent anti-platelet medications.

Transfusions of fresh frozen plasma are indicated for both patients with either significant bleeding in

conjunction with prolonged coagulation studies (>1.5 times control value) and those with

coagulopathic bleeding. Massive bleeding, defined as more than 100% of the blood volume, may induce

a dilutional coagulopathy with prolongation of the coagulation studies. Additional blood products

should be set up in the blood bank in the event of significant bleeding. This may require an additional

blood bank specimen. Intraoperative autologous transfusion devices should also be considered if not

already in use.

Ischemia of the lower extremities has been reported to occur approximately 3% of the time after open

repair.201 The causes are multiple and include distal embolization, thrombosis, clamp injury, and

technical errors. The lumen of the aneurysm is frequently filled with both thrombus and atheromatous

debris that may serve as a source for both macro- and microembolization. The macroemboli usually

lodge at the bifurcations of the major vessels; the microemboli usually lodge in the digital vessels and,

unfortunately, are not amenable to mechanical extraction. Thrombosis may result from inadequate

heparinization, hypercoagulable conditions, or poor arterial runoff. The technical conduct of the

operation outlined above is designed to minimize the ischemic complications. The specific maneuvers

include anticoagulation, selection of a suitable site for distal clamp application and anastomosis,

intraluminal control of severely calcified vessels, flushing of the vessels before clamp removal, and

sequential removal of the vascular clamps. Further intervention is mandatory if the lower extremities

are found to be ischemic. Anastomotic defects should be corrected. This may simply require dissembling

and redoing the anastomosis, but often requires placing the anastomosis further distal on the outflow

artery. If no problems are identified at the distal anastomosis, the femoral vessels should be explored

and an intraluminal thrombus removed with a balloon embolectomy catheter. A transverse arteriotomy

may be created in the common femoral artery if it is anticipated that only a thrombectomy will be

required; a longitudinal incision should be created if a bypass (inflow or outflow) procedure is

anticipated. The transverse arteriotomy can simply be closed with interrupted sutures without

narrowing the lumen in the event that an additional bypass procedure is not necessary, whereas the

longitudinal arteriotomy requires a patch closure. A bypass from the aortic graft to the femoral vessels

is required if adequate inflow cannot be restored with thrombectomy alone. The popliteal artery below

the knee should be explored and a thrombectomy performed if the extremity is still ischemic. This may

be facilitated by creating a longitudinal arteriotomy on the below knee popliteal artery that extends to

the tibioperoneal trunk. This allows the passage of the balloon embolectomy catheter into all three

tibial vessels under direct vision. A below knee popliteal or tibial artery bypass is required if adequate

perfusion to the distal extremity is not restored after patch closure of the popliteal arteriotomy.

Predictably, a complex lower-extremity revascularization in conjunction with an aortic reconstruction is

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associated with a significant degree of morbidity and dramatically increases the mortality rate.207 The

decision to proceed with an infrainguinal bypass depends on the status of the extremity and requires

some clinical judgment. Aborting the procedure and allowing for a period of observation and rewarming is appropriate when popliteal Doppler signals are detected and the foot is cool yet not severely

ischemic. Reoperation and definitive treatment may be necessary in the early postoperative period

unless marked improvement is noted.

Many of the systemic complications that follow open aneurysm repair are not surprising, given the

magnitude of the operation and the age/comorbidities of the patients. Cardiac complications (ischemia,

infarction, arrhythmias, congestive heart failure) occur in up to 25%200,201,208 and are the leading cause

of death after open aneurysm repair in many series. Pulmonary complications (pneumonia, ventilator

dependence >48 hours, acute respiratory distress syndrome) are also quite common and approximately

10% of the patients require prolonged ventilation.200,201 Deterioration of renal function, defined by an

increase in serum creatinine or blood urea nitrogen, occurs in approximately 5% of cases although acute

renal failure requiring dialysis is rare (i.e., <1%).201 The potential causes of renal insufficiency in the

perioperative period are numerous and include contrast nephrotoxicity, hypovolemia,

atheroembolization, and the inflammatory response from the lower torso ischemia/reperfusion injury.

