Abdominal aortic aneurysm with perianeurysmal fibrosis: experience from 11 Swedish vascular centers

Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Inflammatory abdominal aortic aneurysms: a thirty-year review

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.     

Management of tender abdominal aortic aneurysm

Forty-eight patients with tender haemodynamically stable abdominal aortic aneurysms were evaluated. The aneurysms in 18 of these patients (37.5%) were found, at the time of surgery, not to have leaked. The mortality rate in patients with these tender non-leaking aneurysms undergoing emergency surgery was 16.6%. This high mortality rate can be improved by using computed tomography pre-operatively to prevent patients with non-leaking aneurysms from undergoing emergency surgery.     

The Nomenclature of the Veins of the Lower Limbs,Based on their Planar Anatomy and Fascial Relationships

Objectives: Emergency endovascular aneurysm repair (eEVAR) for ruptured abdominal aortic aneurysms (rAAA) is still under investigation. Since installation of an urgent eEVAR kit in our hospital, all patients with a rAAA or urgent thoracic aortic aneurysm are candidates for eEVAR or eTEVAR (emergency thoracic evar), respectively. For this study, we analyzed all rAAA patients treated with eEVAR.

Methods: Data were recorded prospectively. Criteria for an eEVAR were an infrarenal neck > 15mm, acceptable landing zone, angles below 70° and a good femoral approach. We prefer preoperative angio CT-scan but in case of instability, an intra-aortic balloon can stabilize the patient during angiography (in the OR) to decide between open or eEVAR repair. Follow-up was performed on regular intervals by duplex or CT-scan. Thirty-day mortality and overall survival were calculated.

Results: Since 2006, nine male rAAA patients with a mean age of 73 years (range: 62–82) had eEVAR repair. Aneurysm diameter was 8 cm (range: 5.8–11). The Hardman index was 1.5 (range: 0–3). In eight patients an aorto-uni-iliac device was placed succesfully followed by a femorofemoral crossover bypass. The 30-day operative mortality was 12.5% (one patient with septic shock). Three patients showed a type 2 endoleak with stable diameter during follow-up but one patient showed expansion 4 years after treatment.

Conclusions: Treating rAAA with eEVAR in selected patients with acceptable anatomy and a kit permanently available in the operating room yielded good results by a surgical team trained for both open and eEVAR repair. The conversion rate was low (11%) and the survival (immediate and 30-days) was excellent (87.5%).     

Fifteen-year Experience of Transperitoneal Management of Inflammatory Abdominal Aortic Aneurysms

OBJECTIVES: to assess the long-term outcome of patients with inflammatory abdominal aortic aneurysms. MATERIALS AND METHODS: over a fifteen-year period 598 cases of abdominal aortic aneurysm were treated and, of these, 32 cases (5.3%) were inflammatory in nature. The diagnosis was made on preoperative (CT) computed tomography in fifteen cases. Twenty-six patients were symptomatic on presentation and ten cases were repaired on an emergency basis. Only six were repaired electively. The transabdominal transaortic approach without dissection on the nearby adherent structures was used routinely. RESULTS: there was one postoperative death from a respiratory arrest leading to a thirty-day mortality of 3.1%. Early graft thrombosis occurred in three cases (9.3%) and all underwent successful thrombectomy. Colonic ischaemia was encountered in one patient who later developed an aortoenteric fistula. Two patients suffered a non-fatal myocardial infarction postoperatively leading to an overall morbidity of 18.7%. CONCLUSIONS: patients with inflammatory aortic aneurysms fare worse than patients with aortic aneurysms in general. Preoperative suspicion assists in planning surgery. We believe that the transperitoneal approach with an anterolateral aortotomy and minimal dissection of adherent structures offers excellent results in dealing with this difficult group of patients.     

Management of urgent intact abdominal aortic aneurysms

Fifty patients with acute and urgent but unruptured abdominal aortic aneurysms were reviewed. The mortality rate was 24.3% in 37 patients having aneurysm resection and graft replacement. The mortality rate in patients developing cardiac and renal complications after surgery was 100%. Nine patients did not receive surgery and four patients had a laparotomy but did not have their aortic aneurysms repaired. Patients presenting with urgent but stable and unruptured abdominal aortic aneurysms require careful but swift assessment before surgery, and have a higher mortality than patients undergoing elective aneurysm surgery.     

Mid-term results after endovascular repair of the atherosclerotic descending thoracic aortic aneurysm.

