Surg Clin N Am 87 (2007) 1035–1045

Ruptured Abdominal Aortic

Aneurysms: Remote Aortic Occlusion
for the General Surgeon
CPT Zachary M. Arthurs, MDa,*,
CPT Vance Y. Sohn, MDa,
Benjamin W. Starnes, MD, FACSb
a
Department of Surgery, Madigan Army Medical Center, Fitzsimmons Drive,
Building 9040, Tacoma, WA 98431, USA
b
Division of Vascular Surgery, University of Washington, Harborview Medical Center,
325 Ninth Avenue, Seattle, WA 98104, USA

When Parodi and colleagues [1] implanted the first endograft to treat an in-
frarenal abdominal aortic aneurysm (AAA) in 1991, they forever changed the
treatment of aortic aneurysmal disease. This technology has reduced the mor-
tality risk compared with open repair, and it has eliminated the associated
morbidity of an abdominal operation in high-risk patients [2–5]. Similarly,
whereas open surgery has remained the primary therapy for ruptured abdom-
inal aortic aneurysms (RAAA), it is nonetheless associated with significant
morbidity and mortality ranging from 30% to 80% [6]. Despite technological
advances and advances in critical care, the actual surgical approach and resul-
tant mortality has only marginally changed over the last 50 years [7,8].
The success of endovascular aneurysm repair (EVAR) for elective aneu-
rysms has been slow to transition into the treatment of emergent aneurysmal
disease. There are several obstacles preventing this from occurring, ranging
from institutional limitations, imaging, graft availability, and availability of
an endovascular surgeon. Although not all vascular surgeons and general
surgeons are capable of performing EVAR, there are basic endovascular
techniques that can be useful for standard open repair.
During the Korean War, Lieutenant Colonel Hughes [9] introduced the
technique of remote aortic occlusion by placement of transfemoral Foley
catheters in three injured soldiers who presented in hemorrhagic shock
from penetrating truncal trauma. He used this technique as compassionate

* Corresponding author.
E-mail address: arthursz@mac.com (Z.M. Arthurs).

0039-6109/07/$ - see front matter Ó 2007 Elsevier Inc. All rights reserved.
doi:10.1016/j.suc.2007.07.002 surgical.theclinics.com
1036 ARTHURS et al

use and noted all three patients to temporarily experience hemodynamic im-
provement. A decade later, Hesse and Kletschka [10] used intralumenal aor-
tic occlusion specifically for ruptured abdominal aneurysms in 1961. Their
technique involved placing a Foley catheter through the aneurysmal rent
in the aorta and guiding it into the thoracic aorta. If the aneurysm was
not easily defined, the balloon was placed through an arteriotomy placed
in the common iliac artery. Within the past 2 decades, endovascular proce-
dures have become commonplace in the United States, and vascular sur-
geons are using remote aortic occlusion to manage RAAAs [11–13].
This article addresses the challenges associated with performing endovas-
cular procedures in an after-hours environment, the preoperative prepara-
tion of patients who have RAAAs, and the technique of remote aortic
occlusion.

Remote aortic occlusion for ruptured abdominal aortic aneurysms

Institutional preparation
When a patient presents to the emergency room with a presumed RAAA,
the institution must have a predetermined algorithm to rapidly assess the
patient, prepare the operative suite, obtain axial imaging, and transport
the patient to the operative suite. At the authors’ institution, endovascular
training is provided on an annual basis to the house officers, surgical staff,
and operating room technicians to rehearse the prepared algorithm for
RAAAs. Mehta and colleagues [14] found that mock preparation for emer-
gent ruptured aneurysms highlighted the importance of early diagnosis and
institutional readiness. Additionally, rehearsing the emergent algorithm
with each elective aneurysm prepared the anesthesiologists, operating
room staff, and radiographic technicians for emergent cases.
In order to use endovascular techniques, the institution must have an avail-
able fluoroscopic C-arm and operative imaging table. In addition, there must
be a basic set of endovascular supplies readily available for the surgeon. The
scrub technicians and circulating nurses must also have familiarity with access
needles, wires, sheaths, and contrast agents. Whereas most general surgeons
have had experience with intraoperative cholangiograms, few have used intra-
operative vascular imaging in their practice. The majority of general surgeons
are extremely comfortable with gaining access in the groin using Seldinger’s
technique, however. Having a team with basic endovascular knowledge is
imperative for using this technique for emergent cases.