Postoperative bleeding requiring reexploration, intra-abdominal abscess, and abdominal wound

complications are all relatively infrequent complications and are associated with all major intraabdominal procedures.

Ischemic colitis has been reported to occur in approximately 2% to 13% of cases after open aneurysm

repair.209,210 The reported incidence depends on the diagnostic algorithm and modality (routine

sigmoidoscopy vs. selective sigmoidoscopy) and is dramatically increased after ruptured aneurysm

repair. Indeed, the incidence of colonic ischemia after ruptured aneurysm repair in patients undergoing

routine colonoscopy is approximately 25% to 40%.209,211 Multivariable analysis of patients undergoing

both open and endovascular repair demonstrated that the duration of the procedure and preoperative

renal insufficiency were also predictors of colon ischemia.210 The sigmoid colon is affected most

frequently although all the sections of the colon may be involved. The ischemia may result from

inadequate resuscitation, disruption of collaterals, and/or failure to revascularize a hemodynamically

significant inferior mesenteric artery. Patients usually present with bloody diarrhea in the early

postoperative period. However, the diagnosis should be considered in the absence of bloody diarrhea in

patients with thrombocytopenia, multiple-organ dysfunction, increasing abdominal pain/peritonitis, and

generalized “failure to thrive.” The diagnosis may be confirmed by endoscopy. Although sigmoidoscopy

is used most frequently, a complete colonoscopy is likely optimal due to the potential involvement of

the other colon segments. Treatment depends on the endoscopic findings and clinical setting. The

endoscopic findings range from mucosal ischemia to transmural necrosis. Unfortunately, it is often

difficult to differentiate diffuse mucosal ischemia from transmural necrosis. In the absence of peritonitis,

patients with mucosal ischemia alone should be treated with bowel rest, broad-spectrum antibiotics,

total parenteral nutrition, and serial endoscopic examinations. Many of these lesions resolve

spontaneously without long-term sequelae although colonic strictures may develop in a subset of

patients. Patients with transmural colonic necrosis should undergo laparotomy with resection of the

involved segment, a proximal diverting colostomy, and a distal Hartmann’s pouch. After laparotomy,

they should be maintained on broad-spectrum antibiotics and parenteral nutrition. The reported

mortality rate in patients with transmural necrosis may range up to 85%.209,210 Maintaining antegrade

flow through the internal iliac vessels, routinely implanting the inferior mesenteric artery, and avoiding

disruption of the colonic collateral circulation may reduce the incidence of this adverse outcome.

Several other gastrointestinal complications are common after standard infrarenal AAA repair.212 A

postoperative ileus develops in essentially all patients with bowel function usually returning within 3 to

5 days. An ileus may persist beyond this time period in a subset of patients although no additional

therapy is usually required. Nasogastric decompression should be continued, narcotics minimized,

electrolytes normalized, and ambulation encouraged. Either calculous or acalculous cholecystitis may

develop after aneurysm repair. The mortality rates reported historically for postoperative cholecystitis

were significant213 and served as the catalyst for simultaneous cholecystectomy and aneurysm repair.

Although this approach has been found to be safe and not associated with an increased risk for graft

infections, it is usually reserved for patients with small stones or evidence of chronic cholecystitis.

Pancreatitis may develop after AAA repair although the incidence is surprisingly low in light of the

obligatory manipulation of the pancreas during repair. The treatment of pancreatitis in this setting is

conservative and includes bowel rest, parenteral nutrition, and serial imaging.