INTRODUCTION: Thoracic aortic aneurysms (TAA) are the most common condition of the thoracic aorta requiring surgical treatment. Despite significant improvement in anesthetic, surgical techniques and postoperative care, the mortality and morbidity rate in TAA-repair remains high. The aim of this study was to assess the morbidity and mortality rate after endovascular stent-graft treatment of atherosclerotic (non-dissecting) TAAs. METHODS: Thirty-one patients, ASA-classification III-IV, with symptomatic or expanding atherosclerotic TAAs underwent endovascular stent-graft repair between May 1997 and August 2003. Procedures were performed on an emergency basis in 13 patients and elective in 18 patients. Patients were assessed postoperatively by routine CT-scan within 48 h. Further follow up investigations were performed after 3, 6, 12 months and annually thereafter. RESULTS: Stent-graft placement was successful in all but one patient in whom the stent-graft procedure had to be postponed due severe hemodynamic instability. Perioperative mortality rate was 19% including three haemorrhages, two cardiac events and one respiratory failure (6/31). Technical success rate was 55% (17/31). Completion CT scans performed in 30 patients within 2 days of stent-graft procedure showed type I leaks in seven patients (23%), type II leaks in four patients (13%) and type III leaks in two patients (6%). Further complications included one stroke, one paralysis, one spinalis anterior syndrome and five relevant access related complications. New onset endoleaks, all type I, were observed in seven patients (23%) occurring after 3, 4, 7, 8, 17, 25 and 26 months. Mean follow-up was 15 months (range 2-69 months). CONCLUSION: Thoracic aortic atherosclerotic aneurysm stent-grafting is feasible but not without significant morbidity and mortality.     

Infected aortic aneurysms: clinical outcome and risk factor analysis

PURPOSE: Infected aortic aneurysms are difficult to treat, and are associated with significant mortality. Hospital survival is poor in patients with severe aortic infection, Salmonella species infection, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location. We reviewed the clinical outcome in 46 patients with primary infected aortic aneurysms and identified clinical variables associated with prognosis. METHODS: Data were collected by means of retrospective chart review. Univariate and multivariate logistic regression models were used for risk factor analysis. RESULTS: Between August 1995 and March 2003, 48 patients with primary infected aortic aneurysms were treated at our hospitals. Two patients with negative culture results were excluded. Of the remaining 46 patients, 35 patients had aortic aneurysms infected with Salmonella species and 11 patients had aortic aneurysms infected with microorganisms other than Salmonella species. There were 20 suprarenal infections and 26 infrarenal infections. Surgical debridement and in situ graft replacement were performed in 35 patients, with an early mortality rate of 11%. The incidence of late prosthetic graft infection was 10%. The 90-day mortality rate in patients operated on was 0% for elective operation and 36% for nonelective operation (P =.006, Fisher exact test). Independent predictors of aneurysm-related death were advanced age, non-Salmonella infection, and no operation. CONCLUSION: With timely surgical intervention and prolonged antibiotic treatment, in situ graft replacement provides an excellent outcome in patients with primary infected aortic aneurysms and elective operation. Mortality is still high in patients undergoing urgent operation. Advanced age, non-Salmonella infection, and no operation are major determinants of mortality.     

Management and Course of Hydronephrosis Secondary to Inflammatory Aneurysms of the Abdominal Aorta

The objective of this study was to evaluate the management and course of obstructive uropathy secondary to inflammatory aneurysms. From January 1981 to December 2000 a total of 52 patients underwent surgical intervention for inflammatory aneurysms of the abdominal aorta. Eleven of these cases (21%) had obstructive uropathy, which was bilateral in five cases. Preoperative drainage of the urinary tract was done in five ureters in three patients with four double J catheters and one percutaneous nephrostomy; surgical ureterolysis was also carried out in one case. Endoaneurysmorraphy and placement of an aortic graft were performed in all 11 patients. Operative mortality was zero. There was no recurrence of hydronephrosis in seven patients during a mean follow-up of 55 months. Three patients were lost to follow-up and one died. When compared with 41 inflammatory aneurysms in which hydronephrosis did not develop, there were statistically significant differences with respect to lumbar pain and renal insufficiency. The ureter is a structure adjacent to the aorta that is trapped by fibrosis in 21% of patients with inflammatory abdominal aortic aneurysms. The natural tendency of the periaortic fibrosis is to remit following surgery to correct the aneurysm. This results in spontaneous remission of the hydronephrosis, making routine intraoperative manipulation of the ureter unnecessary.     

