1. Early course (postop., day ≤ 30)
Secondary bleeding, hematoma
- Causes: Technical errors such as suture failure; slipped ligatures; inadequate hemostasis; also: needle track bleeding; iatrogenic vascular lesions; surgery under platelet aggregation inhibition
- Management: Urgent management of active and hemodynamically significant hemorrhage; broad indication for evacuating hematomas as a breeding ground for infection and possibly also compression of other structures (compartment syndrome)
- Prevention: Careful dissection, painstaking hemostasis
Early thrombotic/embolic occlusion of the arterial revascularization
- Cause: Mostly technical error
- Diagnosis: Color-coded duplex sonography, possibly CTA.
- Management: Revision surgery, embolectomy if needed; monitoring of coagulation status
- Prevention: Careful atraumatic, anatomically correct surgical technique
Wound infection
- Diagnosis: Local findings, lab panel, fever
- Management: If unavoidable, open wound; take a swap for microbiology; debridement; negative pressure wound therapy (NPWT),if necessary; antibiotics according to susceptibility testing
- Caution: In the presence of alloplastic material (vascular graft) the cause may always be infection of the graft itself; conversely, a wound infection can also spread to alloplastic material!
- Prevention: Careful atraumatic, anatomically correct surgical technique, painstaking hemostasis, avoidance of lymph vessel lesions
Graft infection
- Risk factors: Age; diabetes; obesity; malnutrition; gangrene / ulcer; duration of preop. hospitalization; duration of surgery; inguinal access; blood loss; revision surgery; lymphocele; hematoma; seroma; wound healing disorders; wound infection
- Varied clinical picture: Rather bland findings (elevated inflammation parameters); febrile infections up to dramatic progression with active bleeding/perforation, erosion of adjacent organs with fistula formation
- Diagnostic work-up: Clinical findings; laboratory panel including swab and blood culture for microbiology; abdominal ultrasonography (perigraft fluid) or CTA (trapped perigraft gas indicating microbial colonization); color-coded duplex sonography; granulocyte scintigraphy; fluorodeoxyglucose positron emission tomography (perigraft metabolic activity)
- Management: Surgical treatment of infections (revision surgery, removal, or replacement of graft, possibly with a silver or antibiotic-coated graft), antibiotics according susceptibility testing
- Prevention: Careful atraumatic, anatomically correct surgical technique, painstaking hemostasis, avoidance of lymph vessel lesions
Compartment syndrome
- Cause: Reperfusion after complete or incomplete ischemia damages the capillary membrane with increased permeability and edema formation in the soft tissues, resulting in increased pressure in the muscle compartment with tissue loss
- Symptoms: See Red Flags
- Diagnostic work-up: Symptoms, see Red Flags; quantify by intracompartmental pressure measurement (measurements of 30-50 mm Hg over 6 hours and pressures above 50 mm Hg are pathologic)
- Management: Immediate dermatofasciotomy with complete longitudinal fascial incision of all muscle compartments; later dermatotraction via artificial skin or NPWT, mesh graft
Lymph fistula, lymphocele
- Risk: Inguinal access predestined for lesion of the lymphatics
- Diagnosis: Localized clinical finding
- Treatment: Nonsurgical management of lymphoceles taking into account the risk of infection; lymph fistulas should be drained without suction for an extended period, alternatively after ruling out infection injection of fibrin sealant or revision surgery with suture ligation (methylene blue, magnifying glasses), very rarely plastic surgery
- Prevention: Lateral access spares the lymphatics; displace the lymphatic tissue anteromediad
Ischemia of the colon and pelvic organs
- Cause: Ligature/occlusion of the inferior mesenteric artery, which is why the sigmoid (86%) and descending colon (60%) are most often affected
- Symptoms : Bloody stools; diarrhea; abdominal pain; peritonitis
- Diagnostic work-up: Rectosigmoidoscopy, possibly colonoscopy (caution: increased risk of perforation!); lab panel is non-specific!
- Management: Non-surgical wait-and-see only in case of transient mucosal ischemia/severity A; otherwise bowel resection depending on location, possibly Hartmann procedure
- Prevention: In primary procedures broad indication for anastomosis of the IMA with the graft, if signs of ischemia are present during cross-clamping
Urinary or fecal incontinence; gluteal claudication including necrosis of the buttocks and sexual dysfunction may be caused by impairment of the branches of the internal iliac arteries.