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Sexual dysfunction is quite common after both open and EVAR as noted above. Erectile and/or

orgasmic dysfunction has been reported to occur in 5% to 18% of men undergoing aortoiliac

reconstruction.214 The responsible mechanisms include interruption of the pelvic perfusion and injury to

the autonomic nerves that overlie the distal aorta/proximal common iliac arteries. Injury to these

autonomic nerves disrupts the internal sphincter mechanism of the bladder and results in retrograde

ejaculation. Care should be exercised during aneurysm repair to maintain pelvic perfusion and avoid

nerve injury to prevent these untoward complications. It is imperative that these potential

complications be discussed with patients preoperatively.

Paraplegia after open infrarenal AAA repair occurs with an incidence of 0.25%.215 The potential

mechanisms for this devastating complication include embolization, thrombosis of the spinal artery, and

disruption of the spinal blood supply. Paraplegia after aneurysm repair is usually an irreversible injury.

Maintaining adequate antegrade pelvic perfusion through the internal iliac arteries may minimize this

complication.

The long-term outcome after open repair is generally favorable. Long-term survival is improved after

aneurysm repair, although it falls short of the age-matched controls with survival rates of approximately

90%, 65%, and 40% at 1, 5, and 10 years.2,13,216 Cardiovascular causes account for the leading cause of

death.217 This underscores the importance of long-term medical follow-up and the AHA/ACC Guidelines

for preventing myocardial infarction and death.170,217 Prosthetic aortic grafts are associated with longterm complications with a reported incidence of approximately 10% to 15% at 15 years.136,218,219

Notably, bifurcated grafts are associated with a higher incidence of complications (13%) than tube

grafts (5%).196 The long-term graft-related complications include infection, aortoenteric fistula,

thrombosis, and pseudoaneurysm formation. Additional aneurysms of a sufficient size to merit

intervention develop in approximately 5% to 15% of patients in either the iliac vessels or the aorta

above the prosthetic graft.196,197 It is recommended that patients undergo CT of the complete aorta and

iliac vessels 3 to 5 years postoperatively to screen for graft complications and additional aneurysms.220

Endovascular Repair of Intact Abdominal Aortic Aneurysms

Technique

The preoperative evaluation and preparation before endovascular AAA repair is significantly more

complicated than for the open approach. The various imaging studies must be reviewed before it can be

determined whether the endovascular approach is even feasible. Appropriate measurements must be

taken and the necessary devices/components selected. An operative plan must be generated including

specific modifications of the standard approach to overcome the patient’s anatomic limitations and,

thereby, extend the feasibility of the technique. Indeed, “preoperative planning, preoperative planning,

and preoperative planning” have facetiously been identified as the three most important components of

a successful repair.

A variety of imaging techniques (i.e., CT, catheter-based arteriography) been employed to determine

the feasibility of an aneurysm for endovascular repair and select the appropriate devices/components.

However, CT arteriography with 3D reconstructions has emerged as the optimal approach. It is

important to emphasize that no imaging technique is perfect and, consequently, a certain degree of

flexibility is necessary for the operative plan. Measurements obtained from the 3D CT tend to

overestimate the actual renal artery–internal iliac artery length assumed by the graft when deployed in

vivo. Similar sizing limitations are associated with the catheter-based arteriography techniques and

these have been attributed to the course of the catheter, the presence of intraluminal thrombus, and the

conformational changes in the aorta that result from the stiff guide wires and/or the device itself.

The various devices/components should be selected using the underlying principles that the main

body of the device should sit as close to the orifices of the renal arteries as possible while the iliac limbs

should extend to the orifices of the internal iliac arteries. This methodology not only provides exclusion

of abnormal tissue, but also extends the length of seal and fixation of the endograft, and may provide

additional column strength for grafts requiring this for durability. Furthermore, the manufacturers’

recommendations for sizing and device selection should be followed, although many publications have

demonstrated reasonable durability of some grafts even when used outside of the “IFU”.221 Grafts

seated well below the orifices of the renal arteries have been associated with proximal migration222

while oversizing the graft diameter beyond that recommended has been associated with both graft

migration and aneurysm reexpansion.223 The endograft is sized according to the anatomic configuration

of the aneurysm and adjacent arteries, and this must be performed in advance of the procedure to

ensure that the appropriate devices are available. The diameter and length of the infrarenal cuff,

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aneurysm, and iliac vessels must be measured precisely. In addition, the distance from the lowest renal

artery to the aortic bifurcation and both renal bifurcations needs to be determined. The diameter of the

proximal graft is chosen to oversize the aortic cuff and iliac arteries by approximately 10% to 20%.

