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 solitary iliac artery aneurysms: a report of two cases

Inflammatory abdominal aortic aneurysms are associated with atherosclerosis, which are characterized by specific clinical manifestation. We treated two patients with unilateral solitary iliac artery aneurysms with perianeurysmal fibrosis which compressed the ureter resulting in ipsilateral hydronephrosis. After the iliac artery aneurysm was repaired with a prosthetic graft, the hydronephrosis resolved. Microscopically, there was clear evidence of atherosclerosis in one case. There was a characteristic inflammatory reaction around the adventitia in both aneurysms. Localized iliac perianeurysmal fibrosis has not been particularly described. The clinicopathologic similarities between these cases and inflammatory abdominal aortic aneurysms suggest the same pathogenesis.     

Left flank retroperitoneal exposure: a technical aid to complex aortic reconstruction

Over the last 5 years an extended left flank retroperitoneal approach was used in 85 of 531 (16%) aortic reconstructions deemed technically complex. Abdominal aortic aneurysm repair was performed in 70 patients (82%), bypass of aortoiliac occlusive disease was performed in 11 (13%), and aortic endarterectomy for mesenteric and/or renovascular disease was performed in 4 (5%). Indications for use of this approach included a "hostile" abdomen (43 patients), juxta/suprarenal abdominal aortic aneurysm (35), large (greater than 10 cm) abdominal aortic aneurysm (12), extreme obesity (10), associated renal and/or visceral artery stenosis requiring endarterectomy (9), inflammatory abdominal aortic aneurysm (2), and horseshoe kidney (2). Suprarenal or supraceliac aortic clamping, averaging 31 minutes, was required in 43 patients (50%). Postoperative recovery was rapid (average length of stay, 10.2 days), and morbidity was minimal despite the complex nature of these reconstructions. The perioperative mortality rate in elective operations was 1.2%. This approach facilitated proximal abdominal aortic exposure and anastomosis, especially in large, pararenal aneurysms or in situations unfavorable to a transabdominal approach. Whereas a left flank retroperitoneal approach can be used in most aortic reconstructions, it seems especially suited to those that pose significant technical challenges.     

Staged endourologic and endovascular repair of an infrarenal inflammatory abdominal aortic aneurysm presenting with forniceal rupture

We present the case of a 79-year-old female who presented with severe left flank pain and a pulsatile abdominal mass. She was diagnosed with left peripelvic urinary extravasation and forniceal rupture secondary to an intact infrarenal inflammatory abdominal aortic aneurysm with extensive periaortic fibrosis. Successful operative repair was performed with staged ureteral and endovascular stenting with subsequent resolution of periaortic inflammation and ureteral obstruction, and shrinkage of the aneurysm sac. Inflammatory abdominal aortic aneurysms (IAAAs) represent 5% to 10% of all abdominal aortic aneurysms. The distinguishing features of inflammatory aneurysms include thickening of aneurysm wall, retroperitoneal fibrosis, and adhesions to adjacent retroperitoneal structures. The most commonly involved adjacent structures are the duodenum, left renal vein, and ureter. Adhesions to the urinary system can cause hydronephrosis or hydroureter and result in obstructive uropathy. An unusual case of IAAA presenting with forniceal rupture is presented, with successful endovascular and endourologic repair.     

Single-stage surgery for distal aortic arch aneurysm and infrarenal abdominal aortic aneurysm through anterolateral approach.

A 58-year-old man with a distal aortic arch aneurysm (DAA) associated with an infrarenal abdominal aortic aneurysm (AAA) successfully underwent a single-stage replacement of the aneurysms. A left anterolateral thoracotomy was used for replacement of the DAA, which was performed using profound hypothermic circulatory arrest and continuous retrograde cerebral perfusion. An extraperitoneal approach in conjunction with a lateral abdominal incision was employed for replacement of the AAA. The combination of an anterolateral thoracotomy and a lateral abdominal incision is useful in combined surgery for DAA and AAA.     

Inflammatory abdominal aortic aneurysm

The inflammatory abdominal aortic aneurysm has received little attention in the literature. To date only four reports have addressed the subject specifically. Controversy remains as to whether this is a variant of the usual atherosclerotic aneurysm or a separate entity. The operative reports of 24 patients with inflammatory abdominal aortic aneurysms are reviewed; 21 were intact and 3 ruptured. Intact aneurysms ranged in diameter from 5 to 12 cm and the ruptured ones from 5 to 10 cm. Nine patients with intact aneurysms had symptoms of abdominal or back pain. Of 13 patients who underwent excretory pyelography before operation, only 3 had evidence of obstruction. Nine patients had tube grafts placed, 10 had aortoiliac grafts and 5 aortofemoral grafts. There was one intraoperative duodenal injury and in another patient it was necessary to divide the left renal vein for proximal exposure. No attempt was made to expose the ureters at operation. All patients were discharged from hospital. The authors believe that the inflammatory aneurysm is a variant of the abdominal aortic arteriosclerotic aneurysm. Intraoperative complications can be avoided by the recognition of the pathological features.     