Surgical repair for aortic aneurysms in aged patients over 70 years of age

From 1960 through 1991, 556 consecutive patients with aortic aneurysms consisting of 173 with abdominal aortic aneurysms (AAA) and 383 with thoracic aortic aneurysms (TAA) were treated surgically. No significant differences were observed in the early mortality rate after AAA or TAA repair between the aged (41 TAA, 52 AAA) and non-aged groups. The 5-year survival rate of aged patients with TAA (47.3 +/- 8.5%) was significantly lower to that of non-aged patients (67.4 +/- 2.8%). However, the 5-year survival rate of aged patients with AAA (63.9 +/- 12.1%) was not significantly different from that of non-aged patients (75.9 +/- 4.3%). The asymptomatic non-ruptured aneurysms in aged-patients present many problems such as the association between surgical intervention and life expectancy, selection of patients by accurate preoperative evaluation of risk factors, and determination of the timing of operation.     

Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome

OBJECTIVE: The purpose of this study is to review our experience with surgical repair of lower thoracoabdominal and suprarenal aortic aneurysms to determine early and late survival rates and identify factors influencing morbidity and survival among these patients. MATERIALS: From 1989 through 1998, 165 consecutive patients underwent repair of 108 thoracoabdominal (55 group III and 53 group IV) and 57 suprarenal aneurysms. The study group consisted of 109 men and 56 women with a mean age of 70 years (median, 70 years; range, 29-89 years). Mean aneurysm diameter was 6.9 cm (median, 6.5 cm; range, 4-12 cm). There were 125 aneurysms (76%) repaired electively; 40 repairs (24%) were nonelective. The cause of 12 aneurysms (7%) was chronic aortic dissection; the remaining 153 (93%) were degenerative aneurysms. RESULTS: The early postoperative (30-day) mortality rates were 7% (9/125) for elective and 23% (9/40) for nonelective operations (P =.016). For both elective and urgent procedures, early mortality was 1.8% (1/57) for suprarenal aneurysm repair, 11% (6/53) for group IV thoracoabdominal aneurysms, and 20% (11/55) for group III thoracoabdominal aneurysms (P =.013, suprarenal vs group III). Spinal cord ischemia occurred after 6% (10/165) of aneurysm repairs (4% paraplegia, 2% paraparesis). None of the 57 suprarenal aneurysm repairs were complicated by spinal cord ischemia, whereas it occurred in 2% (1/53) of group IV thoracoabdominal aneurysms and 16% (9/55) of group III thoracoabdominal aneurysms (P =.001, suprarenal vs group III; P =. 016, group IV vs group III). Three (25%) of the 12 patients with dissection developed spinal cord ischemia; this compared with seven (5%) of 153 patients with degenerative aneurysms (P =.027). The cumulative 3-year survival rate for the entire series was 71% (95% CI, 64%-79%), and 5-year survival was 50% (95% CI, 40%-60%). CONCLUSIONS: Aneurysms involving the suprarenal, visceral, and lower thoracic aorta may be repaired with acceptable perioperative mortality and late survival rates. The risk of spinal cord ischemia is increased for patients with aortic dissection and may be stratified according to the proximal extent of the aneurysm.     

Comparative early and midterm results of open juxtarenal and infrarenal aneurysm repair

Background and aims Since the introduction of endovascular aortic aneurysm repair (EVAR) for aortic aneurysms, the number of juxtarenal aortic aneurysms (JRA) has been growing steadily due to selection bias (neck morphology for EVAR). This case-match study compares the perioperative outcome and midterm results of suprarenally clamped JRA with infrarenal aortic aneurysms (AAA). Methods From 1997 to 2004, patients who received open surgery with suprarenal clamping for JRA were included in the study and compared to matched patients with infrarenal clamping (AAA). Measurements analyzed were the in-hospital mortality and morbidity. Midterm results were obtained through clinical investigation and magnetic resonance angiography imaging. Results Thirty-five patients (mean age, 68.4 years; 30 male and 5 female) received suprarenal cross-clamping for JRA. The overall in-hospital mortality for JRA and for the controls (AAA) with elective aortic repair was 4.5% (6.1% JRA; 3% AAA, p = 0.058). The morbidity of JRA was elevated according to the rate of pulmonary complications (p = 0.021) and the need for re-operation (p = 0.019). The mean follow-up time was 2.3 years (range, 8–96 months). At follow-up, 28 patients (80%) from the JRA group and 29 patients from the AAA group (82.9%) were alive. Conclusion Open aortic surgery for JRA with the need for suprarenal cross-clamping shows a slightly elevated in-hospital mortality rate without statistical significance and equal midterm mortality results in comparison with infrarenally clamped aortic aneurysms.     

