A retroperitoneal approach should be considered for patients in which aneurysmal disease extends to the juxtarenal and/or visceral aortic segment, or in the presence of an inflammatory aneurysm, horseshoe kidney, or hostile abdomen (Grade 1, Level B).
Use of a retroperitoneal exposure or a transperitoneal approach with a transverse abdominal incision may be considered for patients with significant pulmonary disease requiring OSR (Grade 2, Level C).
Division of the left renal vein may be considered to gain suprarenal aortic exposure (Grade 1, Level A).
A high-quality preoperative CT scan is recommended to determine the optimal site of proximal aortic clamping based upon the extent of aneurysmal disease and quality of the aorta (Grade 1, Level A).
A transbrachial or transfemoral balloon for aortic control may be considered prior to anesthetic induction for patients with a ruptured aortic aneurysm (Grade 2, Level C).
A thrombin inhibitor (eg, Bivalirudin, Argatroban) is recommended at the time of aortic clamping for patients with a history of heparin-induced thrombocytopenia (Grade 1, Level B).
Type and configuration of the graft
Straight tube grafts are recommended for OSR of AAA in the absence of significant disease of the iliac arteries (Grade 1, Level A).
The proximal aortic anastomosis should be performed as close to the renal arteries as possible (Grade 1, Level A).
It is recommended that all portions of an aortic graft should be excluded from direct contact with the intestinal contents of the peritoneal cavity (Grade 1, Level A).
Maintenance of pelvic circulation
Reimplantation of a patent inferior mesenteric artery (IMA) should be considered under circumstances that suggest an increased risk of colonic ischemia (Grade 1, Level A).
It is recommended that blood flow be preserved to at least one hypogastric artery in the course of OSR or EVAR (Grade 1, Level A).
Management of associated intra-abdominal non-vascular disease
Concomitant surgical repair of an AAA and co-existent intraabdominal pathology may be considered in highly selective circumstances (Grade 1, Level A).
Approach to inflammatory aneurysm
Preoperative insertion of ureteral stents should be considered for patients undergoing OSR of an inflammatory aneurysm, particularly in the presence of hydronephrosis (Grade 1, Level A).
Immediate repair is recommended for patients that present with documented aneurysm rupture (Grade 1, Level A).
Should repair of a symptomatic AAA be delayed to optimize associated medical conditions, it is recommended that a patient be monitored in an ICU-setting and blood products be available (Grade 1, Level A).
Perioperative outcomes of open AAA repair
Elective OSR for AAA should be performed at centers with a documented in-hospital mortality of less than 5% for open repair of infrarenal AAA (Grade 1, Level A).