Preoperative management
Once the patient is identified as having an RAAA, the patient’s clinical
status dictates the urgency of treatment. The ideal perfusion pressure has
brought about much debate with regards to resuscitation of patients who
have RAAAs. The majority of research in this area has focused on
 RUPTURED ABDOMINAL AORTIC ANEURYSMS 1037

hypotensive (systolic blood pressure !90 mmHg) trauma patients suffering

from hemorrhagic shock, and a consensus suggests that delayed resuscitation
until hemorrhage is controlled improves survival and reduces postoperative
morbidity, primarily multisystem organ failure [15,16]. This literature has
been applied to RAAAs, and although there are multiple animal studies in
this arena, no prospective studies have been performed in patients who have
RAAAs [17]. Increasing the patient’s systolic blood pressure could exacerbate
ongoing hemorrhage or convert a contained rupture to free rupture. If the
patient is mentating, resuscitation (crystalloid and blood products) should
be reserved until the aortic occlusion balloon (AOB) is secured.
If a vascular surgeon is available for potential endovascular repair of an
RAAA, a preoperative CT scan will be valuable for endograft sizing. Trans-
ferring a patient who has an RAAA to the CT scanner contradicts general
surgical training principles, and can be viewed as a deplorable decision;
however, Lloyd and colleagues [18] performed a time-to-death analysis of
patients who presented with RAAAs and were not able to undergo repair
secondary to malignancies or secondary to comorbidities that precluded
open repair. The median time from onset of symptoms to admission was
2.5 hours, and death occurred in 12.5% within 2 hours of admission (4.5
hours from onset of symptoms); the remainder died after 2 hours. The me-
dian time-to-death in this study was 16 hours and 38 minutes [18]. This
study illustrates the feasibility of obtaining preoperative axial imaging.
Most CT scanners can perform 2 to 3 mm collimation imaging of the aorta
in 5 to 10 minutes en route to the operative suite. If the decision is made to
defer preoperative axial imaging, intraoperative sizing of the aneurysm can
be performed with aortography and intravascular ultrasound should a vas-
cular surgeon be available.
Once the decision is made to repair the aneurysm, the patient should pro-
ceed to the operative suite, and it is imperative that the patient be placed
on an imaging table. Having the imaging table and C-arm available in the
assigned operative suite must be part of the operative personnel’s checklist.
Before induction of anesthesia, central access and arterial monitoring should
be obtained. Blood products for massive resuscitation should be in the op-
erative suite. A Foley catheter should be placed, and then the patient should
be prepared and draped. At this time, the surgical team can place the AOB
before induction of general endotracheal anesthesia. If an endovascular ap-
proach is going to be attempted, regional anesthesia or even local anesthesia
can be used based on the hemodynamic status of the patient. Box 1 lists the
basic inventory that should be readily available when placing AOBs.

Technique
Access to the common femoral artery
With the patient prepped and draped, the operator should use a standard
access needle that will accept a 0.035’’ wire. The authors prefer the groin
1038 ARTHURS et al

Box 1. Basic inventory necessary for aortic occlusion balloon

placement
 Fluoroscopic C-arm and imaging table.
 Access needle
 30 cc aspiration syringe
 6 Fr sheath and 11 Fr sheath
 150 cm, 0.035’’ Bentson wire
 150 cm, 0.035’’ Glide wire
 150 cm, 0.035’’ Amplatz wire
 125 cm, 33 mm AOB
 65 cm Kumpe catheter
 65 cm, 11 Fr sheath
 Bottle of contrast (Visipaque, GE Healthcare, Waukesha,
Wisconsin)

