Abdominal aortic aneurysm repair in octogenarians versus younger patients in a tertiary referral center

Operative survival is as high as 96% for elective abdominal aortic aneursym (AAA) repair but as low as 10% for emergency repair. Our primary aim was to compare elective AAA repair in octogenarians with nonoperative management. Our secondary aim was to compare octogenarians with their younger counterparts. From 1998 to 2003, 180 patients with AAA were treated operatively or nonoperatively. Factors determining treatment included American Society of Anesthesiologists grade >or= 4, inoperable malignancy, New York Heart Association class III, forced expiratory volume in 1 second < 35%, creatinine > 6.0 mg/dL, and patient and family choice. A parallel-group observational study was performed to assess age and treatment effects on outcome. Seventy (39%) patients were repaired electively, 68 (38%) were managed nonoperatively, and 42 (23%) underwent emergency repair. Fifty-nine (33%) were octogenarians. The octogenarian 5-year survival rate was 20% following emergency repair, 42% if treated nonoperatively, and 83% following elective repair. Younger cohort rates were 55% (emergency), 44% (nonoperative), and 76% (elective). The octogenarian mean expansion rate was 0.26 cm/yr in those treated nonoperatively and 1.04 cm/yr in confirmed rupture. Rupture rate was related to expansion rate (95% confidence interval [CI] 0.06-0.59, r = .35, p = .01). The rates in the younger subgroup were 0.32 cm/yr and 1.14 cm/yr (95% CI -0.021-0.672}, r = .37, p = .03). The octogenarian survival rate was highest following elective repair. Rupture was closely correlated with aneurysm expansion. Screening should reduce the incidence of octogenarian rupture of AAA and identify those patients most suitable for nonoperative management.     

Emergency surgery of non-ruptured abdominal aortic aneurysm

BACKGROUND AND AIMS: The pain of an abdominal aortic aneurysm (AAA) is believed to signify rupture, and emergency surgery for symptomatic AAA is a widely accepted practice to prevent rupture. To clarify the benefit of emergency surgery we evaluated the clinical course of emergency treated patients with non-ruptured AAAs. MATERIAL AND METHODS: 110 patients (90 men, mean age 69, range 49-93; 20 women, mean age 75, range 63-89) underwent emergency repair of non-ruptured AAA between 1970 and 1992 at the Department of Thoracic and Cardiovascular Surgery of Helsinki University Central Hospital (HUCH). Survival rates after surgery were analysed using product-limit-survivorship method. The survival rates after age-stratification were compared with those of patients undergone elective surgery (n=599) or emergency surgery because of ruptured AAAs (n=363) during the same period. Risk factors affecting early and late survival rates after operation were analysed by logistic regression analysis and Cox proportional hazard model. RESULTS: Thirty-day operative mortality rates were 18 % (20/110) in the emergency non-ruptured group, compared with 7 % (42/599) in the elective group and 49 % (179/363) in the ruptured group (p<0.05). Thirty day survival rate was not changed among the nonruptured emergency group from 1970 to 1992, whereas the rates of ruptured and elective groups became better during the study period. Late survival rates for 30-day postoperative survivors were clearly reduced among the non-ruptured emergency group, without difference between the emergency operated ruptured and non-ruptured groups. Coronary artery disease was decreasing significantly early and late survival rates after emergency surgery for non-ruptured AAAs (p<0.05, logistic regression and p<0.001 Cox proportional hazard). CONCLUSIONS: Early and late mortality risk is significantly higher (p<0.001) after emergency surgery for haemodynamically stable non-ruptured AAA than after elective surgery, mainly because of coronary artery disease.     

Abdominal aortic aneurysmectomy in octogenarian patients

The authors report 56 patients. 80 years of age or older who had an abdominal aortic aneurysm (AAA): twenty seven were operated upon as emergencies, 7 with intra-peritoneal (Group I) and 20 with retro-peritoneal rupture (Group II). Twenty nine underwent elective surgery (Group III). Renal pulmonary and cardiac disease are frequent in octogenarian patients. The surgical repair consisted of 40 knitted bifurcated grafts and 16 aorto-aortic woven grafts. The overall in-hospital mortality rate is high (28.5%: 16 patients) essentially in "emergency" surgery: 71% for the seven Group I patients and 45% for the twenty Group II patients. The in-hospital mortality rate of 6.9% for the Group III of "elective" procedure is higher than the mortality rate of patients of all ages operated on for asymptomatic AAA in our institution which is 4.3%. Once a patient has been operated on successfully his life expectancy tends to parallel that of a normal population for his age group. These results can be improved with preventive measures such as elective surgery for asymptomatic AAA with a diameter of 6 cm or more. Operative contraindications are severe congestive heart failure, advanced pulmonary disease or neoplastic disease. The age "per se" is not a contraindication to aneurysmectomy. Physiologic rather than chronologic age should determine the selection for AAA in the over-80 age group. CT scans and MR are safe fast and non-invasive preoperative examinations for AAA.     

