The 30-day mortality rate associated with open aneurysm repair ranges from 1.2% to 8.4%. The discrepancy in the reported mortality rate depends on whether a single institution study or community-wide experience is being described. Hertzer reported a 1.2% mortality rate in more than 1,000 consecutive patients undergoing open aneurysm repair at the Cleveland Clinic. Of the 14 patients who died following open aneurysm repair, only 3 died as a result of a myocardial infarction (MI). The remainder of the patients died from pulmonary dysfunction, multi-organ failure, or other causes.

Multicenter studies provide another perspective on the mortality following aneurysm repair. ADAM, the small aneurysm trial performed in the U.S., recently reported a 1.8% mortality rate, which is comparable to that reported by Hertzer. However, in a similar study performed in England, the mortality rate was 7.9%. Using national Medicare databases, Lawrence reported a national mortality of 8.4%, which is similar to statewide data in Florida and California, where the mortality rate was 6.5%.

There are numerous risk factors that determine a patient’s risk for death following open aneurysm repair (Table 20-1). These risk factors include advanced age, female gender, aneurysm morphology, and associated comorbidities. However, the successful outcome of an aortic aneurysm repair also depends upon surgeon training, as well as surgeon and hospital volume. A recent report by Dimick shows a clear relationship between surgeon and hospital volume and outcome for AAA surgery. Hospitals with high surgical volumes had a lower mortality rate than those with medium and low volumes. The mortality rate in Dimick’s study was 5.6% in high-volume hospitals, compared to 6.8% in medium-volume hospitals and 8.7% in low-volume hospitals. Independent predictors of mortality included postoperative complications, such as pulmonary failure, acute MI, shock, and septicemia. Surgical training and the vascular experience of the surgeon performing aortic aneurysm surgery also affect the mortality rate. Vascular training has been correlated with lower mortality, and surgeons who perform other vascular operations generally report lower operative mortality rates. Thus, the mortality following open aneurysm repair depends not only upon the patient’s risk factors, but also on the characteristics and volume of the surgeon and the hospital where the operation is performed.

The urgency of the operation is also an important predictor of mortality following open aneurysm repair. In a 4-year prospective audit of infrarenal aneurysm repairs, Sandison found a relationship between mortality and the urgency of the operative procedure. In patients undergoing elective repair, mortality was 3.7% and the causes of death included multiple organ failure,
pneumonia, cerebrovascular accident, and aspiration. Mortality increased to 9.2% in patients undergoing an urgent operative procedure. Urgent operations were performed in patients complaining of abdominal pain, back pain, or embolic complications. Here patients died of multiple organ failure, ischemic colitis, pulmonary embolus, paraplegia, and respiratory failure. In emergency situations, the mortality rate rose to 35%. In this group, the majority of patients died from multiple organ failure or MI, bleeding, ischemic colitis, and cerebrovascular accident. Even though mortality following open repair of ruptured AAA has decreased, the mortality remains high (30% to 40%). Independent risk factors include female gender, pre-operative hypotension, and prolonged operative procedure.

Cardiac mortality and morbidity following open aneurysm repair are generally considered the most common complications following elective open repair (4% to 10%). Pre-operative cardiac evaluation is recommended to reduce this complication. However, cardiac catheterization, stenting, and prophylactic revascularization are expensive and may not be associated with an overall decrease in mortality. A more rational approach has been suggested by Froehlich, who used the American College of Cardiology’s and the American Heart Association’s pre-operative assessment guidelines in the evaluation of patients undergoing vascular surgical procedures. Froehlich found that following these guidelines, the mortality rate was reduced from 3% to 2%. Implementation of these cardiac risk assessment guidelines reduced the resource utilization and did not change operative mortality rate. In addition, pre-operative beta blockade has further reduced cardiac morbidity following open aneurysm repair.

Renal failure occurs in 1% to 2% of patients following open aneurysm repair. Risk factors for postoperative renal failure include pre-existing renal dysfunction, hypotension, nephrotoxic drug or contrast, suprarenal clamping, and aneurysms presenting to peripheral emboli. Renal dysfunction can be minimized by hydration, intra-operative mannitol, or fenoldopam infusion.

Morbidity following open aneurysm repair varies between 13% and 23%. Recently, the definition of postoperative morbidity has changed with the introduction of endovascular repair. This new technology introduced the concept of major and minor morbidities. Table 20-2 provides a reported incidence of a variety of complications associated with open aneurysm repair. Reoperation for bleeding is an uncommon complication. In Hertzer’s report, 0.4% of patients required operations for bleeding, while Zarins reported a 4% rate in patients undergoing open procedures when compared with endovascular procedures.

Groin complications occur in 2% to 3% of patients and represent a potentially life-threatening complication. Wound infections and infected lymphocele may spread to the graft material, leading to a graft infection. In fact, the majority of aortic graft infections can be traced back to a postoperative wound infection. Groin infections are more likely to occur in obese patients with a large panniculus, in diabetic patients, and in patients with open skin lesions in the ipsilateral leg. Groin lymphoceles can be avoided with knowledge of the underlying lymphatic anatomy and the importance of a single vertical incision directly over the arterial vessels (Fig. 20-1). Transected lymphatics and lymph nodes when visualized should be ligated. Lymphoceles are particularly common with extensive exposure of the profunda femoris artery (25%). Nondraining lymphoceles are generally observed and will spontaneously resolve. Early groin lymphatic leaks are treated with diuresis, leg wraps, and wound care. However, if the lymphatic leak persists or a lymphocele becomes infected, the wound must be explored and the transected lymphatics ligated if identified. Blebea reported an interesting technique using a thigh injection of isoulfane blue to identify the leaking lymphatics.

Aortic aneurysms may be exposed transabdominally through a long midline incision or through a retroperitoneal approach with a flank incision. The long midline incision is associated with a higher incidence of pulmonary complication, prolonged ilieus, and incisional hernia. Raffetto and colleagues reported a 28.2% incidence of incisional hernias in patients undergoing open AAA repair as compared with 11% in patients having aortic reconstruction for occlusive disease. Inguinal hernias were also more common in AAA
patients (23.7% vs. 6%). The midline incision has been associated with incisional hernias in patients not undergoing aneurysm repair. It is uncertain whether this region of the abdominal wall is predisposed to hernia formation.