In-hospital mortality of ruptured abdominal aortic aneurysm

Background: New Zealand, like Australia, has a widely dispersed population in towns at long distances from the main centres. We set out to estimate the in‐hospital mortality rate for ruptured abdominal aortic aneurysms in New Zealand and identify factors associated with mortality. Methods: Data were gathered prospectively as part of the Vascular Society of New Zealand’s continuous audit programme of all member surgeons. Data collection was validated by random record audit. In‐hospital mortality of ruptured abdominal aortic aneurysms, defined as death during hospital admission irrespective of cause, was determined for the period 1993–2005. Along with other performance indicators, differences in outcomes were assessed to take into account the trend over the time period, hospital size and number of non‐operative admissions. Results: Of the 740 patients admitted with a mean age of 73.9 ± 8.5 years, 78% were men and 17.8% were declined an operation. The in‐hospital mortality was 48.3% and the operative mortality was 37.8%. With univariate analysis increasing patient age, American Society of Anesthesiology score, hospital size and female sex were predictors of in‐hospital mortality. Only age and American Society of Anesthesiology score were independent predictors of operative mortality. Women were less likely to have surgery. Conclusion: Over the past 13 years in‐hospital mortality of ruptured abdominal aortic aneurysms in New Zealand remained unchanged. In provincial hospitals the operative outcomes were satisfactory, but the reported number not offered surgery was higher.     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

Abdominal compartment syndrome after ruptured abdominal aortic aneurysm

Abdominal Compartment Syndrome (ACS) is an increasingly recognized syndrome of intra-abdominal hypertension and generalized physiological dysfunction in critically ill patients. Patients suffering a ruptured abdominal aortic aneurysm (rAAA) are at risk of developing ACS. The objective of the study was to compare the current views on the importance, prevalence and management of ACS after rAAA among Australian vascular surgeons and intensivists. A questionnaire was mailed to 116 registered vascular fellows from the Royal Australasian College of Surgeons and 314 registered fellows of the Joint Faculty of Intensive Care Medicine. Data were collected on the prevalence and importance of ACS after rAAA and whether prophylactic measures were or should be taken to prevent ACS. Hypothetical clinical scenarios representing a range of ACS after rAAA were also presented. The responses were compared using chi(2)-test and t-test. Sixty-seven per cent (78 of 116) of surgeons and 39% (122 of 314) of intensivists responded. Both groups estimated the prevalence of ACS after rAAA as between 10 and 30% and considered it an important entity. Only 30% of surgeons and 50% of intensivists suggested routine intra-abdominal pressure (IAP) monitoring. In patients with borderline IAP (18 mmHg), both groups believed that surgical intervention was unnecessary. Intensivists were more inclined to suggest surgical intervention for clinically deteriorating patients with an increased IAP (30 mmHg) compared with surgeons. Forty-three per cent of intensivists and 17% of surgeons suggested prophylactic (leaving the abdomen open) measures to prevent ACS in high-risk patients. Surgeons and intensivists have similar views on the prevalence and clinical importance of ACS after rAAA. Intensivists more frequently monitored IAP and suggested both early prophylactic and therapeutic intervention for ACS based on physiological and IAP findings.     

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目的分析影响腹主动脉瘤破裂病人手术治疗预后的危险因素。方法回顾性分析1999年8月至2010年12月重庆医科大学附属第一医院行手术治疗的40例腹主动脉瘤破裂病人资料。从病人年龄、性别、合并其他基础疾病、瘤体直径、输血量、手术时间以及术前低血压持续时间几方面进行研究,采用单因素分析和多因素分析了解影响腹主动脉瘤破裂病人手术治疗预后的危险因素。结果单因素分析:术前有低血压表现的病人(P=0.034)死亡风险为术前无低血压病人的3.2倍,低血压持续时间≥2h病人(P=0.008)为低血压持续时间<2h病人的2.6倍。术前合并冠心病(P=0.028)、慢性阻塞性肺疾病(P=0.012)及肾功能不全(P=0.028)的病人病死率显著升高。病人年龄≥70岁的(P=0.031)和瘤体直径≥5cm的病人(P=0.016)病死率显著升高。病人病死率与输血量(P=0.225)、性别(P=0.689)及手术时间(P=0.360)无明显关系。多因素分析:低血压持续时间(P=0.042)、术前合并冠心病(P=0.036)和年龄(P=0.040)三种因素差异有统计学意义,而术前合并慢性阻塞性肺疾病(P=0.102)、肾功能不全(P=0.057)和瘤体直径(P=0.225)在多因素分析中差异无统计学意义。结论低血压持续时间、合并冠心病和高龄是影响腹主动脉瘤破裂病人预后的危险因素。缩短低血压持续时间可以明显改善腹主动脉瘤破裂病人预后。     

腹主动脉瘤破裂行腔内修复术1例

患者女,80岁,因急性脑梗死伴腹痛9h入院。查体:下腹部左侧触及6～7cm搏动性包块,右侧中枢性面瘫,右上肢肌力0级,疼痛刺激无反应,右下肢外旋,可屈曲,无自主运动;左侧肢体肌力Ⅳ级,左侧Babinski征阳性,右侧病理征未引出。既往有糖尿病、高血压及腹主动脉瘤病史。     

