Abdominal aortic aneurysms.

The dangers of any abdominal aortic aneurysm are discussed, and the disastrous combination of an aneurysm and abdominal pain emphasised. These anerysms can be divided into 4 groups. The presentation and operative mortality for each group is discussed, as is the long term survival, state of the peripheral circulation and general health after operation. How results can be improved is considered. It is concluded that all such aneyrysms should be operated upon because of the good immediate and long term results in comparison with those not operated upon.     

Ascending aortic aneurysms with associated aortic regurgitation

A safe method for replacement of the entire aortic valve, root, and ascending aorta for aortic insufficiency associated with an ascending aortic aneurysm is supported. This method utilizes a composite synthetic graft and valve with direct annular suture and implantation of the coronary arteries in the graft. The advantages of the technique include a shortened operation and freedom from postoperative hemorrhage, paraprosthetic leakage, and recurrent aneurysm formation.     

Increased plasma levels of metalloproteinase-9 are associated with abdominal aortic aneurysms

Purpose: Previous investigators have identified disease-specific elevations of metalloelastase-9 (MMP-9) in aneurysm tissue biopsies. We hypothesized that circulating MMP-9 might also be elevated in patients with aneurysms. The purpose of this study was to compare plasma and aortic tissue MMP-9 levels in patients with infrarenal aneurysms (AAAs), patients with symptomatic aortoiliac occlusive disease (AOD), and healthy patients. Methods: A sandwich enzyme-linked immunosorbent assay was used to measure plasma MMP-9 in patients with AAA (n = 22; mean age, 72.7 years), with AOD (n = 9; mean age, 60.5 years), and without disease (n = 8; mean age, 35.3 years). The MMP-9 levels also were measured in 48-hour supernatants of organ culture tissue explants from patients with AAA (n = 10; mean age, 66.2 years) and AOD (n = 5; mean age, 50.4 years) and organ donors (n = 7; mean age, 48.1 years). The results were reported as the mean ± the standard error of the mean and analyzed with analysis of variance with multivariate regression. Results: The plasma MMP-9 levels were significantly higher in the patients with AAA (85.66 ng/mL ± 11.64) than in the patients with AOD (25.75 ng/mL ± 4.159; P < .001) or the healthy patients (13.16 ng/mL ± 1.94; P < .001). No significant difference in plasma MMP-9 levels between patients with AOD and healthy patients was identified. The patients with multiple aneurysms had significantly higher levels of plasma MMP-9 than did the patients with an isolated AAA (134.68 ng/mL ± 17.5 vs 71.03 ng/mL ± 10.7; P < .04). In organ culture, AAA and AOD tissue explants produced significantly higher levels of MMP-9 (3218.5 ng/gm ± 1115.2 and 1283.1 ng/gm ± 310.6 aortic tissue) than did disease-free explants (6.14 ng/gm ± 2.3 aortic tissue; P < .0001). No significant difference in MMP-9 production between AAA and AOD explants was identified. Conclusion: Plasma MMP-9 levels are significantly higher in patients with AAA than in patients with AOD or in healthy volunteers. The patients with multiple aneurysms have higher levels than those patients with an isolated AAA. Organ culture studies suggest that diseased aortic tissue is the source of MMP-9. (J Vasc Surg 1999;29:122-9.)     

Abdominal aortic aneurysms: case report

A 71-year-old male presented to a chiropractic clinic with subacute low back pain. While the pain appeared to be mechanical in nature, radiographic evaluation revealed an abdominal aortic aneurysm, which required the patient to have vascular surgery. This case report illustrates the importance of the history and physical examination in addition to a thorough knowledge of the features of abdominal aortic aneurysms. The application of spinal manipulative therapy in patients with (AAA) is also discussed.     

