Advances in the surgical repair of ruptured abdominal aortic aneurysms.

Over the past two decades, the mortality rate for elective repair of infrarenal abdominal aortic aneurysms has improved to an acceptable level (< 5%). However, surgical results of ruptured abdominal aortic aneurysms have remained fairly constant with about 50% in hospital mortality rates. Growing experience with the use of the left retroperitoneal exposure for elective aortic surgery allowed the authors to extend the use of this technique to the repair of ruptured abdominal aortic aneurysm. The extended left retroperitoneal approach using a posterolateral exposure through the 10th intercostal space allowed the surgeon expeditiously and reliably to obtain supraceliac aortic control by dividing the left crus of the diaphragm in all patients. In total, 104 aortic replacements were performed for ruptured abdominal aortic aneurysm during the past 7 years. Of these patients, 87 were men and 17 women; mean(range) age was 72(52-95) years. Hemodynamic instability (as defined by a systolic blood pressure of < 90 mmHg) was present before surgery in 41% (43/104) of patients. The operative mortality rate was 27.9% (29/104). Preoperative hemodynamic instability, time of operative delay and aortic cross-clamp time did not correlate with operative mortality. The median duration of intensive care unit stay was 4 (range 1-60) days and hospital stay 11 (range 6-175) days. The results of this series identified that a change in the operative technique for the repair of ruptured abdominal aortic aneurysm beneficially affected patient survival. The authors suggest that expeditious supraceliac control without thoracotomy is an excellent alternative and offers an advantage in the surgical management of ruptured abdominal aortic aneurysm.