Treatment options for aneurysms in high-risk patients

The increasing prevalence of aneurysms in an aging population bears with it increasing numbers of patients who are less than optimal candidates for resection. It is likely that the majority of such patients can undergo standard resection, either by referral to a center where the management of the elderly chronically ill is commonplace or by providing intensive preoperative metabolic, cardiac, pulmonary, and nutritional resuscitation. Such preoperative preparation might well include coronary revascularization or carotid endarterectomy. For the occasional patient in whom medical comorbidity is advanced and fixed, or in whom rapid aneurysm expansion or worsening symptoms mandate immediate management, yet operative risk for standard aneurysm resection seems inordinately high, several nonresective options have been identified and tested. Among these options, aneurysm exclusion appears to have significantly better results (in terms of lower rates of operative mortality and subsequent aneurysm rupture) than distal aneurysm ligature. A more recent technique, aneurysm bypass, may have potential but has not been tested for a long enough period, or by an adequate number of surgeons, to have established itself as a nonresective option. Clinical judgment, technical expertise, and a willingness to seek assistance and consultation remain the hallmarks of the optimal management of the patient with an abdominal aortic aneurysm.