Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative?

Aortic aneurysm thrombosis with extra-anatomic bypass has been proposed for persons with infrarenal aortic aneurysms who are "too debilitated" to undergo standard aortic reconstruction. Thirteen patients (mean age, 75 years) were selected between January 1980 and June 1984 for axillobifemoral bypass with bilateral iliac artery occlusion to manage their infrarenal aortic aneurysms (mean size, 6.3 cm; range, 4.9 to 7.5 cm). Preoperative risk factors were cardiac (angina, compensated congestive heart failure, and significant preoperative arrhythmias), 100% of patients; pulmonary (symptomatic chronic obstructive pulmonary disease with a 1-second forced expiratory volume less than 50% of the predicted value), 46% of patients; renal (creatinine value greater than or equal to 2.0 mg/dl or creatinine clearance less than 20 ml/min), 46% of patients; or nutritional (albumin less than or equal to 3.5 gm/dl or body weight less than 90% of ideal), 46%. Ninety-two percent of the patients had two risk factors whereas 46% had three or more risk factors. The operative mortality rate was 31%; three patients died of multisystem organ failure and another died of thrombin-induced consumptive coagulopathy and hemorrhage. (Our operative mortality rate for conventional graft replacement of abdominal aortic aneurysms is less than 3%.) Morbidity in persons surviving at least 1 month included thrombosis of the extra-anatomic bypass graft requiring thrombectomy (three patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and bilateral above-knee amputations (one patient). Thrombosis of the aneurysm was not achieved in two patients despite use of fluoroscopically controlled embolization of runoff vessels.(ABSTRACT TRUNCATED AT 250 WORDS)     

Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair

OBJECTIVE: Renal dysfunction is among the most commonly occurring morbidities following descending thoracic and thoracoabdominal aortic repair. We hypothesized that myoglobin nephrotoxicity might arise from leg ischemia caused by femoral artery cannulation, which is required for distal aortic perfusion. Lacking complete historical laboratory data on myoglobinemia, we studied somatosensory evoked potential (SSEP) changes in the leg (a functional marker of leg ischemia), as a surrogate predictor of acute postoperative renal failure. METHODS: Intraoperative leg SSEP function and preoperative glomerular filtration rate (GFR - an essential covariate) were available for 299 patients. Change in SSEP was defined as 10% increase in latency or 50% decrease in amplitude. Postoperative renal dysfunction was 1mg/dl/day increase in creatinine for 2 days, clinical diagnosis of ARF or need for dialysis postoperatively. RESULTS: Change in SSEP in the cannulated leg occurred in 108/299 (36%) of cases intraoperatively. All recovered normal SSEP function at decannulation. Patients with SSEP changes had 41/108 (38%) postoperative renal failure compared to 49/191 (26%) without (odds ratio 1.8, p<0.03). Modeled with GFR, aneurysm extent, and chronic obstructive pulmonary disease (COPD), SSEP changes had an adjusted odds ratio of 1.9, p<0.03. Pre-op GFR was also a highly significant predictor of postoperative renal failure (OR 0.98/ml; p<0.0001). CONCLUSION: This is the first study to show a relationship between intraoperative leg ischemia and postoperative renal failure. It provides epidemiological evidence that the ischemic leg may be an important contributor to rhabdomyolysis-like renal morbidity after thoracoabdominal aortic surgery.     

Analysis of risk factors for myocardial infarction and cardiac mortality after major vascular surgery

