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ALL ABOUT AORTIC DISSECTIONS
Björck M., Steuer J., Wanhainen A.
Institution of Surgical Sciences, Department of Vascular Surgery, Uppsala University, Uppsala, Sweden
In this article the pathophysiology and epidemiology of increased intra-abdominal pressure (IAP) and abdominal compartment syndrome (ACS) after repair of ruptured Abdominal Aortic Aneurysms are reviewed. Different methods to measure the IAP are discussed and guidelines how to treat the patient are suggested. In summary, an IAP >20 mmHg (grade III-IV intra-abdominal hypertension, IAH) occurs in approximately 50% of patients treated with open repair (OR), and in 20% after endovascular repair (EVAR), the incidence of ACS is somewhat lower. Patients selected for EVAR are often more hemodynamically stable and have a more favorable anatomy, resulting in less bleeding and consequently a decreased risk of developing IAH/ACS, even if they had been operated on with OR. There is no randomized data. When the pathophysiology is analyzed, the fact that even low grades of IAH have a negative impact on urinary output and respiratory function is highlighted, and early medical therapy is advocated. Medical therapy includes neuromuscular blockade and hypertonic colloid solutions combined with furosemide. This proactive strategy may reduce the number of decompressive laparotomies. An algorithm in how to handle this situation is suggested. When treatment with an open abdomen becomes necessary, it is important to choose a temporary abdominal closure that permits maintaining sterility during prolonged treatment, and that minimizes the risk of fistulation and future abdominal hernia. The suggested method is combining Vacuum-Assisted Wound Closure with mesh-mediated traction, preventing lateralization of the abdominal wall