The cost-effectiveness of early surgery versus watchful waiting in the management of small abdominal aortic aneurysms

Purpose: The purpose of this study was to compare the relative cost-effectiveness of two clinical strategies for managing 4 to 5 cm diameter abdominal aortic aneurysms (AAAs): early surgery (repair 4 cm AAA when diagnosed) versus watchful waiting (monitor AAA with ultrasound size measurements every 6 months and repair if the diameter reaches 5 cm).Methods: We used a Markov decision tree to compute the expected survival in quality-adjusted life years (QALYs) for each strategy, based on literature-derived estimates for the probabilities of different outcomes in this model. We determined hospital costs for patients undergoing elective and emergency AAA repair at our center. With standard methods of cost accounting, we then calculated the additional cost per year of life saved by early surgery compared with watchful waiting (cost-effectiveness ratio, dollars/QALY).Results: Mean hospital costs for elective and emergency AAA repair were $24,020 and $43,208, respectively (1992 dollars). For our base-case analysis (60-year-old men with 4 cm diameter AAAs, with 5% elective operative mortality rate and 3.3% annual rupture rate), early surgery improved survival by 0.34 QALYs compared with watchful waiting, at an incremental cost of $17,404/QALY. Increased elective surgical mortality rate, decreased AAA rupture risk, and increased patient age all reduced the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery. Future increases in elective operative risk, noncompliance with ultrasound follow-up and increased threshold size for elective AAA repair during watchful waiting all improved the cost-effectiveness of early surgery.Conclusions: The cost effectiveness of early surgery for 4 cm diameter AAAs in carefully selected patients compares favorably with that of other commonly accepted preventive interventions such as hypertension screening and treatment. With an upper limit of $40,000/QALY as an "acceptable" cost-effectiveness ratio, early surgery appears to be justified for patients 70 years old or younger, if the AAA rupture risk is 3%/year or more and the elective operative mortality rate is 5% or less. Although not a substitute for clinical judgment, this cost-effectiveness analysis delineates the essential tradeoffs and uncertainties in treating patients with small AAAs. (J VASC SURG 1994;19:980–91.)     

THE QUALITY OF SURGICAL CARE PROJECT: BENCHMARK STANDARDS OF OPEN RESECTION FOR ABDOMINAL AORTIC ANEURYSM IN WESTERN AUSTRALIA

Background: The Quality of Surgical Care Project (QSCP) was established in May 1996, to evaluate surgical outcomes and where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). The purpose of this study is to establish benchmark standards in WA for operative mortality, 5-year survival and length of stay in all patients who were surgically treated for aneurysm of the abdominal aorta (AAA) in WA. Methods: The WA Linked Database was used to link the morbidity and mortality records of all patients admitted and surgically treated for AAA in WA from 1985 to 1994. The linked chains of de-identified hospital morbidity and death records were selected using diagnostic and procedure codes pertaining to AAA. Three groups were separated for analysis: those admitted for rupture, those admitted for elective repair, and those who were admitted to hospital as an emergency without mention of rupture but who underwent repair for AAA. Independent analysis for gender and patients 80 years or more were included in the study. Patients were excluded from the study if they were less than 55 years of age. Results: A total of 1475 cases (1257 males, 218 females) were identified. The mean age in elective cases was 70.4 years in males and 72.4 years in females, and for rupture the mean ages were 71.9 and 74.8 years, respectively. Median length of stay for males was 12 days for elective cases. Admission type or age did not significantly influence length of stay. Thirty-day mortality in males was 4.4% for elective repair and 36.7% for ruptured AAA and 5-year survival was 71.7 and 47.7%, respectively. The overall case fatality rate for ruptured AAA was 79.3% which included those cases who died from rupture without being admitted to hospital. Conclusions: These community-wide data provide a realistic measure of surgical performance for open repair of AAA. The outcomes for elective and rupture repair for AAA compare favourably with standards reported by international centres of excellence. They also support the use of this procedure in patients over 80 years of age with rupture. This information can be used for ongoing audit purposes and as a benchmark for the introduction of new treatment modalities.     

