Open AAA Repair

1. Purpose & indications

Purpose. Exclude the aneurysm from arterial pressure by sewing a durable prosthetic conduit between non-aneurysmal proximal and distal artery. The old aneurysm wall remains around the graft and is closed over it.

When open repair is considered. The patient has an AAA that meets repair criteria, is fit for major abdominal surgery, and open repair offers the preferred balance of durability and peri-operative risk after shared decision-making. [1,2]

PRACTICE DIVERGENCE

• ESVS: EVAR should be considered the preferred option for most patients with suitable anatomy and reasonable life expectancy; open repair should be considered preferable when life expectancy is long. [1]
• UK/NICE: offer open repair to suitable patients; consider EVAR when abdominal copathology or person-specific factors favour it, and EVAR or conservative management when anaesthetic risk or medical comorbidity contraindicates open repair. [2]
• Practical interpretation: the decision is a trade-off between early operative risk and long-term durability, modified by anatomy, life expectancy and patient preference.

This operation is a separate scope when: the aneurysm is ruptured; the proximal clamp must be above one or both renal arteries; visceral revascularisation may be required; infection is suspected; or the repair is for a graft complication.

Consent themes. Death; myocardial infarction and respiratory failure; bleeding/transfusion and return to theatre; renal injury; bowel or pelvic ischaemia; lower-limb embolisation or graft occlusion; venous, ureteric or bowel injury; wound infection or hernia; graft infection; sexual dysfunction; late para-anastomotic aneurysm or aorto-enteric fistula; and further intervention.

2. Anatomy & planning

A very simple anatomy map

Plan three things: where the clamps go, where the graft is sewn, and how kidney, bowel, pelvic and leg blood flow will be maintained.

Think of the infrarenal aorta as a vertical pipe lying on the spine:

• Above: the renal arteries leave the aorta for the kidneys. The infrarenal neck is the non-aneurysmal segment below the lowest renal artery; its length and suitability for clamping must be assessed.
• Across the front of the upper neck: the left renal vein usually crosses from the left kidney to the IVC; check CTA for retroaortic or circumaortic variants. It is the key landmark for the top of the exposure.
• To the patient's right: the IVC is a thin-walled, high-flow vein. Traction or blind dissection on the right side of the aorta can tear it.
• In front: the third and fourth parts of the duodenum, small-bowel mesentery and bowel cover the aorta. The duodenum turns into jejunum at the ligament of Treitz, just left of the aorta. These structures are moved away gently to reach the neck.
• Behind the sac: lumbar arteries enter from the posterior wall. They can bleed briskly backwards when the sac is opened.
• From the front/left of the distal aorta: the inferior mesenteric artery (IMA) supplies the left colon through a collateral network.
• Below: the aorta divides into common iliac arteries. Common iliac veins lie behind them, especially the left common iliac vein near the bifurcation.
• To each side: the ureters descend on psoas and cross the iliac vessels near their bifurcations. Identify their likely course and avoid trapping them in vessel loops or sutures.
• Around the bifurcation: sympathetic fibres of the superior hypogastric plexus contribute to ejaculation; avoid unnecessary circumferential dissection and diathermy.

Read the CT as a control-and-reconstruction plan

Before operating, identify:

1. Proximal control: lowest renal artery; length and quality of clampable infrarenal neck; calcification/thrombus; relationship of left renal vein; backup clamp site.
2. Distal control: distal aorta, both common iliacs, iliac bifurcations, aneurysmal extension, occlusive disease and whether internal iliac (pelvic supply) and external iliac (leg supply) control may be needed.
3. Graft choice: a tube graft when a healthy distal aortic cuff permits a durable aorto-aortic anastomosis; a bifurcated graft when no suitable distal aortic cuff remains or iliac disease requires reconstruction. Extent and severity of iliac disease determine the distal targets.
4. Perfusion risks: renal arteries/accessory renals, SMA/IMA patency, both internal iliac arteries and lower-limb runoff. Preserve flow to at least one internal iliac artery (ESVS Recommendation 53, Class I C). [1]
5. Exposure hazards: venous anomalies, horseshoe kidney, retroaortic left renal vein, inflammatory change, hostile abdomen and prior operations.