Abdominal aortic aneurysms: the changing natural history

The records of all patients with abdominal aortic aneurysms (AAAs) in a Midwest city with a stable population over a 30-year period were reviewed. There were 296 patients (196 men and 100 women) for an incidence of 21.1 aneurysms/100,000 person-years. The median age at diagnosis was 69 years for men and 78 years for women. Seventy-eight percent of patients were asymptomatic at the time of diagnosis; their aneurysms were incidental findings. Rupture occurred in 60 patients (20.3%). Thirty-six patients (12.2%) had rupture of the aneurysm as the presenting complication. For previously diagnosed aneurysms that subsequently ruptured, the average period from diagnosis to rupture was 48.7 months. Rupture occurred in only two aneurysms smaller than 5 cm. The overall mortality rate from rupture was 15.5%. Evaluation of data (including autopsy reports) by decade revealed an absolute increase in the incidence of AAAs in the population under study. More aneurysms of all sizes occurred from 1971 to 1980 than in the previous two decades combined. Although ultrasound examination has increased the detection of small aneurysms, the incidence of aneurysms 7 cm or larger at the time of diagnosis has also increased; the frequency of rupture was greatest in the last decade. To compare the data of the population-based study with the statistics for patients seen in a referral practice, the records of 616 patients from a referral population were also reviewed. In the referral population the ratio of men to women was 5:1, and the age at diagnosis was lower for both groups.(ABSTRACT TRUNCATED AT 250 WORDS)     

Indicators of infection with Chlamydia pneumoniae are associated with expansion of abdominal aortic aneurysms

PURPOSE: Chlamydia Pneumoniae has been shown to be associated with atherosclerosis, myocardial infarction, and abdominal aortic aneurysms (AAAs). The possible association between AAA expansion and C pneumoniae infection was therefore assessed. METHODS: Blood samples were taken from patients with an AAA that was considered for surgical repair after having been diagnosed by means of the Chichester aneurysm screening program (UK) as having an initially infrarenal aortic diameter of 3.0 to 5.9 cm. The patients were examined prospectively for as long as 11.5 years (mean, 4.1 years) with ultrasound scanning. Of 110 patients considered for surgery, 90 men and 10 women had blood samples taken. Their IgG and IgA antibodies against C pneumoniae were measured by means of a microimmunofluorescence test. Unpaired t tests, multiple linear regression analyses, and logistic regression analyses were used for statistical analysis. RESULTS: A total of 44% (95% CI, 31%-55%) of the men with an AAA had an IgA titer of 64 or more, an IgG titer of 128 or more, or both, compared with 10% of the women with an AAA (OR = 7.2; 95% CI, 1.05-160.8). A titer of IgG of 128 or more was significantly associated with higher expansion (5.3 vs 2.6 mm per year), even after adjustment for initial AAA size and age. A significant positive correlation between both IgA and IgG titers and mean annual expansion was observed (r = 0.28; 95% CI, 0.05-0.49; and r = 0.45; 95% CI, 0.24-0.62, respectively), persisting after adjusting for initial AAA size and age. An IgG titer of 128 or more was present significantly more often in cases with an expansion greater than 1 cm annually (adjusted OR = 12.6; 95% CI, 1.37-293). CONCLUSION: A high proportion of men with an AAA has signs of infection with C pneumoniae. The progression of their AAAs was positively correlated with the presence of indicators of C pneumoniae infection.     

Abdominal aortic aneurysms infected with salmonella: problems of treatment

Seven patients with abdominal aortic aneurysms infected with salmonella organisms were surgically treated between 1985 and 1988. Salmonella culture was obtained from the wall of the aneurysm in every patient, and in five patients it was identified as Salmonella typhimurium. S. choleraesuis and salmonella group D (isolated from this patient but not speciated) were found in the other two remaining patients. Three patients underwent aneurysmal resection with axillofemoral bypass grafting, and three patients were treated by aneurysmal resection with in situ graft; two of this group had the wall and infective periaortic tissue excised. One patient died during the operation as a result of rupture of the aneurysm. Therapeutic doses of antibiotic drugs were given to all of the patients. Although two of the patients in the first group (with the axillofemoral bypass graft) died and the remaining patient had very complicated postoperative course, all the patients in the second group (with in situ graft) survived. We think that in situ graft placement after an extensive debridement of the aneurysmal wall and infected periaortic tissue together with more effective and adequate antibiotic therapy for at least 6 weeks after the operation is a satisfactory method of surgical treatment of this condition. However, graft infection is still a possibility, therefore regular follow-up is needed.     