THE COST OF ELECTIVE AND EMERGENCY REPAIR OF AAA IN PATIENTS UNDER AND OVER THE AGE OF 80

Background : As Australia’s population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained. Methods : A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN-DRG) costs. Results : Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30 000) and group D patients ($60 000). In comparison with AN-DRG calculated costs, the true costs of groups A and B were equivalent to AN-DRG costs. In the emergency groups, how- ever, there were marked discrepancies between the true cost ($61 000) and that calculated by the DRG ($25 000) in group D, with similar differences seen in group C to a lesser extent. Conclusion : Emergency repair of AAA is significantly more expensive and has a high mortality in the over-80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.     

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

Purpose:Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). Methods:The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. Results:Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8,p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively,p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age p = 0.0001), cerebrovascular disease p = 0.009), and number of days on mechanical ventilation p = 0.01) to be independent prognostic determinants of late survival in group I. Conclusions:Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified. (J Vasc Surg 1998;27:813-20.)     

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.     

Ergebnisse der konventionellen chirurgischen Therapie des abdominellen Aortenaneurysmas seit Beginn der „endovasculären Ära“

INTRODUCTION: In 1990 the new method of endovascular graft treatment of abdominal aortic aneurysms (AAA) emerged. For this reason we analyzed the results of open surgery for AAA in our department to consider the question of standard therapy. METHODS: In a retrospective study the medical data of 941 consecutive patients treated by open surgery in a single center from 1990 to 1997 (mean age 67 years, 14.5 % female, 3.2 % suprarenal AAA) were analyzed. Operations were performed electively in 778 asymptomatic patients, urgently in 104 symptomatic patients, and as emergency operations (immediately after admission) in 59 symptomatic patients (45 patients presenting with rupture). RESULTS: Mortality was 1.54 % (elective operations), 8.65 % (urgent operations), and 35.6 % (emergency operations, rupture). Morbidity was 15.9 % (elective operations), 28.8 % (urgent operations), and 66.7 % (emergency operations, rupture). Mortality was not increased in patients undergoing additional procedures of the renal, iliac, femoral, or crural arteries. CONCLUSION: Because of its low mortality and morbidity today open surgical repair remains the standard therapy for AAA.     

The cost of elective and emergency repair of AAA in patients under and over the age of 80.

BACKGROUND: As Australia's population ages, the number of elderly patients presenting for surgery of abdominal aortic aneurysms (AAA), both elective and ruptured, will increase. The aim of the present study was to compare the costs of treatment of patients with AAA, under and over the age of 80, in the elective and emergency settings in a hospital with a divisional structure in which the true costs can be accurately obtained. METHODS: A total of 40 patients were selected at random from a series of 267 patients treated with open surgery for AAA between January 1987 and December 1994, 10 in each of four groups: group A, elective repair in patients aged < 80 (171/267); group B, elective AAA repair in patients aged > 80 (25/267); group C, emergency AAA repair in patients aged < 80 (50/267); and group D, emergency AAA repair in patients aged > 80 (11/267). A retrospective analysis of the hospital costs of treatment of these patients at St George Hospital was conducted. These true costs were then compared to Australian National Diagnostic Related Group (AN-DRG) costs. RESULTS: Group A and B had no mortality. In Group C and D the mortality was 20 and 60%, respectively. The emergency treatment groups also had longer lengths of stay. A statistically significant difference in cost of AAA repair between elective and emergency groups in both age groups was seen; that is, group A cost less than group C and group B cost less than group D. Costs per survivor, however, showed a dramatic difference between the cost of group C patients ($30000) and group D patients ($60000). In comparison with AN-DRG calculated costs, the true costs of groups A and B were equivalent to AN-DRG costs. In the emergency groups, however, there were marked discrepancies between the true cost ($61000) and that calculated by the DRG ($25000) in group D, with similar differences seen in group C to a lesser extent. CONCLUSION: Emergency repair of AAA is significantly more expensive and has a high mortality in the over-80 age group. Also, there is a substantial shortfall between the true costs of treating these patients and the funds allocated for treatment in this group.     