Ischemic spinal cord injury and paraplegia
- Cause: Impaired perfusion of the spinal cord due to open aortic graft surgery or endovascular overstenting of arteries relevant for spinal perfusion in combination with other risk factors such as perioperative hypotension, major blood loss/anemia; especially in thoracic and combined thoracic abdominal surgery
If at least two territories of the spinal perfusion are compromised, the probability of spinal ischemia increases.
- Symptoms: Range from minor transient paresthesia and dysfunction of the bladder and large bowel to total paraplegia with life-long confinement to bed and nursing care
- Management: Elevation of spinal perfusion pressure, e.g. elevation of mean arterial pressure by drugs and placement of a CSF drain to reduce the counterpressure of arterial perfusion in the CSF spaces
- Prevention: Prevention of intra- and postoperative hypotensive phases and, after segmental artery occlusion, maintenance of a mean arterial pressure of 80-90 mm Hg for at least 48 h; prophylactic placement of CSF drainage if at least two territories of the spinal perfusion (see above) are impaired and cannot be restored by revascularization measures (e.g. carotid-subclavian artery bypass); perioperatively adequate central venous saturation (ScvO2) of ≥70% and intraoperative central venous pressure (CVP) of ≤10 mmHg; keep hemoglobin level ≥ 8 mg/dl and intraoperative blood loss as low as possible; cell savage; postop. rapid extubation to assess neurological status; follow-up
Systemic complications
- For instance, acute coronary syndrome; myocardial infarction; pneumonia; cerebrovascular events; renal failure -> appropriate interdisciplinary management
Late course (postop., day> 30)
Pseudoaneurysm
- Cause: Bleeding into the surrounding tissue with formation of an extravascular pulsating hematoma after vascular puncture near anastomoses and patch angioplasty, also due to infection/suture failure
- Diagnostic work-up: Color-coded duplex sonography (circulating perivascular blood flow, evidence of an aneurysm neck with oscillating flow)
- Management: Watchful waiting in small asymptomatic aneurysms, otherwise endovascular or open repair
Late occlusion of the revascularized arterial axis by stenosis
Suture aneurysm
- Cause: Broken sutures; low aortic anastomosis; turbulent flow; thrombendarteriectomy; infection; graft deterioration.
- Symptoms: Depending on location, e.g. pulsating inguinal tumor, also hemorrhagic shock in rupture.
- Diagnostic work-up: Color-coded duplex sonography, CTA
- Management: Revision surgery, endovascular intervention
Sexual dysfunction (in men)
- Cause: Neurogenic due to intraoperative injury of the hypogastric plexus, which is located anterior to the abdominal aorta, aortic bifurcation and iliac arteries and which passes the signals for erection and ejaculation; vascular due to microemboli entering the penile arteries when the aorta is cross-clamped, or uni-/bilateral occlusion of the hypogastric artery when simultaneously repairing iliac artery aneurysms.
- Symptoms: Temporary or irreversible erection and ejaculation disorders
- Prevention: Sparing the hypogastric plexus by anterolateral aortotomy on the right or appropriate tunneling and placement of the left limb of an aorto(bi)iliac or aorto(bi)femoral bypass; alternatively primarily retroperitoneal access on the left; preserving the antegrade perfusion of the internal iliac artery at least on one side, better on both sides
Secondary aortointestinal/periprosthetic fistula
- Definition: Connection between aortic graft and intestinal lumen (usually horizontal or ascending segment of duodenum, also colon), iliaco-ureteral fistula extremely rare
- Cause: Late suture failure; suture aneurysm; late infection; no tissue cover over graft; erosion of the intestinal wall by graft with graft migration into the intestinal lumen
- Symptoms: Massive intestinal hemorrhage, also less severe intermittent bleeding possible
- Diagnostic work-up (if CV status of patient is stable): Abdominal sonography, CTA, endoscopy (esophagogastroduodenoscopy/colonoscopy)
- Management: Revision surgery -> explantation, intestinal suture, complete/partial graft replacement, omental flap
- Prevention: During primary surgery adequate coverage of the alloplastic aortic graft or bypass in the retroperitoneum with reliable protection against the intestine
Persistent lymphedema
- Manual lymph drainage and in adequate arterial perfusion (!) rigorous compression treatment
Incisional hernia
- Surgical repair according to the current standards of hernia surgery (sublay/onlay mesh technique or laparoscopic hernia repair with intraperitoneal onlay mesh)