Retroperitoneal approach to high-risk abdominal aortic aneurysms

During a 14-month period we used a left-flank, retroperitoneal, retrorenal approach in 23 high-risk patients with abdominal aortic aneurysm (AAA). Fourteen patients underwent suprarenal/celiac cross clamp for juxtarenal/suprarenal AAA and/or associated occlusive disease. Other indications for this approach included diminished cardiac and/or pulmonary reserve, previous extensive abdominal surgery, obesity, and inflammatory AAA. There was only one death (4%) in this high-risk group and minimal operative morbidity. The flexibility afforded by this approach for high aortic exposure allowed expeditious proximal anastomoses with minimal postoperative renal dysfunction. Pulmonary complications, ileus, and pain were reduced and patient mobilization was rapid despite the complex nature of the operative procedures. We believe that this approach offers significant advantages for all cases of AAA but particularly for anatomically complex lesions and medically high-risk patients.     

Factors Affecting the Regression of Surgically Replaced Abdominal Aortic Aneurysms

Purpose After endovascular therapy for abdominal aortic aneurysms, aneurysm sac shrinkage is considered to be the best marker of successful treatment. Such shrinkage, however, is infrequent and the rate of shrinkage is variable because of endoleaks. To investigate the factors that influence such contraction, the aneurysm sac regression after a conventional surgical replacement of the abdominal aortic aneurysm in an inclusion fashion was studied. Methods Abdominal aortic aneurysms that measured 5 cm in diameter or larger were studied in 35 patients who underwent surgical replacement. The aneurysm sac was closed anterior to the prosthesis. Of the 35 cases, 4 aneurysms were inflammatory and 10 had aneurysm wall circumferential calcification of greater than 40%. Computed tomography was performed preoperatively, and at 1 week, and then 3 months postoperatively. Results The maximum major and minor diameters of the aneurysmal sac decreased significantly from 1 week to 3 months after surgery (major diameter: 49 ± 12 to 32 ± 8 mm and minor diameter: 39 ± 10 to 26 ± 7 mm). In inflammatory aneurysms, the maximum major and minor diameters were significantly larger at 3 months postoperatively, in comparison to nonspecific aneurysms. Among the 31 patients with nonspecific aneurysms, the maximum major diameter was significantly larger in those with aneurysmal calcification of greater than 40% of its circumference at 3 months postoperatively, in comparison to noncalcified aneurysms. Conclusions The surgically repaired abdominal aortic aneurysm contraction tends to develop over 3 months, and inflammation, thickening, and calcification of the aneurysm wall are all considered to influence the regression of the aneurysm.     

Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms

Emergency surgery is the only effective treatment of ruptured abdominal aortic aneurysms, even though morbidity and mortality rates remain high. We have studied the feasibility of left retroperitoneal aortic exposure in these cases in an effort to reduce postoperative complications. Over a 33 month period, 29 patients underwent emergency surgery for either a ruptured or symptomatic infrarenal abdominal aortic aneurysm. Of 13 patients with ruptured aneurysms, 4 underwent repair through a midline transperitoneal approach (3 deaths) whereas the remaining 9 were repaired through the retroperitoneal exposure (1 death). Supraceliac aortic clamping through the same incision prior to aneurysm exposure maintained hemodynamic integrity. The remaining 16 patients with symptomatic aneurysms were all treated through the retroperitoneal exposure (3 deaths). In the retroperitoneal groups, the cause of death was cardiac in two patients, hypertensive stroke in one, and necrotizing pancreatitis in one. Morbidity consisted of prolonged intubation, respiratory distress syndrome, and thrombophlebitis in one patient each and acute tubular necrosis in two patients. We believe that the left retroperitoneal approach is a useful option in the emergent treatment of abdominal aortic aneurysms.     