Endovascular abdominal aortic aneurysm repair in high-risk patients: a single centre experience.

OBJECTIVES: to evaluate the role of endovascular repair (ER) of abdominal aortic aneurysm (AAA) repair in American Society for Anaesthesiology [ASA] class IV patients. PATIENTS AND METHODS: between April 1997 and March 2000, 266 consecutive patients underwent ER for AAA. There were 26 patients (10%) with ASA grade IV. The remaining 240 patients, ASA grade between I and III (ASA相似文献   

Payer status is related to differences in access and outcomes of abdominal aortic aneurysm repair in the United States

BACKGROUND: The hypothesis of this study was that differences exist among patients with private insurance compared with patients with Medicaid or no insurance, regarding access to the timely treatment of abdominal aortic aneurysms (AAAs) and the outcomes of AAA repair. METHODS: The study comprised 5363 patients aged less than 65 years (mean age, 59 years) with a diagnostic code for intact or ruptured AAA and a procedure code for AAA repair in the National Inpatient Sample for 1995 to 2000. Dependent variables included ruptured AAA, intact AAA, and in-hospital postoperative mortality rates. Independent variables included payer status, median income, race, gender, age, and comorbid disease. Risk-adjusted analyses were performed with the use of binary logistic regression. RESULTS: AAA rupture was most likely (P <.001) to affect patients with no insurance (36%) or Medicaid (18%), compared with patients with private insurance (13%). After an adjustment for case-mix had been made, data showed that patients without insurance had an increased risk of rupture compared with patients with private insurance (odds ratio, 2.3; 95% CI, 1.5-3.5; P <.001). Operative mortality rates after elective AAA repair were greater (P =.04) for patients with no insurance (2.6%) or Medicaid (2.7%), compared with patients with private insurance (1.2%). Similarly, operative mortality rates for AAA repair after rupture were greater (P =.001) in patients without insurance (45.3%) or Medicaid (31.3%), compared with patients with private insurance (26.2%). CONCLUSIONS: Uninsured patients more often seek treatment of ruptured AAAs compared with patients with private insurance. Operative mortality rates in uninsured patients are greater for elective and emergent AAA repair. These data support the tenet that payer status is associated with mortality rates after AAA repair.     

Abdominal aortic aneurysm repair in octogenarians: myth or reality?

AIM: We studied the thirty-day mortality and morbidity rate to assess the value of conventional open repair vs endovascular aortic repair (EVAR) in an elderly population presenting with a ruptured, symptomatic or asymptomatic abdominal aortic aneurysm (AAA) undergoing emergency, urgent or elective repair. METHODS: During the period from January 2004 to May 2007, 329 consecutive patients were treated for AAA in our Department. Among these, 81 (24.6%) were aged >80 years (mean age 83.6, range 80-95 years). These older patients were divided into groups according to their clinical presentation: ruptured AAA group (rAAA) - 22 cases (4 emergency EVAR, 18 emergency open repair); symptomatic non-ruptured AAA group (sAAA) - 15 cases (11 urgent EVAR, 4 urgent open repair); asymptomatic AAA group (asAAA) - 44 cases (32 elective EVAR, 12 elective open repair). The main outcome measures were 30-day mortality and 30-day morbidity rate. RESULTS: The mortality rate following open surgery vs EVAR was 66.6% vs 50% (P=NS) in the rAAA group, 25% vs 0% (P=NS) in the sAAA group, and 9% vs 3.2% (P=NS) in the asAAA group. When comparing postoperative morbidities in the octogenarians, 3 of the patients that received EVAR (6.4%) and 15 of those that received open repair (48.4%) had a severe complication (P<0.01). CONCLUSION: The introduction of EVAR has considerably changed the balance of risks and benefits for AAA treatment. Our study confirms the high mortality rate for octogenarians with rAAA and haemodynamic instability, and supports the value of an active EVAR approach for octogenarians with AAA to prevent rupture. Moreover, the introduction of endovascular techniques as part of an overall treatment algorithm for ruptured AAAs appears to be potentially associated with improved outcomes in terms of mortality and morbidity as compared to open surgical repairs alone.     