Abdominal aortic aneurysms after heart transplantation.

BACKGROUND: In recent years abdominal aortic aneurysms were diagnosed in several heart transplant recipients at our center. Only case reports or small series have been reported previously and little is known about abdominal aortic aneurysms after heart transplantation. Therefore, the goals of this study were to estimate the incidence of this condition after heart transplantation, to identify risk factors for its development, and to assess its clinical consequences. METHODS: Our investigation was a retrospective, single-center cohort study of 368 consecutive patients transplanted between 1984 and 1999. RESULTS: During a mean follow-up of 75 +/- 49 months, 37 of the 368 (10%) transplant recipients and 36 of 202 (18%) of the sub-group with a history of ischemic heart disease were found to have an abdominal aortic aneurysm. All patients were male, and all except 1 had a history of ischemic heart disease. A history of ischemic heart disease prior to heart transplantation was the sole independent risk factor for developing an aneurysm by multivariate analysis. Aneurysm-related events occurred earlier and more frequently in the 7 transplant recipients who already had a dilated abdominal aorta prior to transplantation. The abdominal aortic aneurysm was the direct or indirect cause of death in at least 9 patients. CONCLUSIONS: Abdominal aortic aneurysms are relatively frequent after heart transplantation, occur at a younger age than in the general population, and have serious clinical consequences. Close ultrasonographic follow-up of patients with a history of ischemic heart disease or with an abnormal abdominal aorta prior to heart transplantation seems indicated.     

Abdominal aortic aneurysms following orthotopic heart transplantation

The purpose of these authors' study was to analyze their center's experience with orthotopic heart transplantation (OHT) and abdominal aortic aneurysms (AAA) with particular attention to corticosteroid dosing, hemodynamic parameters, and aneurysm growth rate. A retrospective review of all patients (453) who underwent OHT at their university-affiliated medical center over an 18-year period (1981-1999) was undertaken. Nine (2%) patients who developed AAAs were identified and aneurysm growth was correlated with corticosteroid immunosuppression and hemodynamic parameters. The mean age of OHT patients was 44.5 +/-15 years and the majority were males (371 males, 82%). Median follow-up was 5.7 years. Ischemic cardiomyopathy (IC) was the most common indication for transplantation (45.5% of patients). All AAA patients were male (p=0.157), with a mean age of 58.4 +/-4.8 years (p=0.001), and had undergone OHT for IC (p=0.001). Mean arterial blood pressure and ejection fraction in the AAA patients had increased from pretransplant values of 107 mm Hg and 14.3 +/-5.7% to 142 mm Hg (p=0.017) and 54.1 +/-14.1% (p<0.001), respectively, before aneurysm repair. Mean aneurysm diameter at the time of repair was 6.0 +/-0.8 cm, and the average growth rate was 1.2 +/-0.4 cm/year in the 4 patients in whom it could be measured. Aneurysm repair was performed urgently in 2 patients and electively in 7 patients with 1 early postoperative death (11%). The extent of corticosteroid immunosuppression, corticosteroid pulses, and total corticosteroid dosing did not correlate with the rate of aneurysm growth. Improved hemodynamics and progressive posttransplant hypertension may contribute to aneurysm formation and growth in this group of patients.     

Abdominal aortic aneurysms infected by Escherichia coli

Three cases of atherosclerotic abdominal aneurysms infected by Escherichia coli urinary tract sepsis are presented together with a review of four additional cases of E. coli-infected aneurysms. Pathophysiology and a current system of classification of aortic infection are discussed. Important clinical features of gram-negative aortic infection include a diagnostic triad and the tendency to early rupture. Resection of infected tissue and extra-anatomic bypass for revascularization are the cornerstones of operative management. The mortality rate of E. coli aortic infection is high, with one known survivor. Death is contributed to by the high frequency of preoperative rupture, the age of the patient, and the extent of atherosclerotic disease.     

