The Justification of Open Surgical Repair for an Abdominal Aortic Aneurysm: A Retrospective Comparison of Outcomes of Endovascular Aneurysm Repair and a Brief Review of the Literature

Figures

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  Figure 1. CT and surgical images of an abdominal aortic aneurysm in a 78-year-old male presenting with a pulsating abdominal mass. The patient, a non-smoker with no comorbidities, reported, ’I feel my heart beating in my abdomen’. A 3D CT image (A) shows a neck angulation >60° (white arrow) and venous dilatations (V) from the left popliteal to iliac veins (yellow arrows) due to an arteriovenous fistula. Intraoperative findings (B) revealed a thin-walled aneurysm with chronic partial dissection (white star) but no thrombus. (C) demonstrates severe venous dilation and adhesion between the left common iliac artery (A) and vein (V), complicating surgical exploration.

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  Figure 2. CT images of abdominal aortic aneurysm (AAA) cases incidentally detected during evaluations for unrelated clinical indications. (A) A saccular aneurysm was identified in a 60-year-old male during an emergency CT scan after a traffic accident. (B) An asymptomatic aneurysm was detected in a 68-year-old hypertensive male with a heavy smoking history (≥2 packs/day) during a prostate cancer evaluation. (C) An aneurysm was discovered in a 58-year-old female during a CT scan assessing the vena cava and iliac veins after developing deep vein thrombosis in the left lower extremity while being monitored for cystic kidney disease (yellow arrows) and atrophic kidney.

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  Figure 3. CT and surgical images of a patient with anatomical contraindications for EVAR. A 67-year-old bedridden male with bilateral lower limb amputation and hypertension presented with severe abdominal pain. (A) CT angiography revealed a ruptured aneurysm (11.7 × 10.5 cm) with a probable contained rupture (yellow arrow). (B) 3D CT reconstruction demonstrated hostile neck anatomy and iliac artery configurations. (C) The aneurysm was massive, and (D) after excision, a graft was placed, extending to the femoral arteries due to the inability to perform iliac anastomoses. In such cases, rapid surgical intervention is critical, and adjuncts like autotransfusion, aortic occlusion balloons, or Foley catheters may be necessary to ensure hemostasis and improve intraoperative management.

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  Figure 4. CT images of patients requiring open surgery immediately after EVAR. Three patients—(A) a 72-year-old female, (B) a 38-year-old male with a dissecting ruptured aneurysm (black arrow indicating the rupture site), and (C) a 66-year-old male (yellow arrow indicating a Type 1b endoleak)—developed persistent abdominal distension after EVAR, accompanied by metabolic acidosis. This led to a diagnosis of abdominal tamponade, necessitating open surgery (red stars indicate hematoma). (D) A CT image of a 68-year-old male patient who underwent emergency EVAR for rupture but later required open surgery due to superior mesenteric artery (SMA) thrombosis (green arrow) in the postoperative period. A detailed preoperative evaluation of aortic branches is essential before EVAR, and if necessary, mesenteric anastomoses should be performed via open surgery.

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  Figure 5. CT and surgical images of Type 1 endoleak. (A–C) CT scans taken at the first, fourth, and sixth months following EVAR in a 70-year-old male patient demonstrate progressive aneurysm enlargement due to a Type 1 endoleak (red stars indicate contrast agent outside the stent graft; G, stent graft). Despite an intervention with a fenestrated tube graft in the fourth month, aneurysm expansion continued. (D,E) During open surgery, the aneurysm sac was opened without cross-clamping using an endovascular occlusion balloon. The anterior leakage site (forceps tip) was repaired with pledgeted sutures, and the aneurysm sac was wrapped around the graft. (F) The patient’s postoperative second-month CT scan (green arrow) is shown. Stent-preserving surgery is a less invasive alternative to stent explantation in managing EVAR-related complications.

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  Figure 6. CT and intraoperative images of stent graft infection following EVAR. A 63-year-old male, who underwent EVAR four years ago, was admitted with severe back pain and fever. Blood cultures confirmed Enterococcus faecalis infection. (A) CT showed air (yellow arrow) within the aneurysm sac, indicating infection. (B) Surgery revealed an inflamed aneurysm sac and an infected protrusion (white arrow). (C) The infected stent graft (with iliac limb separation) was removed after proximal occlusion with a balloon. (D) A silver-coated, antibiotic-impregnated Dacron graft was placed and wrapped with a pericardial patch (black arrow) and omentum.

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  Figure 7. CT and angiographic images demonstrating causes of reintervention following EVAR. (A,B) In a 75-year-old male patient, a Type 1 endoleak originating from the posterior aspect (yellow star) of the proximal stent graft fixation site (mouse pointer) was treated using the fenestrated technique with proximal extension of a tube graft (1: previous graft; 2: new graft) (C) In a 66-year-old male patient, malposition and displacement of the left iliac fixation site (red arrow) were observed. In such cases, aneurysm expansion or infection should be investigated. (D) In an 83-year-old female patient, thrombotic occlusion of the iliac stent (yellow arrow) was detected within the first year after EVAR.

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  Figure 8. Kaplan–Meier survival curve and causes of death. Kaplan–Meier survival curves comparing EVAR (blue) and Open Surgery (yellow) indicate no significant difference in long-term survival between the treatment modalities. Causes of death are listed by months.

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  Figure 9. Silent aneurysm growth over six years: CT and surgical images. (A,B) A 57-year-old female smoker, undergoing hypertension treatment and socially active, presented with severe abdominal pain and syncope. Her poor clinical condition, absence of an aneurysm neck, dissection (green arrow) extending from the left renal artery (yellow arrow), and the presence of a hematoma (red star) necessitated open surgery. (C) Intraoperatively, a 7 cm longitudinal rupture (white square) was identified on the posterior aneurysm wall (AS, Aneurysm sac wall). (D) Retrospective review of a CT scan from six years earlier, initially performed for urinary stone evaluation, revealed an abdominal aorta measuring only 3 cm. (Alan; which means ‘area’ in English). Unaware of its silent progression, the patient lived for six years without intervention. This case underscores the importance of early detection of aortic pathology across all clinical disciplines and reinforces the need for population-based screening programs.

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  Figure 10. CT images demonstrating aneurysm sac enlargement after EVAR. (A,B) A 73-year-old male developed limb graft migration due to progressive iliac artery dilation, leading to a Type 1b endoleak and a 1 cm sac expansion two years post-EVAR. (C,D) A 60-year-old male with coronary artery disease and COPD experienced persistent abdominal pain one year after EVAR, revealing a 2 cm sac enlargement. A hypodense area within the sac, without extraluminal contrast, indicated a Type 5 endoleak (red star). In both cases, continued smoking and poor adherence to antihypertensive therapy contributed to disease progression.