Surgical Considerations

Emerging technology has been responsible for multiple new treatments in patients with aortic disease, including percutaneous transluminal angioplasty (PTA), either with or without stenting, stent grafts in patients with aortic aneurysms, and improved tech niques with the "gold standard" of open surgical repair. Whatever modality is used, the underlying question should address whether any treatment is needed. For example, based on the natural history and rupture risk, most surgeons will consider treatment for an aneurysm of the abdominal aorta greater than 5 cm, but this decision may be modified in a high-risk patient. Similarly, an active middle-aged person with lifestyle-limiting buttock, and thigh claudication secondary to aortoiliac occlusive disease should be approached differently from an elderly patient who is bedridden.

Insofar as operative approaches are treating a localized manifestation of a systematic process (i.e., atherosclerosis), consideration should be directed toward some assessment of coronary reserve and cardiac risk. Multiple studies and scoring systems have focused on this, and their discussion is beyond the scope of this chapter; however, suffice it to say that more than 50% of patients undergoing vascular reconstruction will have some element of cardiac disease. Specifically, this becomes more important in the patient undergoing aortic surgery, in that clamping of the aorta presents a tremendous increase in cardiac afterload and strain. Ultimately, preoperative evaluation (including bedside assessment, physiologic functional testing, coronary angiography, or some combination of these) should be tailored to the individual patient, and postoperative care should include a heightened awareness that the most common cause of death in these patients remains cardiac-related.

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