Additional devices should be ordered for each case including two iliac limbs and an aortic extension cuff

to allow for any discrepancy between the preoperative plan and the actual course of the graft in vivo.

Each endograft procedure and device configuration is “custom fit” for an individual patient. Work sheets

are available from the manufacturers to confirm the suitability of an aneurysm for endovascular repair

and to aid in the selection of an appropriate device. Technical assistance is available from the various

manufacturers to facilitate every step of the process from initial assessment to component selection to

deployment. Furthermore, physicians typically are required to complete a training course comprised of

sizing exercises and monitored deployments.

The choice of the specific endovascular device is contingent upon the anatomic constraints of the

aneurysm, device associated outcome, and surgeon preference. There are specific differences between

the various grafts that lend themselves to different clinical scenarios. The specific considerations include

neck diameter, neck length/angulation, renal–internal iliac artery distance, common iliac artery

diameter, and access vessel diameter. For example, a graft with suprarenal fixation may be more

suitable for a shorter neck while a lower profile system (i.e., smaller outer diameter of the delivery

sheath) may be most appropriate for patients with smaller access vessels (i.e., common femoral and

external iliac arteries). Despite the initial concerns about compromising renal function, suprarenal

fixation has been consistently shown to be safe.157,224 Deployment of the various endografts is

reasonably involved from a technical standpoint; thus, it is not particularly surprising that most

surgeons elect to concentrate on one or two devices. All available endografts currently on the market

can treat a patient with “straightforward” anatomy, and a high level of comfort with a limited number

of devices has some benefit. However, a working knowledge and comfort level with all devices on the

market is advised given the benefits that each graft may have over the others in certain scenarios. This

allows use of a graft that best meets the individual patient’s needs.

The need for adjunctive procedures to facilitate the endovascular repair is usually determined by the

preoperative imaging and should be factored into the overall plan. The major concerns include stenotic

access vessels and the absence of a suitable common iliac artery landing zone due to aneurysm

enlargement. The remedial procedures for small access vessels or significant occlusive disease include

serial dilation or a retroperitoneal prosthetic iliac conduit. Repeated attempts to pass the devices

sheaths through a diseased native vessel should be avoided and can result in vessel rupture at the

common iliac bifurcation. Aneurysm degeneration of the common iliac artery can be overcome by

seating the iliac limb in the external iliac artery. This necessitates either embolizing or bypassing the

ipsilateral internal iliac artery. Alternatively, the iliac limb of the endograft can simply occlude the

internal iliac artery flush provided the iliac bifurcation is sufficiently tapered.225 Several reports have

documented that accessory renal arteries may be covered at the time of the endograft with little clinical

sequelae, although the individual patient’s baseline renal function certainly must be taken into account.

The intraoperative preparation for endovascular repair is similar to that for the open approach

although there are several significant differences. The appropriate imaging equipment is mandatory.

Ideally, this would entail a complete endovascular suite with a fixed fluoroscopic unit although a

portable unit with the appropriate vascular software and an imaging table is adequate. General

endotracheal anesthesia, local and regional anesthesia can all be used for endovascular repair,

depending on the individual patient, the clinical scenario, the planned length/complexity of the

procedure, and the comfort level of the surgeon and anesthesiologist. Indeed, the endovascular

approach is well suited for these less invasive alternatives particularly considering the feasibility of a

completely percutaneous approach. For a straightforward endovascular repair, intraoperative

autologous transfusion devices and a nasogastric tube are unnecessary. It is currently quite rare to

convert to an open repair at the time of the initial implantation despite the early experience that

reported a rate of up to 5%.75,76,78,226 However, it should be emphasized that EVAR is a surgical

procedure and most would agree that the procedure should be performed in an operating room with

strict aseptic technique.