3. Setup

• Team brief: display CTA and state the primary and backup proximal clamp sites, distal control sites, tube versus bifurcated plan, intended anastomoses, internal iliac preservation, blood/cell-salvage plan and major bailouts.
• Patient and access: supine; arms positioned safely; prep from chest to both groins so femoral exposure is possible. Insert appropriate large-bore venous access, arterial pressure monitoring, urinary catheter and temperature monitoring. Record pedal pulses/signals.
• Anaesthesia: general anaesthesia. NICE says epidural analgesia can be considered in addition for unruptured open AAA repair; ESVS says epidural or catheter-based continuous wound analgesia may be considered (Recommendation 43, Class IIb A). Agree the haemodynamic plan for clamping and declamping. [1,2]
• Prophylaxis and equipment: peri-operative IV antibiotic prophylaxis (ESVS Recommendation 42, Class I A), VTE prevention according to risk/local protocol, warming, cell salvage, cross-matched blood, suitable vascular clamps, grafts, monofilament sutures, pledgets and embolectomy capability. [1]
• Before incision: confirm a normal artery can be controlled above and below the aneurysm. If that cannot be described from the CT, the operative plan is incomplete.

4. Perform — step by step

Phase A — Enter and expose

1. Midline laparotomy. Enter through the linea alba and inspect the abdomen. Protect bowel and avoid traction injury.
2. Pack the viscera away. Reflect the transverse colon/omentum cranially and place the small bowel to the patient's right in a moist pack. Check that retraction does not compress the small-bowel mesentery. The goal is a clear view of the posterior parietal peritoneum over the aorta.
3. Open the retroperitoneum and move the duodenum. Identify the ligament of Treitz. Open the posterior peritoneum near the fourth part of the duodenum, extend cranially towards the neck and caudally towards the bifurcation, and keep the lower dissection to the right of the aortic midline where feasible to protect the IMA/sigmoid mesentery and autonomic plexus. Divide the ligament of Treitz as needed and reflect the distal duodenum to the patient's right. Control visible preaortic lymphatics. Expose only what is needed for a safe clamp and anastomosis. [4,5]
4. Find the proximal landmark. Identify the left renal vein crossing the aorta and relate it to the lowest renal artery. Mobilise only as much as needed. If left renal vein division becomes necessary, divide close to the IVC and preserve collateral tributary pathways where possible; reconstruction may be considered if important collaterals have been sacrificed (ESVS Recommendation 51, Class IIb C). Expose enough infrarenal aorta for a safe clamp and proximal anastomosis. Avoid blind right-sided dissection beside the IVC. [1,4]
5. Obtain distal control. Expose the distal aorta/common iliac arteries according to the graft plan. If disease extends distally, expose the internal and external iliac arteries as required. Stay close to the arterial wall: the iliac veins lie behind, and the ureters cross near the iliac bifurcations. [4,5]

Phase B — Prepare control before using it

1. Choose clamp sites by touch and CT. Avoid heavily calcified, thrombus-filled or aneurysmal segments. Create only the space needed for safe clamp jaws; excessive circumferential dissection risks venous and autonomic injury.
2. Confirm readiness. The graft and sutures are open, suction and cell salvage work, proximal and distal clamps fit the planned sites, and anaesthesia is ready for the haemodynamic change.
3. Systemic heparinisation. Give IV heparin 50–100 IU/kg for elective repair (ESVS Recommendation 46, Class I C). ACT-guided additional dosing may be considered (Recommendation 47, Class IIb B). Follow local timing and account for bleeding risk/HIT. [1]
4. Clamp. Apply proximal and distal clamps at the planned sites in the sequence agreed by the operating surgeon. The anchor sources do not specify a universal proximal-versus-distal order. Announce clamp-on time. Confirm control before opening the aneurysm.

Phase C — Open the sac and control back-bleeding

1. Open the aneurysm longitudinally on its anterior surface, staying away from the duodenum and planned anastomotic cuffs.
2. Remove loose mural thrombus to expose the inner wall and identify bleeding branches.
3. Control branch back-bleeding. Oversew lumbar and median sacral branches from inside the sac. Control IMA back-bleeding at its origin. If ligating, do so at the sac origin to preserve left-colic collaterals; retain the option of selective reimplantation where colonic perfusion is at risk.
4. Prepare the cuffs. Divide the aorta within the sac as required and fashion clean proximal and distal edges. Remove obstructing calcium cautiously; avoid tearing a thin neck. Place reinforcing pledgets selectively if tissue is friable.

