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 perioperative measures that can aid surgical recovery. MATERIAL AND METHODS: In elective repair of AAAs, high-risk patients are those with severe coronary or valvular heart disease, decompensated chronic obstructive pulmonary disease, severe cerebrovascular disease, chronic renal failure, hepatic cirrhosis with portal hypertension, and chronic hematologic disorders associated with bleeding dysfunction. Patients with unstable or severely symptomatic heart disease should undergo preoperative coronary angiography and ventriculography. Pharmacologic stress testing is recommended for patients with clinical markers of serious coronary 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 preference for the midline abdominal incision in high-risk patients is substantiated by an operative mortality rate of 5.7% in comparison with a reported 7% mortality rate for nonresective therapy. Approximately one in three high-risk patients will have a serious postoperative complication, the most common of which is a cardiac event. Most patients recover after a slightly prolonged hospital stay. CONCLUSION: Despite an increased operative risk, patients with a stable medical condition and an AAA larger than 6 cm in diameter should be considered for elective repair. High-risk patients with smaller aneurysms (5 to 6 cm in diameter) should undergo efforts to stabilize or to improve their general medical condition before elective operation.