Although the technique for implanting the various endografts is somewhat specific to the individual

device, the basic steps for deploying a “generic” modular bifurcated device using an open femoral artery

exposure is illustrated (Fig. 96-10).

2742

2743

Figure 96-10. General steps involved in the endovascular repair of an abdominal aortic aneurysm. The common femoral arteries

are exposed bilaterally (alternatively, and more commonly, percutaneous access is achieved and “preclose” sutures are placed) and

stiff wires are introduced into the thoracic aorta under fluoroscopic guidance. An appropriate sized large diameter introducer

sheath is inserted over the stiff wire into the body of the aneurysm at approximately the L3 vertebral space on the side

contralateral to the one chosen for the main device. If the device is contained within its own deployment system, a sheath may not

be required. A: The main body delivery catheter is introduced over the stiff wire through the ipsilateral groin and the upper limit

of the main body positioned between the L1 and L2 vertebral bodies. An aortogram is obtained and the location of the renal

arteries identified. The location of the renal arteries is marked on the imaging screen and the position of the main body finely

adjusted. B, C: The main body is deployed exposing the opening of the contralateral docking limb. The contralateral docking limb

is cannulated and a stiff wire advanced into the thoracic aorta. After confirming successful cannulation of the docking limb,

deployment of the contralateral limb is deployed after marking the origin of the hypogastric artery. The hypogastric origin can be

identified by using intravascular ultrasound or by obtaining a retrograde arteriogram through the sheath in the opposite oblique

projection to identify the orifice of the internal iliac artery. D,E,F: The location of the orifice is marked on the imaging screen the

contralateral limb is then introduced over the stiff wire, appropriately positioned, and deployed A compliant aortic occlusion

balloon is advanced over the stiff wire and inflated in the region of the infrarenal neck to mold the proximal and distal attachment

sites, and used to ensure the overlapping devices are well sealed.

Percutaneous access to the common femoral arteries has become standard for many physicians using a

“preclose” methodology that involves placing a suture-based closure system that is deployed prior to

delivery of the device and closed at the conclusion of the procedure.163,164 If the surgeon is

uncomfortable with that approach, or the femoral artery anatomy precludes use of closure devices, an

open exposure works well and can be done through transverse, longitudinal or oblique incisions,

depending on the clinical scenario. Briefly, the common femoral arteries are exposed and an umbilical

tape or vessel loop is wrapped circumferentially around the vessels at the level of the inguinal ligament

to facilitate vascular control. Approximately 2 cm of the common femoral artery is dissected free. It is

not usually necessary to dissect the superficial femoral and profunda femoris branches. While the

dissection is being performed, the various device components are prepared on the back table by the

surgical technologist. A purse string suture using a 4-0 or 5-0 cardiovascular suture can be placed on the

anterior aspect of the common femoral artery and left untied until the completion of the procedure. The

various catheters/sheaths may be introduced through the center of the purse string, thereby, facilitating

a rapid/simple closure of the artery at the completion of the procedure. The common femoral artery on

the side chosen to introduce the main body of the device (ipsilateral groin) is punctured using an

angiographic needle and a 0.035-in standard working wire (e.g., Bentsen) is passed into the abdominal

aorta using fluoroscopic guidance. A 5-Fr introducer sheath is advanced over the guidewire using a

Seldinger technique and vessel entry is confirmed by manual contrast injection. The working wire is

further advanced into the thoracic aorta and exchanged for a longer 0.035-in stiffened guidewire (e.g.,

