Management of sterile para-anastomotic aneurysms of the aorta

The history of surgical reconstruction of the aorta for aneurysmal and occlusive disease now spans over 50 years. The continued performance of these operations with minor modifications attests to their durability and efficacy. Despite this, some late complications do occur. One such complication is the development of a sterile para-anastomotic aneurysm. This has been reported in 1% to 4% of patients; however, the true incidence of para-anastomotic aneurysms of the aorta (PAAA) may be closer to 25% as evidenced by studies with standardized long-term surveillance. PAAA include true and false aneurysms, which occur in the absence of infection. Computed tomography (CT), magnetic resonance imaging (MRI), and labeled white blood cell scans are vital in excluding the presence of infection and differentiating PAAA from infected false aneurysm, aortic graft infection, and aorto-enteric fistula. The surgical approach to PAAA may require complex reconstruction of the suprarenal or supraceliac aorta similar to thoracoabdominal aortic aneurysm repair. Results of surgery are improved with asymptomatic detection and elective repair of PAAA. Methods of prevention rely mainly on technical perfection, but even with this PAAA likely will never be eliminated. This review will cover the incidence, pathophysiology, presentation, diagnosis and operative treatment of sterile para-anastomotic aneurysms of the aorta. Implications for prevention and the role of surveillance will also be discussed.