Surgical treatment of "inflammatory" aneurysms of the abdominal aorta

Two cases of "Inflammatory" aneurysm of the abdominal aorta and a review of this type of lesion were presented. The incidence of inflammatory aneurysm of the abdominal aorta in the literature is 2.5 to 15%, but there were no detail reports concerning with this in Japan. The pathogenesis is not clear, but it is evident both macroscopically and microscopically that the inflammatory aneurysms are different from athelosclerotic ones. They are characterized by perivascular peel of inflammatory fibrous tissue. It is possible that this type of aneurysms are merely a variant of Takayasu's disease. Until recently, the diagnosis of this type of aneurysm has not been made before surgery. The symptom of abdominal pain, weight loss, elevated ESR in a patient with abdominal aortic aneurysm are highly suggestive an inflammatory aneurysm. Characteristics of CT scan lead to more frequent preoperative diagnosis of inflammatory aneurysms of the aorta. It reveals a thickened often calcified aortic wall surrounded by a soft tissue mantle. Dynamic scanning shows an enhancing perianeurysnal mass. Graft replacement in these patients is often difficult and associated with increase in morbidity and mortality. At surgery, no attempt should be made to mobilize adjacent viscela in order to avoid injury. Arterial control should be obtained with as little as possible dissection. Some reports refer to successful steroid therapy resolving the inflammatory process and alleviating symptoms. Further research may resolve the treatment of choice for this type of lesion and optimize the timing of surgery.     

The impact of walking impairment,cardiovascular risk factors,and comorbidity on quality of life in patients with intermittent claudication

PURPOSE: This study assessed the cardiovascular disease, perioperative results, and survival after surgical abdominal aortic aneurysm repair in young patients (< or = 50 years) compared with randomly selected older patients who also underwent abdominal aortic aneurysm repair. METHODS: We reviewed hospital records to identify young and randomly selected control patients (3 for each young patient, > or = 65 years, matched for year of operation) with degenerative (atherosclerotic) abdominal aortic aneurysms undergoing repair between Jan 1, 1988, and Mar 31, 2000. Patients with congenital aneurysms, pseudoaneurysms, aortic dissections, post-coarctation dilations, aortic infection, arteritis, or aneurysms isolated to the thoracic aorta were excluded. Mortality data and cause of death were obtained from medical records and the National Death Index RESULTS: Among 1168 patients who underwent abdominal aortic aneurysm repairs, 19 young patients (1.6%) and 57 control patients were identified. The mean age was 48.4 years in the young group and 72.2 years in the control group. There were no differences in sex or race between the two groups. When comparing existing cardiovascular disease between the groups, there were no differences in the incidence of earlier coronary revascularization (26% vs 16%) or non-cardiac vascular surgery (5% vs 9%), but aneurysms were more commonly symptomatic in young patients (53% vs 21%; P <.01). Aneurysmal disease was limited to the infrarenal aorta in similar proportions of patients (89% vs 88%). No statistically significant differences were seen in the incidence of perioperative deaths (16% young vs 9% control; P =.40) or postoperative complications (37% young vs 26% control; P =.38). The estimated survival rate of the young group was not different from that of the control group (3-year survival rate, 73% vs 69%; P =.32) or the entire cohort of patients (older than 50 years; n = 1101) who underwent repair of abdominal aortic aneurysms during the study period (3-year survival 73% vs 75%; P =.63) CONCLUSION: After abdominal aortic aneurysm repair, young patients had perioperative results and follow-up mortality rates similar to those of control patients. Cardiovascular disease was the predominant cause of death after abdominal aortic aneurysm repair in the young patients. When compared with an age older than 50 years at the time of abdominal aortic aneurysm repair, young age alone was not associated with increased survival.     