2744

Lunderquist, Meier) using a catheter. Attention is then directed to the contralateral groin and in a

similar manner a guidewire is advanced into the aorta and an appropriate sized introducer sheath is

inserted over the guidewire into the body of the aneurysm at approximately the L3 vertebral space. An

angiographic catheter is advanced to the L1 vertebral body through the contralateral sheath and the

catheter connected to the power injector. The patient is then anticoagulated with heparin using a

standard protocol (100 units/kg) and therapeutic anticoagulation (ACT twice baseline) is maintained

throughout the procedure. The main body delivery catheter is introduced over the stiff wire through the

ipsilateral groin and the upper limit of the main body positioned between the L1–L2 vertebral bodies.

Devices that do not have an integral sheath as part of their delivery system require an 18- to 22-Fr

sheath to be inserted prior to introduction of the actual delivery catheter. Radiopaque markers on the

graft facilitate the positioning and orientation of the main body.

As imaging has improved, multiple techniques allow for determining the proper location of endograft

deployment. This may involve the use of IVUS or 3D overlay imaging, both of which can decrease the

use of contrast and the radiation exposure to both the patient and practitioner. In the absence of these

advanced imaging techniques, an aortogram can be obtained after delivery of the endograft to the

location of the renal arteries and the renal arteries marked for device deployment. In this scenario, the

flat panel or image intensifier should be adjusted to optimize visualization of the infrarenal neck. A 5- to

10-degree craniocaudal angulation is usually sufficient to account for the anterior angulation of the

infrarenal neck caused by the natural lumbar lordosis of the spine and the posterior bulging of the

aneurysm sac. However, the optimal angulation or orientation may be estimated based upon the

preoperative 3D CT images. The location of the renal arteries is marked on the imaging screen and the

position of the main body adjusted. The main body is now deployed exposing the opening of the

contralateral docking limb. Using a combination of a hydrophilic wire and a curved catheter, the

contralateral docking limb is cannulated. This can be challenging at times and requires a modest degree

of catheter skills. Various maneuvers including different fluoroscopic projections, different shaped

catheters, and proper orientation of the contralateral docking limb prior to deployment of the main

body device can facilitate this step. It is imperative to confirm that the cannulating guidewire is actually

within the body of the main endograft. There are a number of methods to confirm entry into the main

aortic graft, but the surgeon should use that which he/she is most comfortable. The most definitive way

to determine successful cannulation of the docking limb is to use IVUS, but this can be accomplished by

a number of methods. A common method is to place a reverse curve catheter such as a SOS or a pigtail

catheter into the main body at the level of the neck and spinning the catheter. If the catheter spins

freely, this confirms that it is not outside of the endograft where it would be trapped between the aortic

wall and endograft. Alternatively, an arteriogram can be performed using a catheter within the main

body, confirming that dye fills the aortic graft, but not the aneurysm on initial injection. Once this is

confirmed, the contralateral wire is advanced into the proximal descending thoracic aorta under

fluoroscopic guidance and exchanged for a stiff wire using a catheter.

If IVUS is used, the hypogastric artery can be identified and marked during withdrawal of the catheter

after confirmation of docking limb catheterization, and the length measured using the radiopaque marks

on the IVUS catheter. Alternatively, placing the imaging equipment into the proper position for optimal

visualization and a retrograde injection then performed through the sheath can mark the hypogastric.

The optimal angle can be variable, and is best-determined using preoperative 3D imaging. If not

available, the typical angle required to see the hypogastric is in the opposite obliquity about 300 from

the side of the vessel (i.e., Right Anterior Oblique for the Left internal iliac artery). The location of the

orifice is marked on the imaging screen and a marker catheter is used to measure the distance from the

contralateral docking limb to confirm the preoperative measurements and device selection. The

contralateral limb is then introduced over the stiff wire, appropriately positioned relative to the docking

limb and the orifice of the internal iliac artery, and then deployed.