The systemic inflammatory response syndrome,organ failure,and mortality after abdominal aortic aneurysm repair

BACKGROUND: Organ failure is a major cause of morbidity and mortality after abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the relationships between the systemic inflammatory response syndrome (SIRS), organ failure, and mortality after AAA repair and to determine whether the clinical monitoring of SIRS was a useful adjunct to clinical method. METHODS: One hundred consecutive patients undergoing open AAA repair were prospectively studied. Patients were divided into three groups: those undergoing elective AAA repair, those with symptomatic but nonruptured AAA, and those with ruptured AAA. The presence of SIRS and organ failure was recorded on a daily basis for each patient until discharge or death. RESULTS: Most patients had SIRS develop during the postoperative period: 89% of the elective group, 92% of the emergency nonruptured (urgent) group, and 100% of the ruptured group. Multiorgan failure occurred in 3.8% of the elective group, 38% of the urgent group, and 64% of the ruptured AAA group. After ruptured AAA repair, the concurrent absence of both SIRS and any organ failure for 48 hours had a sensitivity of 93% and a specificity of 91% as a predictive indicator of subsequent survival to hospital discharge. Patients in whom multiorgan failure developed after ruptured AAA repair had a significantly higher mortality rate (69%) than those who did not (0%; P =.001; 95% CI for the difference, 30.2% to 85.8%). CONCLUSION: The differences in the incidence rate of multiorgan failure between the patient groups compared with the high incidence rate of SIRS in all patient groups supports the two-hit hypothesis of multiorgan failure. The presence of multiorgan failure after ruptured AAA repair is associated with poor outcome. The absence of SIRS and organ failure in these patients is a good predictive indicator of survival.     

Late Reoperations in Patients with Aortic Dissection

Aortic dissection is an evolving process that may require one or several reoperations after the initial emergency repair. From January 1977 to September 1993, 148 patients undement emergency surgery for type A acute aortic dissection. The replacement of the ascending aorta was extended to include the transverse arch in 43 patients (29%). One hundred fifteen patients (78%) survived surgery. During the same period, 37 patients required reoperation once (28), twice (7), or three times (2), for a total of 48 reoperations. Wenty-one patients had undergone initial repair in our instltution; 16 patients had been operated on elsewhere. Reoperation was indicated for: aortic valve disease (4); a new dissecting process (7); threatening aneurysmal evolution of a persisting dissection (34); or false aneurysm (3). The redo procedure involved: the aortic root and/or ascending aorta in 12 cases (group I); the ascending aorta and the transverse arch in 6 cases (group 11); the transverse arch alone in 8 cases (group III); the transverse arch and descending aorta, or the descending aorta alone in 11 cams (group IV); and the thoracoabdominal aorta in 11 cases (group V). Risk factors for reoperation were analyzed in the 115 survivors initially operated on at our institution. Seven of 20 Marfan patients (35%) versus 12 of 95 non-Marfan patients (12.6%) required reoperation (p < 0.02). None of the 31 patients surviving arch replacement at initial repair required a reoperation, versus 21 of 84 (25%) patients surviving replacement limited to the ascending aorta (p < 0.01). The overall mortality rate of reoperation was 18.9% (7/37), with a risk of 14.5% (7/48) at each procedure (group I 8.3%, group II 0%, group III 20%, group IV 18%, group V 27%). Hospital mortality was influenced by whether the operation was done as an emergency (5/10) (p < 0.005), and whether thoracoabdominal replacement was required (3/11) (p < 0.03). The late survival rate after reoperation is 67.1%± 17.6% at 1 year, and 57%± 19.6% at 5 years (Kaplan-Meier CI 95%). The late survival rate, after initial repair, of reoperated patients is 89.6%± 11.0% at 1 year, 79.3%± 14.7% at 5 years, 53.9%± 18.1% at 10 years, and 35.9%± 21.8% at 12 years. In conclusion, elective reoperation should be considered before the occurrence of complications, especially in patients with Marfan syndrome. It entails a relatively low risk, except in the case of thoracoabdominai replacement, and allows satisfactory long-term survival. In our experience, resection of the entry site at initial emergency operation, when it is located on or extends to the transverse arch, reduces the incidence of reoperation. (J Card Surg 1994;9:740–747)     

Rupture of abdominal aortic aneurysms: A concurrent comparison of outcome of those occurring after endoluminal repair versus those occurring de novo.