Phase D — Construct the graft

1. Proximal anastomosis. Cut the graft square and sew an end-to-end anastomosis with running non-absorbable monofilament. Place it as close as safely possible to the renal arteries to avoid leaving a long diseased infrarenal segment (ESVS Recommendation 52, Class I C). [1,3,5]
2. Test the proximal suture line. Before constructing the distal anastomosis, apply an atraumatic clamp to the graft body and, with native distal vessel control maintained, slowly release the proximal aortic clamp to pressurise the proximal anastomosis. Inspect the whole suture line, particularly the posterior wall. If a repair stitch is needed, reapply proximal aortic control, expose the exact bleeding point and place a directed stitch with reinforcement as required; retest before proceeding.
3. Choose the distal reconstruction:
   • Tube graft: sew end-to-end to a healthy distal aortic cuff above the bifurcation.
   • Bifurcated graft: tailor enough main-body length for future endovascular access without redundancy or kinking. Lay each limb without twist or excess length and sew to suitable outflow arteries. If common iliac targets are unsuitable, use appropriate distal targets while preserving or reconstructing pelvic inflow as needed. Preserve blood flow to at least one internal iliac artery (ESVS Recommendation 53, Class I C). [1,3,5]
4. Flush before completing. Before the final distal sutures are tied, forward-flush the graft, allow controlled distal back-bleeding and remove air/debris. Protect the opposite limb during sequential flushing. The exact clamp sequence depends on the reconstruction. [1,3,5]

Phase E — Declamp, prove the repair and close

1. Warn anaesthesia before reperfusion. Confirm adequate circulating volume, temperature and readiness for hypotension/acidosis from washout. Minimise cross-clamp time, but never rush an unsafe anastomosis.
2. Reperfuse gradually and sequentially. Release flow in a controlled sequence, one graft limb at a time for a bifurcated graft, while watching blood pressure and the suture lines.
3. Check the repair. Inspect proximal and distal anastomoses, graft orientation and haemostasis. Palpate both femoral/pedal pulses and use Doppler if needed. A new weak/absent signal means kink, thrombosis, dissection or embolisation until proved otherwise.
4. Check bowel and pelvic perfusion. Inspect the left colon after reperfusion and assess the wider mesenteric/pelvic collateral circuit. Routine IMA reimplantation is not indicated; reserve it for selected cases with suspected inadequate pelvic organ perfusion and risk of colonic ischaemia (ESVS Recommendation 54, Class III C). [1]
5. Cover the graft. Close the aneurysm sac over the prosthesis, then close the retroperitoneum where possible. If there is insufficient sac for coverage, interpose a mobilised omental flap between the graft and bowel. Ensure bowel/duodenum is separated from the graft and no ureter or bowel is caught.
6. Abdominal closure. Recheck swabs, bleeding and distal perfusion. Close the fascia with an evidence-based midline technique. Prophylactic mesh reinforcement should be considered for midline open AAA repair (ESVS Recommendation 55, Class IIa A), modified by contamination risk and local policy. [1]

5. Technical pearls & pitfalls

• Control comes before reconstruction. Do not open the sac until the proximal and distal plan is real, exposed and clampable.
• The left renal vein is a landmark, not the renal artery. Confirm the renal level on CT and in theatre. Mobilise the vein only as needed. If division is unavoidable, divide close to the IVC to preserve collateral drainage; consider reconstruction if important collaterals were sacrificed (ESVS Recommendation 51). [1,4]
• Stay close to artery at the bifurcation. The veins are behind; a deep blind pass can cause major haemorrhage.
• Limit dissection along the left of the lower aorta. The IMA and sigmoid mesentery are nearby, and autonomic nerves cross the bifurcation. At the upper neck, check CT for a retroaortic or circumaortic left renal vein before passing a clamp behind the aorta.
• Do not mobilise a ureter unnecessarily. Know its course, see it if the distal exposure requires it, and keep loops, clamps and sutures away.
• Tube versus bifurcated is an anatomical choice. A tube graft limits dissection and anastomoses when the distal aorta is healthy. An unsuitable distal aortic cuff or iliac disease requiring reconstruction may require a bifurcated graft.
• Agree the flushing sequence. Forward flushing, distal back-bleeding and removal of air/debris precede final completion and controlled reperfusion. Clamp handling depends on the graft configuration; flushing reduces but does not eliminate embolic risk.
• A patent IMA does not automatically need reimplantation. Judge the whole mesenteric/pelvic collateral circuit and the colon after reperfusion.
• Never declamp silently. Anaesthesia must anticipate the fall in afterload and metabolic washout.
• The distal pulse check is part of the operation. Document the comparison with baseline before leaving theatre.