Abdominal aortic aneurysms: some controversial points

A retrospective review of the surgical treatment of 51 abdominal aortic aneurysms is reported. Thirty-five (69%) patients were operated on electively, and 16 (31%) had emergency surgery. Fissurated aneurysms were included in the elective surgery group. The operative death rate was respectively 2.7% and 50%. Controversial points about diagnosis, treatment of associated diseases, surgical technique, and selection of the patients for surgery are presented and discussed.     

Abdominal aortic aneurysms and ureteric obstruction.

Ureteric obstruction is rarely encountered in abdominal aortic aneurysms and is due to perianeurysmal fibrosis. 3 cases are described in which aortic aneurysm and retroperitoneal fibrosis are found. Excision of the aneurysm and ureterolysis with intraperitonization of the ureter is the most appropriate surgical procedure but treatment must be individualized according to the patient's condition and the operative discoveries.     

Intracranial aneurysms associated with unsuspected aortic coarctation

Intracranial aneurysms (IAs) are found more often in patients with aortic coarctation (AC) than in the general population and aneurysm rupture occurs much earlier in the lives of these patients when there is coexistent AC. The diagnosis of AC is frequently made only after a serious cerebrovascular complication has developed. The aim of this paper is to call attention to AC in patients presenting with aneurysmal subarachnoid hemorrhage. The literature is reviewed, the key clinical features are highlighted, and the proposed pathogenesis of this association is discussed. The authors present clinical information and imaging data obtained in three young patients with ruptured IAs that were associated with initially unnoticed AC. Abnormal results of cardiovascular examinations led the authors to consider an underlying AC, which was later confirmed by aortography. These aneurysms were successfully treated prior to correction of the ACs. The diagnosis of AC should be considered in adolescent and young adult patients presenting with IAs.     

Abdominal aortic aneurysms. Results of surgical treatment

One hundred and twenty-one aneurysms of the abdominal aorta were operated on during a ten year period (1971-1981). Elective surgery was carried out in 89 patients (73.5%). Thirty-two patients were operated on for impending or frank rupture. Most of the patients treated electively had no symptoms on admission. The mortality of this group of patients was 6.7% (6 patients). All the patients treated as emergencies had acute abdominal or back pain. Six cases presented with shock and acute renal failure. The hospital mortality was high in this group of 11 patients (34.3%). Nine of them were operated on because of suspected rupture but this was not confirmed at operation. Only one patient in this group died after the operation (11.1%). The hospital mortality of the 23 patients with ruptured aneurysms was 43.4% (10 patients). Six of them died in the operating room. While elective surgery carries an acceptable mortality, the emergency procedure involves a high risk. All the aneurysms must be resected electively in spite of the absence of symptoms.     

Abdominal aortic aneurysms in the New Zealand Maori population

BACKGROUND: Abdominal aortic aneurysm (AAA) is believed to be a rare disease in people of non-European descent. Maori, New Zealand's indigenous people, are thought to originate from South East Asia, so their incidence of AAA might also be expected to be low. The aim was to investigate the incidence and phenotypic factors associated with AAA in the New Zealand Maori population. METHODS: A retrospective study was performed using the audit database of the New Zealand Society of Vascular Surgeons. Age-standardized rates of admission and death were calculated for Maori and non-Maori. RESULTS: Maori comprised 3.9 per cent of the population who had an AAA repaired, similar to the percentage of the Maori population aged over 65 years. However, the death rate from AAA in Maori was 2.4 times the rate in non-Maori. Maori were younger at diagnosis than non-Maori (65.2 versus 71.8 years; P < 0.001), had more emergency procedures (46.6 versus 30.2 per cent; P = 0.018) and a significantly higher proportion of Maori admissions were for a ruptured aneurysm. CONCLUSION: Maori had a higher mortality rate from AAA than non-Maori New Zealanders. Although admission rates between Maori and non-Maori were similar, the earlier age of onset and the increased proportion of ruptured aneurysms may indicate that the disease is more severe in Maori.