Abdominal aortic aneurysm causing duodenal and ureteric obstruction

We report a unique case of an abdominal aortic aneurysm complicated by both duodenal and ureteric obstruction and review the literature on these conditions. Duodenal obstruction is a consequence of compression of the duodenum in its fixed retroperitoneal course between the aneurysmal aorta and the superior mesenteric artery. Treatment should be based on replacement of the aneurysm as gastrointestinal bypass alone does not resolve the risk of aneurysm rupture. Ureteric obstruction is related to encasement of the ureters in an inflammatory perianeurysmal fibrosis of unresolved etiology rather than secondary to aneurysm compression. Although urinary tract symptoms are often seen with aortic aneurysms, they tend to be nonspecific and are often overlooked. As many as 71% of patients with abdominal aortic aneurysms may have radiologic evidence of ureteric involvement. Although aneurysm replacement alone may resolve the perianeurysmal fibrosis with resultant relief of ureteric obstruction, most authors advise simultaneous ureterolysis. Aortic aneurysm should be considered as a possible cause of duodenal or ureteral obstruction in the elderly, especially in the presence of a pulsatile abdominal mass.     

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.     

The accuracy of computed tomography in the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm

The use of computed tomography (CT) in the management of patients who are hemodynamically stable with symptoms suggestive of ruptured abdominal aortic aneurysm and in hemodynamically unstable patients without palpable or known aortic aneurysms was analyzed in a retrospective study. One hundred forty-two CT scans were performed; 48 patients had abdominal aortic aneurysms and 35 had no evidence of rupture or retroperitoneal blood. Ten patients had CT scans that showed evidence of rupture, and three patients had CT scans that were thought to be indeterminate for rupture, probably inflammatory. Forty patients underwent laparotomy. Excluding the three patients with inflammatory aneurysms, the results of CT scanning were compared with the findings at laparotomy. The sensitivity of CT scanning for the diagnosis of retroperitoneal blood in the presence of abdominal aortic aneurysm was 77% and the specificity was 100%, with an overall accuracy of 92%. An algorithm for the management of the patient with symptoms suggestive of a ruptured aneurysm is presented.     

Midterm Follow-up of Inflammatory Abdominal Aortic Aneurysms Following Endovascular Repair

The role of endovascular therapy in the management of inflammatory aneurysms of the infrarenal abdominal aorta has been controversial. Review of our endovascular database identified six patients who have undergone treatment for preoperatively diagnosed inflammatory abdominal aortic aneurysms. Outcomes measured were primary success of the procedure, variation in computed tomographic (CT) scan-defined perianeurysmal fibrosis, change in aneurysm size, development of endoleak, requirement of reintervention, aneurysm rupture, and progression or resolution of symptoms. At a median follow-up of 20 months (range 4-56 months), endovascular repair has been successful in all six patients. All patients demonstrated CT reduction of perianeurysmal fibrosis, with a median of 47% absolute reduction (range 33–69%, p = 0.014). All patients had aneurysm sac shrinkage, with a mean of 41% (range 6–86%, p = 0.04). There were no aneurysm ruptures or persistent endoleaks. Of the three patients who presented with abdominal or back pain, all are now symptom-free. One patient required reintervention for limb thrombosis of a bifurcated graft after 2 years. In conclusion, endovascular treatment of an inflammatory abdominal aortic aneurysm is safe and effective and the treatment of choice in anatomically suitable patients.Presented at the Annual Meeting of the Canadian Society for Vascular Surgery, Quebec City, Quebec, Canada, October 22, 2004.     

Inflammatory Abdominal Aortic Aneurysm and Bilateral Complete Ureteral Obstruction: Treatment by Endovascular Graft and Bilateral Ureteric Stenting

Inflammatory abdominal aortic aneurysms may present a challenge to the surgeon, especially because of associated retroperitoneal fibrosis and possible ureteral complications. We present a case of inflammatory abdominal aortic aneurysm with bilateral ureteral entrapment and complete anuria, successfully treated by endovascular grafting and temporary ureteral stenting.     

Inflammatory abdominal aortic aneurysm treated by endovascular stent grafting: a case report

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.     

Inflammatory aneurysms of the abdominal aorta involving the ureters: is combined treatment really necessary?

