Abdominal Aortic Aneurysm (AAA)

Comorbid vascular disease - Assume coexisting coronary and cerebrovascular disease, hypertension, and renal impairment; optimize and continue cardiac medications. These are high cardiac-risk patients.

Aortic cross-clamp physiology (open repair) - Clamping abruptly raises afterload with hypertension above and ischemia below; unclamping causes sudden hypotension from reperfusion and vasodilation. Anticipate both, communicate with the surgeon, and titrate vasoactive drugs and volume around clamp on and off.

Blood loss and access - Potential for massive hemorrhage: place large-bore IV access and an arterial line, have blood available, and use a warmer and cell salvage.

Organ protection - Maintain renal and, for higher clamps, spinal cord perfusion; follow urine output and be alert to spinal cord ischemia in extensive repairs.

Rupture is an emergency - A ruptured AAA is uncontrolled hemorrhage — resuscitate, tolerate permissive hypotension until clamp control, and move fast; mortality is high.

EVAR versus open - Endovascular repair is less physiologically stressful but watch for contrast load, access-site bleeding, and endoleak; many are done under regional or MAC.

An abdominal aortic aneurysm is a pathologic dilation of the aorta (usually infrarenal) from degeneration of the vessel wall. The main threat is rupture — a risk that climbs with diameter and is a catastrophic hemorrhagic emergency.

Elective repair, open or endovascular, is common. The anesthetic concerns center on a diseased, atherosclerotic patient (coexisting coronary, cerebrovascular, and renal disease), large potential blood loss, the physiology of aortic cross-clamping in open repair, and protection of the kidneys, spinal cord, and gut.