Alternative exposure: left retroperitoneal

The left retroperitoneal route can be useful for proximal disease, inflammatory aneurysm or a hostile abdomen, but gives poorer access to the right renal/external iliac arteries. ESVS finds no clear major-outcome superiority over the transperitoneal route and recommends choosing by patient factors and surgeon preference (Recommendation 50, Class IIa B). Teach it as a separate exposure, not an improvised variation. [1,4]

6. Completion

Before leaving theatre, state and document:

• Proximal: clamp was infrarenal as planned; proximal anastomosis is dry; renal artery relationships and any concern about renal arterial compromise are documented. Review urine output with haemodynamics; urine output alone does not establish adequate perfusion of both kidneys.
• Graft: correct tube/bifurcated configuration; no twist or compression; graft is separated from bowel by sac/retroperitoneum or an omental flap.
• Distal: both lower-limb outflows have been assessed; femoral and pedal pulse/Doppler findings are recorded; at least one internal iliac remains perfused.
• Viscera: haemostasis secured; left colon appears perfused; no bowel, ureteric or venous injury identified.
• Physiology: clamp and reperfusion communicated; temperature, acid-base state, coagulation, haemoglobin and urine output reviewed with anaesthesia.

7. Complications & rescue

8. Postoperative management

• HDU/ICU: all open AAA repairs should have early HDU/ICU monitoring (ESVS Recommendation 69, Class I C), with haemodynamic, respiratory and cardiac surveillance as clinically indicated. [1]
• Perfusion: repeat abdominal and bilateral limb examinations, pulses/signals and lactate. Escalate new pain, neurological deficit or lost signal immediately.
• Renal: hourly urine output initially; serial creatinine, potassium and acid-base assessment; optimise perfusion and avoid nephrotoxins where possible.
• Bleeding/coagulation: wound/drain findings if present, haemoglobin, coagulation and transfusion needs. Unexplained instability requires active exclusion of haemorrhage.
• Bowel: examine the abdomen and watch for distension, persistent acidosis, diarrhoea or rectal bleeding. Suspected colonic ischaemia is time critical.
• Recovery: VTE prevention, chest physiotherapy, early mobilisation and graded oral intake according to ileus/recovery. Continue cardiovascular secondary prevention.
• Long term: watch for incisional hernia, graft infection, limb occlusion, para-anastomotic aneurysm and aorto-enteric fistula. Imaging of the entire aorta and peripheral arteries every five years may be considered (ESVS Recommendation 112, Class IIb C). [1]

9. Remember / 60-second mental rehearsal

CT control map → midline entry → bowel right/colon up → left renal vein and infrarenal neck → distal iliac control → heparin → planned proximal and distal clamp sequence → open sac → control lumbar/IMA back-bleeding, assess need to preserve IMA → proximal graft anastomosis → test → distal tube or limbs → forward flush/back-bleed/de-air → warn anaesthesia → sequential reperfusion → haemostasis → pulses and left colon → sac over graft → close and HDU.

Five questions before clamping

1. Where exactly are my primary and backup proximal clamp sites?
2. Can I control every distal vessel required by the planned graft?
3. Which structures are immediately at risk: left renal vein, IVC/iliac veins, duodenum, ureters and hypogastric plexus?
4. Why is this a tube or bifurcated graft, and how will I preserve pelvic perfusion?
5. What will I do if there is no distal pulse or the colon looks ischaemic after reperfusion?

References

1. Wanhainen A, Van Herzeele I, Bastos Goncalves F, et al. ESVS 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms. Eur J Vasc Endovasc Surg. 2024;67:192–331. doi:10.1016/j.ejvs.2023.11.002.
2. National Institute for Health and Care Excellence. Abdominal aortic aneurysm: diagnosis and management. NG156. Recommendations. Accessed 25 September 2026.
3. Loftus I, Hinchliffe RJ, editors. Vascular and Endovascular Surgery: A Companion to Specialist Surgical Practice. 7th ed. Elsevier; 2024. Chapter 13.
4. Wind GG, Valentine RJ. Anatomic Exposures in Vascular Surgery. 3rd ed. Wolters Kluwer; 2013. Chapters 11–12.
5. Blazick E, Conrad MF. Advanced aneurysm management techniques: open surgical anatomy and repair. In: Dalman RL, editor. Operative Techniques in Vascular Surgery. Wolters Kluwer; 2015. Chapter 22.