Wrapping of ascending aortic aneurysm with supra-aortic debranching and endovascular repair for aortic arch aneurysm and ruptured descending thoracic aortic aneurysm

We report a case of a hybrid surgical treatment of a 71-year-old fragile female with severe chronic obstructive pulmonary disease with a 5-year history of progressive back pain and diagnosis of descending thoracic aorta aneurysm (DTAA), but refused operation at first. Since the patient presented with an acute expanding painful pulsatile mass due to a ruptured DTAA contained by the subcutaneous tissue and had a high-risk surgical profile, we agreed that the simplest urgent operation should be performed. Cardiopulmonary bypass with or without deep hypothermic circulatory arrest was ruled out as an option. The initial approach would be permanent bypasses to the supra-aortic trunks and endovascular repair of the ruptured DTAA, but we ran into a problem: the absence of suitable diameter in the ascending aorta to land the prosthesis—zone 0. To overcome this obstacle, we opted to perform a diameter reduction of the ascending aorta by wrapping it with a Dacron tube to create a neck where we could land the endovascular prosthesis. Following this step bypasses from the proximal ascending aorta to the brachiocephalic artery, left common carotid artery and left subclavian artery were created. Since we gained ground to act in zone 0, the first endoprosthesis was landed in the wrapped zone and the aortic arch—from zone 0 to zone 3. The second and third endoprostheses covered the ruptured DTAA above the celiac trunk—zones 4 and 5. Good positioning of the endoprostheses was achieved and we attained procedural success.     

腹主动脉瘤破裂的处理及预后分析

目的探讨腹主动脉瘤破裂的处理及影响预后的主要因素。方法回顾性分析12年间收治的42例腹主动脉瘤破裂的临床资料。85．7％的患者术前行影像学检查确诊。36例行手术治疗,其中35例行腹主动脉瘤切除人工血管植入术,术中80％采用肾动脉下腹主动脉阻断, 14．3％采用膈下腹主动脉阻断,5．7％采用Foley尿管球囊阻断（2例）;1例行覆膜支架腔内隔绝术。结果围手术期死亡率45．24％。单因素统计分析表明在围手术期死亡者年龄（72．1±1．0）岁、合并疾病13例和术前收缩压（82±53）mm Hg;存活者年龄（61．5±17．0）岁、合并症7例、术前收缩压（82±28）mm Hg,之间差异有统计学意义（P〈0．05）,而性别、术前Hb、肌酐、瘤体直径和手术失血量则无显著差异（P〉0．05）。结论手术是治疗破裂腹主动脉瘤的惟一有效方法,高龄、合并其他疾病和休克提示预后不良。     

腹主动脉瘤破裂18例救治体会

１８例腹主动脉瘤破裂，１６例经手术治疗。手术方法主要为腹主动脉瘤切除人造血管植入术，围手术期死亡６例（３７５％）。为提高病人生存率，一旦腹主动脉瘤诊断成立，应积极行择期手术治疗。腹主动脉瘤破裂后，正确及时的诊断尤为重要。手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血     

九例腹主动脉瘤破裂死亡原因分析

目的分析总结腹主动脉瘤破裂的死亡原因与救治经验。方法回顾性分析2001-2005年23例腹主动脉瘤破裂手术治疗后9例死亡病例的临床资料。结果23例中死亡9例,术前均伴有休克,总死亡率约39．1％。术前伴发高血压7例、COPD 1例、慢性肾功不全1例。其破裂类型包括向前壁开放性破裂5例;向脊柱左侧方破裂3例;向后方破裂1例。破裂部位分别为肾动脉3例、肾下腹主动脉领域6例。术后分别死于ARDS 4例、急性肾衰2例、人工血管感染2例、DIC 1例。结论死亡率与就诊时的休克状态、破裂部位和类型、术后并发症、人工血管感染密切相关,及时正确地诊断救治、加强围手术期监护有利于降低死亡率。     

破裂性腹主动脉瘤的治疗

目的探讨破裂性腹主动脉瘤急诊救治的治疗经验。方法回顾性研究2002年5月-2013年7月救治的36例破裂性腹主动脉瘤患者的临床资料。其中25例合并高血压病,21例合并慢性阻塞性肺疾病。33例采取急诊开腹主动脉人工血管置换术;3例采取主动脉覆膜支架腔内修复术,其中1例中转开腹手术治疗。结果术后33例存活,另外3例死亡,死亡原因包括1例失血性休克和心功能衰竭,1例术中心跳骤停,1例术后多器官功能衰竭,围手术期病死率为8．3％。术后随访3～61个月,未发生人工血管感染等手术相关并发症及死亡病例。结论积极的手术治疗是提高破裂性腹主动脉瘤患者救治成功率的关键,早期明确诊断,手术中快速有效控制近端瘤颈血流,完善围手术期治疗能有效降低病死率。     

