SELECTION AND PREPARATION OF HIGH-RISK PATIENTS FOR REPAIR OF ABDOMINAL AORTIC-ANEURYSMS

Objective: To discuss the most important risk factors in patients who undergo surgical repair of an abdominal aortic aneurysm (AAA). Design: This update in vascular surgical repair highlights the criteria that identify high-risk patients, the useful preoperative tests, and the pe rioperative measures that can aid surgical recovery. Material and Meth ods: In elective repair of AAAs, high-risk patients are those with sev ere coronary or valvular heart disease, decompensated chronic obstruct ive pulmonary disease, severe cerebrovascular disease, chronic renal f ailure, hepatic cirrhosis with portal hypertension, and chronic hemato logic disorders associated with bleeding dysfunction. Patients with un stable or severely symptomatic heart disease should undergo preoperati ve coronary angiography and ventriculography. Pharmacologic stress tes ting is recommended for patients with clinical markers of serious coro nary artery disease and other medical or physical factors that prevent any type of standard exercise stress testing. Results: Our experience with high-risk patients supports conventional repair of AAAs. Our pre ference for the midline abdominal incision in high-risk patients is su bstantiated by an operative mortality rate of 5.7% in comparison with a reported 7% mortality rate for nonresective therapy. Approximately o ne in three high-risk patients will have a serious postoperative compl ication, the most common of which is a cardiac event. Most patients re cover after a slightly prolonged hospital stay. Conclusion: Despite an increased operative risk, patients with a stable medical condition an d an AAA larger than 6 cm in diameter should be considered for electiv e repair. High-risk patients with smaller aneurysms (5 to 6 cm in diam eter) should undergo efforts to stabilize or to improve their general medical condition before elective operation.