After deployment of all the devices, a compliant aortic occlusion balloon is advanced over the

ipsilateral stiff wire and inflated in the region of the infrarenal neck to mold the proximal attachment

sites. The aortic balloon is then withdrawn and gently expanded at the main body/iliac limb overlap

zone and both distal iliac artery fixation sites. A completion arteriogram is then obtained using an

angiographic catheter placed through one of the introducer sheaths (Fig. 96-11). The arteriogram should

adequately evaluate the proximal/distal fixation sites, the graft/graft overlap zones and the orifices of

the renal/internal iliac arteries. In addition, it should include delayed imaging to help identify any

endoleaks. Problems identified on the completion study should be corrected, if possible. The potential

remedial procedures include balloon dilation or aortic/iliac extension cuffs.

2745

Figure 96-11. Completion arteriogram after an endovascular aneurysm repair is shown. The arrow marks the caudal extent of the

stent graft. Note that the iliac limbs have been intentionally crossed to facilitate the cannulation of the contralateral gate.

With open femoral exposure, all sheaths, catheters, and wires are removed after the completion of the

arteriogram and the femoral arteriotomy closed using the previously placed purse–string suture. When

using percutaneous closure methods, the wire is typically left in during closure to allow placement of

additional closure devices as necessary. Pedal Doppler signals should be confirmed prior to removal of

the wire and completion of arterial closure. The heparin can then be reversed with protamine (1 mg

protamine/100 units heparin) after adequate signals are detected in the feet. The groin wounds are

closed in layers with absorbable suture and the final skin later is closed with a subcuticular technique.

The immediate postoperative course is typically fairly uneventful. Patients are transferred to the

general care ward after recovery in the postanesthesia care unit. Patients are started on an appropriate

diet the evening of the procedure and encouraged to get out of bed. Patients should be kept supine for 4

to 6 hours after the operation when a percutaneous technique is used to ensure successful hemostasis.

Plain radiographs of the abdomen (4 views, optimized for metal) can be obtained on the first

postoperative day for a baseline position of the grafts, but this is not routine in many centers. Most

infrarenal EVAR patients are discharged home on postoperative day 1 or 2, and then seen in the

outpatient clinic at 1 month with an abdominal/pelvic CT scan. It is important to note that mild fever

and the finding of air around the graft on CT are common occurrences immediately after endograft

repair and have not been associated with graft infection.227

9 It is imperative that patients are followed long-term given the uncertainty associated with the

endovascular repair and the need for remedial procedures. As noted above, new endoleaks have been

identified many years after repair.228 A variety of protocols and imaging techniques have been

described although an abdominal/pelvic CT scan with contrast at 12 months and then yearly

noncontrast studies seems reasonable in the absence of any identifiable problems and an aneurysm sac

that is not increasing in size. Indeed, Sternbergh et al.229 reported from a multicenter trial that the

absence of an endoleak at 1 and 12 months predicted favorable long-term outcome. More frequent

imaging may be indicated if the aneurysm continues to grow or there is evidence of an endoleak. The

surveillance CT scans should include noncontrast and biphasic contrast views with delayed images to

help identify any late endoleaks.230 Calcified material will frequently be present in the aortic sac, and

can masquerade as contrast. The noncontrasted portion of the CT will help determine the nature of this

material and can be very helpful when combined with contrasted imaging. Although not part of all

surveillance protocols, early plain radiographs are very helpful to identify structural changes/problems

with the grafts, and are sometimes more useful than CT in identifying issues with the metal skeleton of

the graft. Duplex ultrasound has been employed as a surveillance study, but its accuracy is dependent on

the local expertise of the vascular laboratory.231–233

Complications and Outcome

The mortality rates in the recent randomized trials and national series is less than 2%,69,70,74,111 the

perioperative complication rate is <25%,73,136 the rupture risk is approximately 1%/yr,136,141 and the

2746