Abdominal aortic aneurysm repair

Pushpa1, Anitha2, Abirami3

1OT Nursing In charge, Kauvery Heart city, Trichy, Tamil Nadu

2,3OT Senior Staff Nurse, Kauvery Heart city, Trichy, Tamil Nadu

Abstract

An abdominal aortic aneurysm (AAA) is often asymptomatic, detected incidentally, but symptoms can include a pulsatile feeling near the belly button, and deep pain in the abdomen or back. A ruptured AAA is life-threatening, presenting severe, sudden back or abdominal pain, and signs of shock including low blood pressure. A palpable pulsatile mass in the abdomen is also a key sign, though not always present.

Key words: Abdominal aortic aneurysm (AAA); Perianeurysmal hematoma; Laparotomy

Background on AAAs

An abdominal aortic aneurysm (AAA) is defined as a permanent dilation of the abdominal aorta, with a diameter greater than 3 cm or a diameter greater than 50% of the aortic diameter at the level of the diaphragm. If left untreated, progressive vessel wall degeneration leads to dilation and thinning of the vessel. Eventually, these changes can result in the rupture of the AAA. AAA prevalence and incidence rates have decreased over the last 20 years, both in developed and in developing countries. This decrease has been attributed partially to the decline in smoking. Prevalence is negligible before the age of 55 to 60 years, and after that, the prevalence increases with age. AAA prevalence is up to fourfold more in men (between 1.3% and 12.5%) than women (between 0.0% and 5.2%). The risk of rupture increases with the size of the aneurysm: the 5-year risk for aneurysms less than 5 cm is 1% to 2%, whereas it is 20% to 40% for aneurysms greater than 5 cm in diameter. Abdominal aortic aneurysm represents about 1% of deaths in males over the age of 65 and is the tenth leading cause of death in men 65 years of age or older. The mortality rate of ruptured abdominal aortic aneurysm is over 80%. Early diagnosis and treatment, therefore, are very important before its rupture.

Patient Details

A 74-year-old male presented with c/o abdominal and left lumbar pain since 1week, aggravated the previous day, when patient went to nearby hospital where USG done revealed large fusiform infra renal abdominal aortic aneurysm, 8X62 cm, with surrounding perianeurysmal hematoma on the left side, extending to left lumbar region.

He had h/o SHTN, TB(Pott’s) spine (completed ATT). And, he had a surgical history of Herniotomy 20 years back and both eye cataract surgery 5 years back.

On examination

  • Patient conscious, oriented
  • BP- 110/70 mmHg
  • HR – 96/min
  • SpO2- 98% at RA
  • RR- 20/min
  • Temp- Normal
  • CVS – S1 S2+
  • RS- B/L AE+
  • P/A – Soft
  • CNS – NFND
  • Height-166cm
  • Weight – 70kg

Pre OP Medication

  • Cefactum 1.5 g IV BD
  • PAN 40mg IV BD
  • Paracetamol 1g STAT
  • Dolo 650mg PO TDS

Pre OP Investigation:

  • Hb- 8.0 g/dl
  • PCV- 24.0%
  • RBC Count-2.66ML/10^9
  • WBC Count-10940 Cells/Cum
  • HbA1c- 6%
  • Urea – 57.78mg/dl
  • Creatinine- 1.54mg/dl
  • Na- 134mmol/L
  • K- 4.42mmol/L
  • Blood group – O Negative

ECG

Pre OP X-Ray

Post OP X-Ray

USG Abdomen Report

Carotid Doppler

ECHO

CT Angio Report

Operation Notes

Surgery: Laparotomy + Abdominal aortic aneurysm repair with Intergard 18X9 mm graft

Procedure

  • Under General anesthesia, parts painted &draped.
  • Position – Supine.

Laparotomy

  • Laparotomy was done from xiphisternum to pubic.
  • Incision deepened.
  • Aorta approached after kocherization of the duodenum and opening of peritoneum.
  • Proximal dissection is done till both renal arteries visualized, left renal artery lower than right renal artery.
  • Distal dissection done till common iliac bifurcation on both sides and control taken.
  • Aneurysm starts right below the left renal artery.

Groin Exposure

  • In view of dissection of the aortic wall distal to the aneurysm, which was extending till the CIA left.
  • Left groin incision placed, and common femoral artery exposed.