BACKGROUND: Patients undergoing vascular surgical procedures are at high risk for perioperative myocardial infarction (PMI). This study was undertaken to identify predictors of PMI and in-hospital death in major vascular surgical patients. METHODS: From the Vascular Surgery Registry (6,948 operations from January 1989 through June 1997) the authors identified 107 patients in whom PMI developed during the same hospital stay. Case-control patients (patients without PMI) were matched at a 1x:x1 ratio with index cases according to the type of surgery, gender, patient age, and year of surgery. The authors analyzed data regarding preoperative cardiac disease and surgical and anesthetic factors to study association with PMI and cardiac death. RESULTS: By using univariable analysis the authors identified the following predictors of PMI: valvular disease (P = 0.007), previous congestive heart failure (P = 0.04), emergency surgery (P = 0.02), general anesthesia (P = 0.03), preoperative history of coronary artery disease (P = 0.001), preoperative treatment with beta-blockers (P = 0.003), lower preoperative (P = 0.03) and postoperative (P = 0.002) hemoglobin concentrations, increased bleeding rate (as assessed from increased cell salvage; P = 0.025), and lower ejection fraction (P = 0.02). Of the 107 patients with PMI, 20.6% died of cardiac cause during the same hospital stay. The following factors increased the odds ratios for cardiac death: age (P = 0.001), recent congestive heart failure (P = 0.01), type of surgery (P = 0.04), emergency surgery (P = 0.02), lower intraoperative diastolic blood pressure (P = 0.001), new intraoperative ST-T changes (P = 0.01), and increased intraoperative use of blood (P = 0.005). Patients who underwent coronary artery bypass grafting, even more than 12 months before index surgery, had a 79% reduction in risk of death if they had PMI (P = 0.01). Multivariable analysis revealed preoperative definitive diagnosis of coronary artery disease (P = 0.001) and significant valvular disease (P = 0.03) were associated with increased risk of PMI. Congestive heart failure less than 1 yr before index vascular surgery (P = 0. 0002) and increased intraoperative use of blood (P = 0.007) were associated with cardiac death. The history of coronary artery bypass grafting reduced the risk of cardiac death (P = 0.04) in patients with PMI. CONCLUSIONS: The in-hospital cardiac mortality rate is high for patients who undergo vascular surgery and experience clinically significant PMI. Stress of surgery (increased intraoperative bleeding and aortic, peripheral vascular, and emergency surgery), poor preoperative cardiac functional status (congestive heart failure, lower ejection fraction, diagnosis of coronary artery disease), and preoperative history of coronary artery bypass grafting are the factors that determine perioperative cardiac morbidity and mortality rates.     

Type III and IV thoracoabdominal aortic aneurysm repair: results of a trifurcated/two-graft technique

OBJECTIVE: Thoracoabdominal aortic aneurysm (TAA) repair continues to present a surgical challenge because of obligate intraoperative visceral, renal, and spinal cord ischemia. A novel two-graft technique with a trifurcated graft for sequential visceral revascularization followed by a second graft for inline aneurysm reconstruction minimizes this endorgan ischemia. We herein present our updated experience with this approach for repair of type III and type IV TAAs. METHODS: Thirty-two patients (mean age, 70 years) underwent nonemergent repair of extent III (12 patients) and IV (20 patients) TAAs between March 1996 and October 2001. Repair was achieved with a trifurcated graft for uninvolved descending thoracic aorta-to-celiac/superior mesenteric/renal artery bypass with an additional tube or bifurcated graft for inline aneurysm reconstruction. Adjunctive cerebrospinal fluid drainage was used in the last six patients. Six patients had a solitary kidney, and six had previous infrarenal abdominal aortic aneurysm repair. RESULTS: Mean visceral ischemia times were as follows: celiac artery, 12 minutes; superior mesenteric artery, 12 minutes; left renal artery, 10 minutes; and right renal artery, 33 minutes. The creatinine level at discharge was not significantly different from the preoperative level (1.7 versus 1.3; P =.10). Two patients (6.3%) had transient renal failure; however, the permanent renal failure rate was zero. No patient with a solitary kidney had renal dysfunction develop. Paraplegia occurred in two patients (6.3%), one of whom had prior abdominal aortic aneurysm repair and neither of whom had cerebrospinal fluid drainage. Prolonged ventilatory support (>2 days) was necessitated in six patients (19%). The perioperative mortality rate was 6.3% (two patients). The mean follow-up period was 22 months, with a life-table survival rate of 76% at 36 months. Maintenance of preoperative functional status was achieved in 92% (23/25 patients) of long-term survivors. CONCLUSION: Type III and IVTAA repair with a trifurcated graft for sequential visceral revascularization followed by a second graft for inline aneurysm reconstruction provides short visceral, renal, and spinal cord ischemia times and leads to low rates of endorgan ischemic damage and paraplegia. Preoperative functional status is maintained in most survivors. These results compare favorably with other methods of TAA repair, and this technique presents a useful option in thoracoabdominal aortic reconstruction.     

