Vascular and Endovascular, Health education and Improvement Wales, UK.
105711Barts and The London School of Medicine and Dentistry, Queen Mary University of London, UK.
Asian Cardiovasc Thorac Ann. 2021 Sep;29(7):654-660. doi: 10.1177/02184923211039799. Epub 2021 Aug 19.
In current practice, the place of open surgery in managing abdominal aortic aneurysm is a contentious issue. The principal reason being greater applications of endovascular techniques treating increasingly complicated aortic disease. Development of branched and fenestrated devices enabled this, with numbers increasing annually. This meant a good risk patient with a long infrarenal aortic neck and normal diameter non-tortuous iliac arteries may be suitable for both endovascular and open techniques. However, indications for open surgery are becoming increasingly unclear nowadays due to short-term gains in morbidity and mortality. Exact aortic anatomical morphologies optimum for open or endovascular techniques remains unclear. As graft technology evolves, possibilities for endovascular options are expanding. Currently, establishing optimum treatment plans for complicated abdominal aortic aneurysm (little or no infrarenal neck) is difficult without considering general fitness of the patient. Hence, two sets of possible postoperative complications and follow-up protocols must be explained to patients before either approach. Complicating matters is the optimum surgical approach used for any open repair. The standard approach for open abdominal aortic aneurysm surgery has been transperitoneal as this provides excellent access to the infrarenal aorta and iliac arteries. However, although less commonly used, the retroperitoneal approach has advantages particularly when location of proximal aortic disease indicates suprarenal clamp might be optimum. This paper scrutinises benefits of the retroperitoneal approach performed purely for anatomical reasons where stent graft may be considered complicated. Also, long-term outcomes are examined in terms of endo-leak and subsequent development of true and false aneurysm following both endovascular and open repair.
在当前的实践中，开放手术在治疗腹主动脉瘤中的地位是一个有争议的问题。主要原因是血管内技术越来越多地应用于治疗日益复杂的主动脉疾病。分支型和开窗型设备的发展使这成为可能，其数量逐年增加。这意味着对于一个具有长肾下主动脉颈和正常直径非扭曲髂动脉的风险良好的患者，可能适合血管内和开放技术。然而，由于短期发病率和死亡率的提高，如今开放手术的适应证越来越不明确。目前，对于开放或血管内技术的最佳主动脉解剖形态学仍不清楚。随着移植物技术的发展，血管内治疗的可能性正在扩大。目前，如果不考虑患者的一般健康状况，对于复杂的腹主动脉瘤（肾下颈很小或没有），很难制定最佳的治疗计划。因此，在任何一种方法之前，都必须向患者解释两组可能的术后并发症和随访方案。使事情复杂化的是任何开放性修复所使用的最佳手术入路。开放性腹主动脉瘤手术的标准入路是经腹腔入路，因为它可以提供极好的肾下主动脉和髂动脉通路。然而，尽管经腹膜后入路不太常用，但它具有优势，特别是当近端主动脉疾病的位置表明肾上钳可能是最佳选择时。本文仅出于解剖学原因审查了纯粹为解剖学原因而进行的经腹膜后入路的优点，其中支架移植物可能被认为是复杂的。还根据内漏和随后血管内和开放修复后真性和假性动脉瘤的发展，检查了长期结果。