Sequence of Events

  • Heparin 4000 units given.
  • ACT- 301 After Inj. Protamine 20 mg ACT- 152
  • Distal clamping -Right and Left CIA.
  • Proximal clamping -Inter renal and infra renal.
  • Aortic aneurysm sac opened.
  • Sac excised along with debris – sac wall sent for HPE aerobic, anaerobic, Fungal, AFB cultures.
  • Intergard 18×9 bifurcated graft refashioned into 18mm tube graft.
  • Proximal anastomosis b/w the tube graft and infrarenal aorta using 3-0 prolene sutures.
  • Bleeding lumbar arteries sutured and ligated with 3-0 Prolene.
  • Distal anastomosis b/w the graft and abdominal aorta just above aortic bifurcation with 3-0 prolene, intimal flap taken with vessel wall in distal anastomosis.
  • Post anastomosis, hemostasis achieved.
  • Hematoma adjacent to aneurysm evacuated and thorough wash given.
  • Protamine 20mg+10mg given.
  • Proximal and distal anastomosis reinforced with BioGlue.
  • Abgel placed surrounding the graft.
  • Omentum tacked over the graft.
  • Left retroperitoneal drain, right intraperitoneal drain placed and fixed.
  • Rectus sheath closed using 1 Ethilon.
  • Subcutaneous tissue closed with 1 Vicryl.
  • Skin approximated with staples.
  • Groin incision closed with Vicryl, skin with Monocryl.
  • Sterile dressing done.

Procedure

Benefits of Laparotomy + Abdominal Aortic Aneurysm Repair

The goal of endovascular aneurysm repair is to prevent the abdominal aortic aneurysm from bursting, which is a life-threatening event. The force of blood flow against a weak spot in the wall of the blood vessel (here the aorta) causes the aortic walls to balloon outward, creating an aneurysm.

Post OP Orders

  • RT aspiration.
  • IV fluids as per intensivist orders.
  • Magnex Forte 1.5 g IV BD
  • Targocid 400mg IV BD one day f/b OD
  • Para 1g IV TDS
  • Pan 40 mg IV OD
  • Intake /Output vitals charting.
  • Cultures and HPE sent for lab.

Culture Report

Post-Operative Period

  • POD
  1. Patient received from HCOT with AMBU bag ventilation then connected with mechanical ventilator.
  • Mode – SIMV (PRVC+PS)
  • Fio2 -100%, PEEP- 5cmof H2O, TV-450ml
  1. Patient vitals were stable.
  2. She was managed with necessary support.
  • Adrenaline 0.1ml/hr.
  • NTG 0.1ml/hr
  • Noradrenaline 4.0ml/hr.
  • Fentanyl 2.0ml/hr.
  1. Total Left Retroperitoneal drain – 150ml
  2. Total Right Intraperitoneal drain – 100ml
  3. Every 4h patient was given back care and ET suctioning
  4. Antibiotic Inj. Cefactum 1.5g IV BD administered.
  5. Total Left Retroperitoneal drain – 200ml.
  6. Total Right Intraperitoneal drain – 100ml.
  7. Blood Transfusion – 1-unit FFB, 4-unit Platelet, 2 Unit PRBC.

1st POD

  1. Patient vitals are stable.
  2. Extubation done.
  3. She was managed with necessary support.
  • Noradrenaline 4.0ml/hr.
  • Fentanyl 2.0ml/hr.
  1. Early in the morning patient was given mouth care, combing and dressing done.
  2. Total Left Retroperitoneal drain – 150ml.
  3. Total Right Intraperitoneal drain – 100ml.
  4. 1 Unit Albumin given.
  5. Patient is kept on NPO and IV Fluid 100-125ml/hr.
  6. Blood Transfusion – 1-unit PRBC.

2nd POD

  1. Patient vitals are stable
  2. Early in the morning patient was given mouth care, combing and dressing done.
  3. Oral Sip of Water given.
  4. Total Left Retroperitoneal drain – 200ml.
  5. Total Right Intraperitoneal drain – Nil.
  6. Blood Transfusion – 2-unit PRBC
  7. Arterial line removed.

3rd POD

  1. Patient vitals are stable.
  2. Oral Liquid diet started.
  3. Chest physiotherapy given.
  4. Total Left Retroperitoneal drain – 150ml.
  5. Total Right Intraperitoneal drain – Nil.
  6. Blood Transfusion – 1-unit PRBC.