AIM: to compare the outcome of patients whose abdominal aortic aneurysm (AAA) ruptured following endoluminal repair with those whose AAA ruptured prior to treatment. PATIENTS: over a 4-year period 434 patients underwent treatment for AAA with conventional open (n=253) and endoluminal repair (n=181). Of those having open repair, 216 patients had elective operations while 41 had operations for ruptured AAA. Four patients with ruptured AAA had undergone endoluminal repair previously (Group I) while the remaining 37 patients ruptured de novo (Group II). The patients in both groups were similar in age and sex but differed clinically. All four patients in Group I had major medical co-morbidities versus 56% in Group II (p<0.05). All patients in group I had a known endoleak following endoluminal repair. All patients underwent open repair. RESULTS: the proportion of patients presenting with hypotension in Group I (1/4) was significantly less than in Group II (30/37). The difference in 30-day mortality for Group I (0%) compared with that for Group II (43%) was significant. The four patients in Group I remain alive and well at follow-up 22 months after operation. The outcome for Group I was better than Group II despite the higher incidence of medical co-morbidities. CONCLUSION: endoluminal AAA repair complicated by a persistent endoleak does not protect from rupture, which may not be accompanied by such major haemodynamic changes and high mortality as rupture de novo. Further long-term results in more patients are required to confirm this intermediate level of protection.     

Elective Versus Ruptured Abdominal Aortic Aneurysm Repair: A 1-Year Cost-Effectiveness Analysis

Abdominal aortic aneurysm (AAA) is a life-threatening condition with an overall mortality of 80%. It predominantly affects men 65-74 years of age and is caused by focal distension of the main blood vessel in the abdomen. Most patients go undetected until their aneurysm ruptures. Controversy surrounds the most appropriate form of screening for AAA. Currently, screening is only carried out selectively in patients with peripheral vascular disease. Some patients have their AAA detected incidentally, whilst ultrasound examination of the abdomen is carried out for other indications. These patients have the opportunity to undergo surveillance or elective surgery. The mortality rate of emergency surgical intervention following rupture (50%) is far worse in comparison to that of patients undergoing planned intervention under specialist vascular surgeons (5%). Despite improvements in outcomes from elective intervention for AAA as a result of specialisation, the overall mortality from this condition remains very high (80%) as the commonest presentation of an AAA is rupture. Screening all men aged 65-74 years is considered too costly in the current economic climate. However the cost difference between elective repair and emergency repair of AAA must be considered given that the outcome from elective AAA repair is far superior to that following ruptured AAA repair. Our objective was to retrospectively collect costs and outcomes of elective and emergency AAA repair in order to carry out a cost-effectiveness analysis. Four multiprofessional teams in accident and emergency, operation theatres, intensive care, and surgical wards at the Kent and Canterbury Hospital were selected from health-care professionals including doctors, managers, nurses, and clerical staff with the purpose of obtaining costs. Detailed cost data collection sheets were prepared to calculate costs, which included staff costs, consumables including drugs, intravenous fluids, equipment, investigations, laundry, catering, and stationery. An inventory of costs per item was obtained, and the total cost was calculated from the number of items used. Outcomes were measured in terms of survival. The total costs of emergency AAA repair were ￡96,700.69, with a cost per life saved of ￡24,175.17. The total cost of elective AAA repair was ￡76,583.22, with a cost per life saved of ￡5,470.23. Emergency intervention for AAA was found to cost five times more than a planned intervention per life saved per year.     

INFRARENAL AORTIC ANEURYSM SURGERY IN A RURAL SURGICAL SERVICE: RISK FACTORS FOR MORTALITY

Background : An audit of both the emergency and elective abdominal aortic surgery that was performed in a rural surgical service, was carried out. Methods : Retrospective data analysis was performed on 41 patients who were treated for abdominal aortic aneurysms (AAA) during an 8-year period from 1989 to 1996. Postoperative outcomes were analysed with respect to patient age, mode of presentation (elective or emergency), transfusion requirements and pre-existing cardiac and respiratory disease. Univariate analysis was performed using Fisher's exact test, and the odds ratio for adverse outcome was calculated. Results : A postoperative mortality rate of 5.8% in elective repairs and 68% in cases of rupture was noted. Pre-existing respiratory disease, transfusion requirements of more than six units and presentation with retroperitoneal leak or rupture correlated with postoperative mortality, while age and pre-existing cardiac disease were shown not to be predictive of adverse outcome following surgery. Conclusions : An overall improvement in operative outcomes in the institution (Wimmera Base Hospital) that was audited would be affected by earlier referral for elective repair in selected patients. Like others, the authors believe that age on its own is not a contraindication to elective AAA repair.     