Inflammatory abdominal aortic aneurysms. A 20-year experience

AIM: The aim of the study was to report a 20-year single Institution experience, with the early and late outcomes of surgical treatment of inflammatory abdominal aortic aneurysms. METHODS: In a 20-year period, 2 275 consecutive patients underwent elective surgical repair for non-rupture abdominal aortic aneurysm. Fifty-two patients (2.3%) were classified as inflammatory abdominal aortic aneurysms. Early and late outcomes were analyzed. RESULTS: One patient died in the perioperative period, giving a mortality rate of 1.92%. One patient died from a pseudoaneurysm rupture 7 months after operation. Three patients developed an aortic pseudoaneurysm in the follow-up period (mean 12.1 years, range 1-20 years) and underwent a redo operation. CONCLUSION: Overall surgical outcome of these patients, in terms of short-term and long-term is good. A high rate of pseudoaneurysm formation was observed.     

Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.

OBJECTIVE: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. RESULTS: Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). CONCLUSION: Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.     

香港地区动脉瘤的治疗现状

目的 阐述香港动脉扩张性疾病的流行病学模式及主动脉瘤传统手术与腔内治疗术的发展现状。方法 分析香港医院管理局1999－2000年主动脉瘤统计数值,香港血管外科工作小组在公立医院主动脉瘤调查报告及香港大学外科学系血管外科833例患者经验。结果 主动脉瘤是香港地区目前第10大致命疾病,每年大概发现800例新病例,而主动脉瘤破裂率为10％,破裂病死率为80％。目前一半手术适应证为主动脉瘤破裂,有大比例患者未获手术治疗。在有经验的血管外科中心腹主动脉瘤择期手术病死率已下降至2％,而破裂手术病死率也降低为38％。结论 香港地区主动脉瘤发病率与世界发病率同步增加。近年腔内治疗术迅速发展,有一定的成效,但患者选择与随访至为重要。     

Surgical outcome of infectious aneurysm of the abdominal aorta with or without SIRS

The surgical outcome of infectious abdominal aortic aneurysms was evaluated based on the preoperative presence or absence of systemic inflammatory response syndrome (SIRS). Nine patients were divided into two groups according to the criteria for SIRS such as body temperature, heart rate, respiratory rate, and white blood cell count. In the group with SIRS, rupture and impending rupture of aneurysms occurred in three of the four patients (75%). All aneurysms were resected with a small part as a remnant; two in situ and two extraanatomic reconstructions were performed. Three patients died after surgery: one after in situ (cerebral infarction) and two after extraanatomic reconstruction (sepsis and multiple organ failure). In the group without SIRS, closed en bloc resection in two patients and resection of the aneurysm with a small part as a remnant in three patients were performed. In situ reconstruction in all patients and omentum wrapping in two patients were performed. One of the five patients died of massive hematemesis 70 days after surgery. The overall mortality rate was 75% in the group with SIRS versus 20% in the group without SIRS. The surgical outcome of infectious abdominal aortic aneurysm depends upon the severity of underlying infection. A possibility exists that SIRS is a useful indicator for predicting the surgical outcome of patients.     

Inflammatory aneurysms of the abdominal aorta

The treatment of inflammatory aneurysms of the abdominal aorta presents a formidable challenge to the surgeon. The retroperitoneal inflammatory reaction obliterates normal tissue planes, limiting access to the infrarenal aorta. During a 70-month period 25 (6%) of 439 patients operated on for abdominal aortic aneurysms were found to have the inflammatory type. These patients were more likely to be symptomatic than patients with noninflammatory aneurysms and they were more likely to be male. Although surgical repair of the aneurysms required longer aortic occlusion time and more blood replacement, the outcome was similar to that for patients treated for noninflammatory aneurysms.     

Technical aspects in the management of abdominal aortic aneurysms

During the past decade, resection of abdominal aortic aneurysms has become common. The technical aspects of the operation are now relatively standardized and simplified. With concomitant improvements in anesthesia and intensive care, the operative mortality for elective resection of these aneurysms has declined progressively; several centres report an operative mortality of less than 5%. The author considers the following principles important in managing patients with abdominal aortic aneurysms: (a) simplicity and limited dissection are critical features of the operative technique; (b) tubular grafts should be used whenever possible; (c) selected patients should be transferred to the intensive care unit preoperatively for "fine-tuning" of the cardiovascular system; (d) patients should be monitored intraoperatively and postoperatively; (e) the surgeon should be aware of special problems such as horseshoe kidney, venous anomalies, adherent duodenum and the presence of major arteries arising from the aneurysm; (f) ruptured aneurysms should be diagnosed promptly and the patient operated upon without delay. Using these principles, the author's group achieved an operative mortality of only 1.8% in 168 patients with abdominal aortic aneurysms resected electively. However, the operative mortality for their patients with ruptured aortic aneurysms was 50%, a rate that has not changed appreciably over the years.