Retroperitoneal approach for repair of inflammatory aortic aneurysms

Inflammatory aortic aneurysms (IAAs) are characterized by a markedly thickened aortic wall and dense perianeurysmal fibrosis. The presence of such inflammation and subsequent organ adherence makes surgical repair of IAAs more challenging than repair of simple atherosclerotic aneurysms. From March 1987 to June 1994, twelve patients underwent surgical repair of an IAA by a single surgeon. Ten patients were men (83%) and the mean age was 68.3 years (range 58 to 93 years). All patients except one were symptomatic with back or abdominal pain, yet none had evidence of aneurysm rupture at operation. Preoperatively 90% (9/10) of the patients had an elevated erythrocyte sedimentation rate (ESR), 100% (12/12) had a predictive CT scan, and all patients with aortic wall pathology specimens had their diagnosis confirmed. Six patients had a left flank retroperitoneal surgical approach, five had a transabdominal approach, and one had ligation and extra-anatomic reconstruction. The choice of repair technique was based on the degree and anatomic distribution of perianeurysmal fibrosis. The 30-day operative mortality rate was 0%. Mean follow-up was 56.3 months. Aortoduodenal fistula occurred in one patient 5 months after transperitoneal repair. Technical difficulties encountered during subsequent transperitoneal repairs led to the evolution of a policy in which the retroperitoneal approach was preferred in all patients with CT evidence of IAA. It is concluded that IAA represents a spectrum of retroperitoneal fibrosis and inflammation that is best treated surgically via a retroperitoneal approach.