Surgical Repair of Juxtarenal Abdominal Aortic Aneurysms and safety of Suprarenal Aortic Clamping

Background

Juxtarenal abdominal aortic aneurysm (AAA) comprises 15–20% of all AAAs and often requires open surgical repair (OSR) due to anatomical limitations associated with endovascular aneurysm repair (EVAR), particularly in the case of hostile proximal necks. This study aimed to evaluate short- and long-term outcomes of suprarenal clamping during OSR of juxtarenal AAAs and compare the outcomes of this technique with those of infrarenal clamping for AAAs.

Methods

Between January 1 2014, and December 31 2016, 289 consecutive patients aged ≥40 years underwent primary repair for infrarenal AAAs, including 141 OSRs and 148 EVARs. Of the 141 patients, 20 were excluded and totally, 121 patients were included.

Results

All patients had fusiform-type AAAs and were divided into infrarenal (N = 98) or suprarenal (N=23) clamp groups. The mean follow-up period was 51.4 months (95% CI: 48.6–54.2). Mean survival time was 51.4 months (95% CI: 48.6–54.2). Thirty-day mortality was 0.8%, and there was no significant difference between two groups (P > .999). Renal complication in infrarenal clamp group was 4.1% and suprarenal clamp group was 4.3% (P > .999). Old age (HR: 1.084; 95% CI: 1.025–1.147; P=.005) and high ASA score (HR: 2.361; 95% CI: 1.225–4.553; P = .010) were substantially associated with in-hospital complications.

Conclusions

Although endovascular procedures for repairing juxtarenal AAAs, such as fenestrated EVAR, have been developed, surgical repair is the standard treatment for juxtarenal AAAs. Morbidity and mortality due to open surgery were not higher in the juxtarenal AAA group than in the infrarenal AAA group. Therefore, need for suprarenal clamp should not preclude OSR and also there is continued need for training in surgical exposure of juxtarenal AAA and OSR.

     

Descending Thoracic and Thoracoabdominal Aortic Aneurysm Repair: 15-Year Results Using a Uniform Approach

This review presents the results of surgical repair of descending thoracic (DT) and thoracoabdominal aortic (TAA) aneurysms, using spinal drainage (SD) distal aortic perfusion (DAP), and other adjuncts intended to reduce complications. Records of patients undergoing repair of DT and TAA between 1986 and 2002 were reviewed. Elective operations were performed using single lung ventilation, invasive monitoring, SD, modest anticoagulation, permissive hypothermia (33°F), liberal use of transaortic endarterectomy, and complete repair. Intercostal arteries were reimplanted when possible and DAP was used in DT and TAA types I, II, and III repair. Exceptions to this approach were noted. Some of these adjuncts were used in emergency cases. Actuarial survival was calculated. Fifty consecutive patients with DT (3) or TAA (47), type I (4), type II (16), type III (18), or type IV (9), aneurysms received elective (36) or emergency (14) repair between 1986 and 2002. Mortality was 2/36 (5.5%) in the elective group. In the emergency group, there were 2 intraoperative deaths and mortality was 4/14 (28.5%, p < 0.07). Overall survivor morbidity was 6/34 (17.6%) in elective and 7/10 (70%, p < 0.02) in emergency cases. Paraplegia occurred in one patient in the elective group (2.7%) with dissecting type II TAA aneurysm in whom the intercostal patch was sacrificed. Two of 12 initial survivors developed paraplegia in the emergency group (16.7%); one had SD but neither had DAP or intercostal reimplantation. Serious complications were associated with avoidable deviations from the approach. Five and 10-year survival for the entire series was 64.8% and 46.4%, respectively. These results parallel those in contemporary reports from centers where repair of descending and thoracoabdominal aortic aneurysm is frequently performed. Good long-term results can be achieved using spinal drainage and distal aortic perfusion, combined with other adjuncts as a means of reducing complications. When possible, the same approach should be used in emergency cases.Presented at the 17th Annual Meeting of the Western Vascular Society, Newport Beach, CA, September 22-25, 2002.