Surgical Approach

OSR. We recommend a retroperitoneal approach for patients requiring OSR of an inflammatory aneurysm, a horseshoe kidney, or an aortic aneurysm in the presence of a hostile abdomen. Level of recommendation 1 (Strong), Quality of evidence C (Low)

We suggest a retroperitoneal exposure or a transperitoneal approach with a transverse abdominal incision for patients with significant pulmonary disease requiring OSR. Level of recommendation 2 (Weak), Quality of evidence C (Low)

Aortic clamping

We recommend a thrombin inhibitor, such as bivalirudin or argatroban, as an alternative to heparin for patients with a history of heparin-induced thrombocytopenia. Level of recommendation 1 (Strong), Quality of evidence B (Moderate)

Graft type and configuration

We recommend straight tube grafts for OSR of AAA in the absence of significant disease of the iliac arteries. Level of recommendation 1 (Strong), Quality of evidence A (High)

We recommend performing the proximal aortic anastomosis as close to the renal arteries as possible. Level of recommendation 1 (Strong), Quality of evidence A (High)

We recommend that all portions of an aortic graft be excluded from direct contact with the intestinal contents of the peritoneal cavity. Level of recommendation 1 (Strong), Quality of evidence A (High)

Maintenance of pelvic circulation

We recommend reimplantation of a patent IMA under circumstances that suggest an increased risk of colonic ischemia. Level of recommendation 1 (Strong), Quality of evidence A (High)

We recommend preserving blood flow to at least one hypogastric artery in the course of OSR. Level of recommendation 1 (Strong), Quality of evidence A (High)

Management of associated intra-abdominal vascular disease

We suggest concomitant surgical treatment of other visceral arterial disease at the time of OSR in symptomatic patients who are not candidates for catheter-based intervention. Level of recommendation 2 (Weak), Quality of evidence B (Moderate)

Management of associated intra-abdominal nonvascular disease

We suggest concomitant surgical repair of an AAA and coexistent cholecystitis or an intra-abdominal tumor in patients who are not candidates for EVAR or staged intervention. Level of recommendation 2 (Weak), Quality of evidence C (Low)