Purpose of review: 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.
Recent findings: 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 beta-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.
Summary: 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.