because of the straightforward percutaneous approach, and the right side

keeps the surgeon on the opposite side of the table as the C-arm. Utilizing Sel-
dinger’s technique, the vessel is accessed, ideally over the medial third of the
femoral head. Most of these patients do not have palpable groin pulses; there-
fore the surgeon must rely on anatomic landmarks, image guidance, or a cut-
down procedure. The authors’ standard approach is to place a Kelly clamp
inline with the proposed access site, and then check our planned site with fluo-
roscopic imaging. The tip of the Kelly clamp is then adjusted such that the
tip is overlying the common femoral artery just over the medial third of the
femoral head. Often the calcifications in the vessel wall can be visualized on
fluoroscopic images. Once the vessel is marked, we attempt access.
Another modality that is readily accessible in the operative suite is duplex
ultrasound. If access is difficult, an ultrasound probe can be brought onto
the field to aid in the identification of the common femoral artery. Once dif-
ferentiated from the vein by its lateral location and noncompressibility, the
common femoral artery can be mapped caudally until identification of the
profunda femoris artery, with access obtained just cranial to the profunda
takeoff. Access is obtained with the duplex image in an axial view, and
the access needle placed at a 45 angle to the ultrasound probe. As the nee-
dle is advanced, the path of the needle can be visualized under ultrasound by
separation of the tissue planes. Ultrasound-guided access of the femoral ves-
sels has yielded excellent success and deferred the need for cutdown in the
authors’ practice. Finally, if all attempts at percutaneous access fail, a fem-
oral cutdown can be performed in less than three minutes under local anes-
thesia, still avoiding induction of general anesthesia. Patients in profound
shock require no local anesthesia for access, be it percutaneous or open.
Once adequate flash is obtained from the access needle, The authors first
pass a Bentson wire (Cook Medical, Bloomington, Indiana) into the
 RUPTURED ABDOMINAL AORTIC ANEURYSMS 1039

common femoral artery, and if the wire does not easily pass, we then use
a hydrophilic glide wire. If this fails, we redirect the access needle and repeat
the steps. Once the wire easily passes into the artery, a 6 Fr sheath is placed
in the groin, which is just an initial step to serially dilate the vessel to our
working sheath, the 11 Fr sheath. After the sheath has been flushed, we
then replace the 6 Fr sheath with an 11 Fr sheath. At this point, the operator
has a working system from the right groin that can accept a 33 mm AOB.

Selecting the supraceliac aorta

At this point the Bentson wire should be followed under fluoroscopic guid-
ance through the iliac vessels and into the aneurysm sac. Fig. 1 illustrates the
proceeding steps. The wire should be advanced under direct fluoroscopic im-
aging into the supraceliac aorta. If the wire advances easily into the thoracic
aorta, it has already bridged the RAAA, but not uncommonly, the wire will
coil in the redundant and tortuous aneurysmal sac (see Fig. 1A).
At this point, a selective catheter is required to direct the wire into the
supraceliac aorta. The authors’ catheter of choice is the Kumpe catheter

Fig. 1. Illustration of aortic balloon placement. (A) Placement of the access wire. (B) Using
a Kumpe catheter to select the proximal aorta. (C) Positioning the tip of the Kumpe catheter
just beyond the proximal aorta. (D) Retracting the catheter, applying torque to the catheter,
and advancing the Bentson wire. (E) Purchasing hold in the supraceliac aorta and retracting
the Kumpe catheter. (F) Advancing the AOB into position.
1040 ARTHURS et al

(Cook Medical), which has a hockey-stick bend at the tip. This catheter is
advanced over the Bentson wired through our working sheath (11 Fr
sheath), and then advanced over the tip of the wire (see Fig. 1B). When se-
lecting vessels, the selective catheter and wire should never be pushed into
the orifice; instead, the catheter should be advanced beyond the orifice
with the floppy tip of the Bentson wire just beyond the end of the Kumpe
catheter (see Fig. 1C). From this vantage point, counterclockwise torque
is applied to the Kumpe catheter in the right groin while slowly withdrawing
the catheter and watching the catheter under fluoroscopic imaging. The wire
can then be advanced into the supraceliac aorta (see Fig. 1D). Once the wire
is in the thoracic aorta, the redundant loop in the aortic sac will snap into
a straight line across the aneurysm (see Fig. 1E).