破裂性腹主动脉瘤的腔内治疗体会

目的观察腔内修复术(endovascular aneurysm repair,EVAR)治疗破裂性腹主动脉瘤(ruptured abdominal aortic aneurysm,RAAA)的治疗效果,总结EVAR治疗RAAA的经验。方法收集宁夏回族自治区人民医院2012年2月至2017年2月间收治的13例接受腔内治疗的RAAA病人的临床资料,并对相关临床资料进行分析。结果 13例病人均顺利完成腹主动脉瘤腔内隔绝手术,平均手术时间为(180.3±35.4)min,术中平均出血量为(102.5±8.6)ml。术后死亡2例(15.38%);其余11例均康复出院,平均住院时间为(12.3±2.1)d。结论 EVAR治疗RAAA疗效明确、术后并发症少、创伤小、恢复快,是一种很有前景的RAAA治疗方法。     

破裂性腹主动脉瘤的救治

目的 回顾总结17例破裂性腹主动脉瘤(RAAA)的救治经验.方法 对2002年5月至2008年3月救治的17例RAAA患者的临床资料进行回顾性分析.结果 17例RAAA患者中的15例采用开腹手术救治,紧急应用球囊导尿管阻断动脉以止血,自体出血回输装置进行自体输血,人工血管置换;2例采用腔内血管外科技术行带膜支架植入,成功1例,另1例转为开腹手术后仍成功救治.死亡3例,存活14例.结论 腹主动脉瘤患者一旦出现腹痛等破裂先兆症状,必须尽快争取手术时间,球囊导尿管阻断动脉可以明显缩短失血性休克时间,减少术中出血和输血是抢救成功的关键.     

Surgical treatment of ruptured abdominal aortic aneurysm

Over the last 30 years more than 1000 patients with abdominal aortic aneurysms (AAA) were treated. Results of treatment of 367 patients with disruption of AAA from 1989 to 2002 were analyzed. Elderly and old patients account for 92% (338) of them. In 61% (224) patients after aneurysm's disruption blood outflew into the retroperitoneal space, in 23.4% (86) - into abdominal cavity, in 13,1% (48) patients retroperitoneal hematoma and hemoperitoneum formed, 2% (7) were the patients with functioning aorto-caval fistula, in 0.5% (2) aneurysm disrupted into the duodenum. There was no surgery due to different causes in 161 patients, all these patients died. One hundred and sixty-five patients underwent surgery, lethality was 60% (99 patients). Linear grafting of the aorta or aorto-iliac grafting was performed in the majority of patients - 77 (46.7%). Based on the obtained data three types of clinical picture of AAA disruption are devined: fulminant, acute and sub-acute. Complex treatment improved results of the treatment: lethality from 1989 to 1996 was 71.6%, from 1997 to 2002 - 52%.     

腹主动脉瘤破裂急诊手术与非破裂择期手术对比分析

目的总结腹主动脉瘤破裂（ruptured abdominal aortic aneurysm，RAAA）急诊手术的治疗经验。方法回顾性分析25例RAAA急诊救治过程，并与同期完成的48例择期腹主动脉瘤（abdominal aortic aneurysm，AAA）切除术在输血量、ICU住院天数、瘤体最大直径和死亡率等指标分别进行统计分析比较。结果RAAA急诊手术与择期AAA切除术患者比较，围手术期输血量（2980±2712）ml和（580±314）ml；ICU住院天数（6．8±5．7）d和（2．5±1．5）d；手术死亡率32％（8／25）和2．1％（1／48），差异均有统计学意义（P〈0．01）；瘤体直径（5．9±1．4）cm和（5．3±1．4）cm者差异无统计学意义（P〉0．05）；术后并发症有：脑卒中、肾功能衰竭、成人呼吸窘迫综合征和消化道出血。结论AAA一经发现，应选择尽早择期手术，合理的抢救措施有助于降低RAAA手术死亡率。     

Colon ischemia accompanying ruptured abdominal aortic aneurysm

Myocardial, cerebral, and renal ischemia are recognized as serious sequelae in patients surviving repair of ruptured abdominal aortic aneurysms. Colonic ischemia, though a documented consequence of aortic reconstruction, has received less emphasis in these patients. In a 5-year review of a single hospital's experience, 50 patients underwent an emergency operation for ruptured abdominal aortic aneurysm. Ninety-six percent of the patients were in shock preoperatively. Of the 37 patients who survived the initial surgical procedure, 12 (32%) were subsequently found to have colon ischemia diagnosed by proctoscopy, repeat laparotomy, or autopsy. Among 20 of the initial survivors who later died at intervals up to 6 weeks after aneurysm repair 8 (40%) had colon ischemia as the sole or major contributing cause of death. Because of the high incidence of this serious but remediable problem in patients undergoing emergency operation for ruptured abdominal aortic aneurysm, we now routinely perform: (a) intraoperative Doppler examination of the colonic arterial tree, with consideration of mesenteric revascularization if necessary, (b) daily postoperative sigmoidoscopy and examination of the stool for blood, and (c) aggressive “second-look” laparotomy in patients exhibiting any signs or symptoms suggesting colonic infarction. Our experience suggests that large bowel infarction is a common, lethal, and underemphasized complication following successful repair of ruptured abdominal aortic aneurysms.