PURPOSE: Peri-aneurysmal fibrosis complicating inflammatory aneurysm of the abdominal aorta may involve the ureters, causing urological complications. We assessed patient anatomical and clinical outcomes after conservative ureteral management. MATERIALS AND METHODS: From the operative records of 1,271 consecutive patients who underwent surgical repair of abdominal aortic aneurysms from 1980 to 1999 we identified 77 (6%) who had inflammatory aneurysms, which were complicated in 19 (24.6%) by dense peri-aneurysmal and ureteral fibrosis. Of these 19 patients 15 (78.9%) had coexisting monolateral hydronephrosis, 3 (15.7%) had bilateral hydronephrosis and 1 (5.2%) had renal atrophy. In 14 cases (73.6%) the fibrotic reaction severely impaired renal function. Only 1 patient underwent an emergency operation, while the others underwent elective repair. Only 2 patients (10.5%) underwent a specific urological procedure, including bilateral nephrostomy in 1 and ureterolysis plus ureterolithotomy in 1. Most ureteral complications were treated conservatively by aneurysmectomy only. RESULTS: Immediate postoperative mortality was 7% (1 of 14 cases). Median followup was 48 months. In 1 of the 13 cases (7.7%) a ureteral stent was placed during followup. After aneurysmectomy in 9 of the 12 patients (75%) with renal dysfunction periaortic fibrosis disappeared or decreased as well as associated hydronephrosis. In 11 of the remaining 12 patients (91%) of the 14 with renal failure preoperatively kidney function returned to normal or improved. In the 2 patients who underwent a specific urological procedure renal function improved but did not return to normal. CONCLUSIONS: Inflammatory abdominal aortic aneurysms involving the ureters and compressing the urinary structures respond well to aneurysmal resection only without a urological procedure.     

Inflammatory abdominal aortic aneurysm: an indication for the retroperitoneal approach

In three recent cases, one of which is described in this report, we have found the retroperitoneal approach to have the following significant and distinct advantages over the transabdominal repair of inflammatory abdominal aortic aneurysms: (1) The posterolateral aspect of the aorta characteristically is not significantly involved by the inflammatory process, whereas the anterior aspect is. (2) The duodenum does not need to be dissected away from the aorta and, in fact, is not seen. (3) The left renal vein moves up off the neck of the aneurysm with forward mobilization of the kidney, facilitating proximal control. Now that the computerized tomography scan has become the preferred preoperative imaging technique for abdominal aortic aneurysms, the diagnosis of inflammatory abdominal aortic aneurysm can routinely be made before elective operation allowing the retroperitoneal approach to be selected.     

Aortoenteric fistula: a late complication of endovascular repair of an inflammatory abdominal aortic aneurysm

Endovascular repair provides a reasonable alternative to open repair for the treatment of abdominal aortic aneurysms in select cases. Although the endovascular approach may be preferable for inflammatory aneurysms, aggressive surveillance is needed to monitor for long-term complications. A 61-year-old man underwent endovascular exclusion of a symptomatic inflammatory abdominal aortic aneurysm with an AneuRx bifurcated aortic prosthesis. He presented with gastrointestinal bleeding 51/2 months later and was found to have an aortoenteric fistula involving the third portion of the duodenum. The aneurysm had expanded significantly at the proximal neck. The patient underwent successful removal of the device, aortic ligation, and extraanatomic bypass. Aortoenteric fistula is a rare but now established complication of endovascular aneurysm repair. The pathophysiology in these cases remains unclear. The presence of inflammation and endoleak may predispose to further aneurysmal degeneration.     

Aortic transection and diverting bypass as treatment of repetitive recurrent abdominal aortic false aneurysm rupture in a patient with Behcet's disease

Abdominal aortic false aneurysms in patients with Behcet's disease have been reported frequently and repaired successfully by various procedures; however, anastomotic false aneurysms have often been reported to occur after the operation. In this article, we report a case of four-time repetitive, recurrent suprarenal abdominal aortic false aneurysm ruptures that lasted for 7 years. The location of this aneurysm was not easy to repair not only by open surgical procedures but by endovascular stent because the aortic defect was too close to the visceral arterial branches. The last operation consisted of primary repair of aortic defect, transection of abdominal aorta at the level of supraceliac aorta with end closure, and a thoracic aorta to abdominal aorta bypass with Dacron graft. An 8-year follow-up revealed no more abdominal aortic aneurysm recurrence.     

Are statins an option in the management of abdominal aortic aneurysms?

Medline was searched for studies investigating the perioperative and long-term results that derive from statin use in patients with abdominal aortic aneurysm and the clinical and experimental evidence dealing with aneurysm expansion. Data suggest that statins improve the perioperative and long-term outcomes of aneurysm operations and may also reduce expansion rates. International guidelines recommend the use of statins in these patients because abdominal aortic aneurysms are considered as a coronary heart disease equivalent. These guidelines do not appear to have been widely implemented. Preliminary results suggest that statins might play a role in the management of abdominal aortic aneurysms. Verification of these results in large-scale trials may hold implications for a more comprehensive approach of patients with abdominal aortic aneurysms as well as population-wide aneurysm screening programs. Irrespective of the role of statins on aneurysm expansion rates, it is important to ensure that all abdominal aortic aneurysm patients receive statin therapy to improve perioperative and long-term morbidity and mortality.