Placement of the aortic occlusion balloon

Once the wire is secured in the thoracic aorta, the Kumpe catheter can be
withdrawn over the wire, and the 33 mm AOB can be advanced over the
wire into a supraceliac position (see Fig. 1F). With the balloon in position,
the authors shoot a hand-injected aortogram through the central channel of
the AOB to confirm its position. In addition, we test the balloon by inflation
with contrast and saline mixed 50/50. The compliant characteristic of the
AOB allows conformation to the wall of the fairly noncompliant aorta.
Therefore, the balloon will initially appear spherical, but once it accommo-
dates the endoluminal surface of the aorta, it will expand by elongating
along the walls of the aorta (Fig. 2).
The occlusion balloon is injected under fluoroscopy, and once the balloon
profiles the aorta, the location of the balloon is secured in the right groin by
the assistant. In addition, the volume of contrast required to achieve
a change in balloon profile, and hence occlusion is recorded (Fig. 3). At
this time, the balloon is deflated, and anesthesia can start resuscitation (crys-
talloid and blood products) and prepare for induction.

Perform the open repair

The AOB is reserved only for periods of hemodynamic instability. With
induction of anesthesia or upon opening the abdominal fascia, the patient
may require interval inflation of the AOB and continued resuscitation
from the anesthesia provider. Having proximal control secured allows the
surgeon a relatively bloodless field to dissect the infrarenal neck of the
RAAA (Fig. 4). Once the infrarenal neck is isolated, a vascular clamp can
replace the AOB; the balloon is simply retracted into the aneurysm sac be-
fore clamp application.
Once the balloon has been inflated and deflated, it is more difficult to
retract through an 11 Fr sheath; therefore, once the aneurysm sac is
opened, the authors cut the balloon tip off the catheter and retract
the system through the groin. The standard open repair of an AAA
ensues.
 RUPTURED ABDOMINAL AORTIC ANEURYSMS 1041

Fig. 2. Test inflation of the AOB. The balloon has opposed the aortic wall and started to elon-
gate with continued inflation. Note the wire inferior to balloon buckling against the cranial to
caudal pressure.

Discussion
Although an AOB can be placed in less than 5 minutes in experienced
hands, technical difficulties can occur with any of the above steps. Most gen-
eral surgeons are comfortable with obtaining access in the groin, and de-
pending on their comfort with ultrasound, ultrasound-guided access is an
alternative. If percutaneous attempts fail, general surgeons can perform
a rapid cutdown at the groin and access the common femoral vessel.

Fig. 3. The AOB is secured at the groin. The contrast (large white arrow) has been marked from
test occlusion, and the wire (small white arrow) remains in place throughout the procedure. This
particular patient had a prior right groin exploration; therefore, the AOB was placed from the
left groin.
1042 ARTHURS et al

Fig. 4. Remote AOB for proximal control. The assistant inflates the AOB (large white arrow)
and secures the position (small white arrow) while the open operation ensues. This patient ex-
perienced free rupture of the aneurysm, prompting inflation of the AOB for proximal control.

General surgeons are probably least familiar with selecting the supracel-
iac aorta using a directional catheter (ie, the Kumpe). For endovascular sur-
geons, this is a very common maneuver, and is performed at the beginning
of every elective endovascular aneurysm repair. The authors recommend us-
ing this opportunity under elective circumstances to gain experience with
handling wires in the aneurysm sac and selecting the supraceliac aorta be-
fore attempting this technique in the emergent setting.
Once proximal placement is confirmed, the assistant must secure the
AOB at the groin or the patient’s pressure will force the balloon caudally
into the aneurysm sac. When the test occlusion is performed under fluoros-
copy, the force on the balloon can be felt by the assistant securing the cath-
eter. If the patient’s aortic pressure is greater than the columnar strength of
the catheter system, the wire and balloon will start to buckle. This can be
seen ion Fig. 2 just caudal to the balloon. To increase the columnar support
of the system, the Bentson wire can be replaced with an Amplatz wire (Cook
Medical), which is more rigid. If this fails to secure the balloon in place, then
the AOB can be removed, and a 65 cm 11 or 12 Fr sheath can be placed over
the Amplatz wire into the supraceliac aorta. The AOB can then be passed
through the sheath so that the balloon extends just beyond the tip of the
sheath. When the balloon is inflated, the sheath will wedge against the cau-
dal aspect of the balloon and prevent migration. Veith and colleagues [23]
have described this modification as an adjunct to EVAR for RAAAs. Typ-
ically, an Amplatz wire has enough columnar support to hold the balloon in
position; therefore, the authors only place the 65 cm, 11 Fr sheath if it fails
to secure the balloon.
Some authors have used a transbrachial approach for placement of the
AOB [11,12,20,21]. The primary reported benefit of this approach is lack
of balloon migration into the aneurysm sac. The transbrachial approach,
initially used when the surgeon planned to repair the RAAA with an endog-
raft, allowed both groins still available for graft insertion. The disadvantage
 RUPTURED ABDOMINAL AORTIC ANEURYSMS 1043