4th POD

  1. Patient vitals are stable.
  2. Total Left Retroperitoneal drain – 100ml.
  3. Total Right Intraperitoneal drain – Nil.
  4. Right Intraperitoneal drain tube remove plan.
  5. Patient shifted to ward with stable status.
S NoInvestigation0-POD1st POD2nd POD3rd POD4th POD
1Hb6.28.17.98.59.9
2PCV-1823.325.229.4
3Urea-72.7272.7666.3457.78
4Creatinine-1.621.560.970.77
5Na133136138142140
6K4.64.13.693.623.37
7Ph.7.317.46---
8PO2348224---
9PCo23733---
10HCO318.623.5---
11Glucose329139163--

Pre-operative Nursing Management

  1. Risk Factor Modification: Educate patients on the importance of blood pressure control, smoking cessation, maintaining a healthy weight, and controlling lipid levels to slow aneurysm progression.
  2. Patient Preparation: Provide clear information about the procedure, risks, and benefits to alleviate anxiety.
  3. Assessment: Perform a physical assessment to identify a pulsating abdominal mass and listen for bruits over the aorta.
  4. Medication and Consultations: Ensure the patient has seen the vascular surgeon and anesthesia team, and that informed consent for surgery has been obtained.

Intra-operation Nursing Management

  1. Fluid and Medication Administration: Administer IV fluids to maintain hydration and ensure the timely delivery of prophylactic antibiotics and analgesics.

Post-operative Nursing Management

  1. Vital Sign Monitoring: Closely monitor vital signs, including blood pressure and heart rate, to detect changes that may indicate impending complications such as rupture or dissection.
  2. Pain Assessment and Management: Conduct a thorough pain assessment and administer analgesics as needed, while also positioning the patient for comfort.

Monitoring for Complications

  • Bleeding and Hemorrhage: Assess for signs of bleeding, such as a hematoma on the flank (Grey Turner sign).
  • Ischemic Bowel: Monitor lactate and ALT levels for any indication of ischemic bowel and consider a rectal exam or CT scan if levels increase.
  • Renal Complications: Monitor for acute kidney injury (AKI), a known risk of aortic cross-clamping, which can lead to a prolonged hospital stay and increased mortality.
  • Neurological Deficits: Assess neurological status for any changes in the level of consciousness or motor/sensory function.
  • Infection Prevention: Monitor for signs of infection and administer prescribed antibiotics.
  • Bowel Assessment: Auscultate for bowel sounds and monitor for signs of altered bowel elimination.
  • Mobility and DVT Prophylaxis: Encourage ambulation and deep breathing and provide prophylaxis to prevent deep vein thrombosis (DVT).
  • Patient Education: Educate the patient and family on medication compliance, the importance of follow-up appointments, lifestyle modifications (diet, exercise, Smoking cessation), and restrictions on heavy lifting or strenuous activities to support recovery at home.

Discharge Medications

DrugsDoseFrequency
Tab. Cepodem xp325MG1-0-1 (till review)
Tab. Bactrim ds-1-0-1 (till review)
Tab. Ecosprin75MG0-1-0 (till review)
Tab. Ivabrad5MGSOS
Tab. Corbis1.25MG1-0-0 (till review)
Tab. Nicardia r10MG1-1-1 (till review)
Tab. Pantocid40MG1-0-0 (before food) x 5 days
Tab. Alprax0.5MG0-0-1 (till review)
Tab. Para500MG1-1-1 x 5 days
Syp. Mucolite10ML1-1-1 x 1 week
Syp. Duphalac15ML0-0-1
Neb. Foracort-1-0-1 (10 am/ 10 pm) x 1 week
Neb. Glycohale-1-0-1 (6 am/ 6 pm) x 1 week
Tab. Deslor5MG1-0-0 x 1 week

Conclusion

Long-term prognosis is influenced by coexisting medical conditions and lifestyle factors. Counseling risk factor reduction, especially smoking cessation, is paramount for all patients. A team-based approach involving vascular surgery, cardiology, and other specialists is vital to optimize outcomes, whether through elective repair or in the face of an emergency.

Reference

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  • Conway KP, Byrne J, Townsend M, Lane IF. Prognosis of patients turned down for conventional abdominal aortic aneurysm repair in the endovascular and sonographic era: Szilagyi revisited? J Vasc Surg. 2001 Apr;33(4):752-7. [PubMed]
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