of this technique is the required cutdown procedure over the brachial artery
near the median nerve and the placement of a very large sheath relative to
the normal size of the brachial artery. Additionally, using the right brachial
artery places the patient at risk for cerebral embolization as the innominate
and left common carotid arteries are crossed. Utilizing the left arm will place
the operators in a difficult location between the patient and the C-arm. In
addition, the stiffness associated with the AOB and sheaths make them dif-
ficult to navigate through the arch into the descending thoracic aorta. Rel-
ative risk of ischemic complications to the hand is also a concern.
For these reasons, the authors feel that the femoral approach is superior.
Dr. Veith and colleagues [22] have reported the largest experience treating
RAAAs with EVAR; their group uses a transfemoral AOB and then places
the endograft from the contralateral groin [23]. If a transfemoral AOB is
placed as a temporizing measure until the vascular surgeon arrives, it does
not hinder the placement of an endograft.
The risks associated with AOB placement include a time delay such that
the patient experiences a poor outcome. Those patients that survive through
transport to the hospital typically have a contained rupture that is depen-
dent on the retroperitoneal hematoma and tone of the abdominal wall mus-
culature. Based on Lloyd and colleagues’ [18] time-to-death analysis, most
patients have 2.5 hours after being admitted to the hospital before free rup-
ture. The authors feel that the benefits of securing the proximal aorta before
anesthetic induction and release of the tamponade effect of the abdominal
wall far outweigh the risks of a relatively small time delay.
Manipulating wires and catheters within the aneurysm sac could poten-
tially convert a contained rupture to free rupture. The authors have not ex-
perienced this complication, nor has it been reported in the literature.
Surgeons have used AOBs for penetrating truncal trauma and experienced
the balloon exiting the injury site in the aorta [19]. If this were to occur dur-
ing placement, we feel that it would be recognized by using fluoroscopic
guidance.
The most devastating complication of occluding the aorta is spinal cord,
visceral, and lower extremity ischemia. The balloon is only inflated if the
patient’s hemodynamic status demands proximal control. Based on the
patient’s underlying vascular disease, collateral flow, and moribund state,
the ischemia time is variable. Intermittent periods of aortic occlusion are
better tolerated than prolonged occlusion [19]; therefore, the authors limit
periods of occlusion to 10 minutes with variable periods of reperfusion.
This complication is inherent in all types of proximal control, and the
AOB could theoretically reduce periods of hypotension.
At the authors’ institution, we have adopted the approach of placing
a transfemoral AOB before resuscitation, induction of anesthesia, and ex-
clusion of the RAAA. The availability of commercial endografts and sur-
geons trained in the art of endovascular technique is such that each
patient is considered for endovascular repair. The utility of remote aortic
1044 ARTHURS et al

occlusion has served as an invaluable adjunct to our experience of open

RAAA repair, and we feel that this is a useful adjunct for the general sur-
geon faced with an RAAA.

Summary
Although the treatment and mortality for RAAAs has changed very little
in the last 50 years, the elective repair of abdominal aortic aneurysms has
dramatically changed because of endovascular technology. EVAR for
RAAAs has been limited to relatively few centers, but remote endovascular
occlusion of the aorta is a technique that can be used by both vascular and
general surgeons alike. Preoperative placement of a remote AOB from the
groin is a rapid and effective method of obtaining proximal control and
has the potential to improve the morbidity and mortality in this moribund
population of patients.

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