Combined cardiac operation and carotid endarterectomy during aortic cross-clamping.

We present a surgical technique that we believe provides superior cerebral protection for simultaneous correction of carotid and cardiac pathology with low operative mortality and stroke rate. Our study population consists of 23 consecutive patients undergoing cardiac operation between August 1989 and April 1991 who also had associated critical (greater than 85%) carotid artery stenosis. Using 20 degrees C systemic hypothermia for cerebral protection, we performed simultaneous correction of both lesions during the aortic cross-clamp period, using continuous retrograde blood cardioplegia for myocardial protection. Mean patient age was 69.4 years; 83% were 65 years or older. Eighty-seven percent had angina, 35% had recent myocardial infarctions (within 30 days), and 52% had congestive heart failure. Asymptomatic bruit was found in 39%, and 61% had previous strokes, neurologic symptoms, or both. All had 85% or greater luminal narrowing on cerebral angiography, with 65% having severe or critical contralateral disease as well. Sixty-one percent had associated other vascular pathology, including peripheral vascular occlusive disease, renal artery stenosis, or abdominal aortic aneurysm. There were no postoperative strokes or neurologic events. One early vein graft occlusion resulted in postoperative myocardial infarction and subsequent death (4.3%).     

Combined coronary artery bypass grafting and bilateral renal revascularization for unstable angina and impeding renal failure

The purpose of our article is to describe a patient with severe hypertension and moderate renal insufficiency, unstable angina, and a 6 cm abdominal aortic aneurysm. A previous aortogram had demonstrated severe bilateral renal artery stenoses. Cardiac catheterization demonstrated severe coronary disease. After cardiac catheterization acute renal failure and pulmonary edema requiring dialysis developed in the patient. In addition, evidence of impending myocardial necrosis developed. Because of the critical nature of the myocardial and renal ischemia it was necessary to perform combined myocardial and renal revascularization rather than staged procedures. At the time of coronary artery bypass grafting, a vein graft was anastomosed to the right coronary artery vein graft and tunneled through the diaphragm into the abdomen to revascularize both renal arteries. After surgery renal function gradually improved, and no further dialysis was required. The abdominal aortic aneurysm was repaired at a subsequent operation. At 2-year follow-up all grafts remained patent. The serum creatinine is 1.2 mg/dl. Although most patients with combined coronary artery disease and renal artery disease can be treated with staged operations, our procedure may be of value in patients in whom staged procedure are not feasible and in whom the infrarenal aorta is severely diseased or aneurysmal.     

Comparison of cardiac morbidity between aortic and infrainguinal operations. Study of Perioperative Ischemia (SPI) Research Group.

We prospectively compared the differences in perioperative cardiac ischemic events in 140 patients undergoing major abdominal (n = 53) versus infrainguinal (n = 87) vascular operations. Preoperative dipyridamole thallium cardiac scintigraphy was performed in a subset of 38 of these patients, with treating physicians blinded to the test results. Myocardial ischemia was measured during operation with use of continuous 12-lead electrocardiography (ECG) and transesophageal echocardiography. Continuous two-lead ambulatory ECG (Holter monitoring) was performed before, during, and after operation for 4 days. Outcome events were cardiac death, nonfatal myocardial infarction, unstable angina, ventricular tachycardia, and congestive heart failure. Results of the study indicated that most demographic variables, such as age, hypertension, cigarette smoking, serum cholesterol, were comparable between patients having aortic or infrainguinal arterial operations. However, in the infrainguinal group more patients had diabetes, second vascular operations, angina pectoris, heart failure, dysrhythmias, and used digitalis. Abnormalities in preoperative Holter monitoring, ECGs, and thallium scan abnormalities were equivalent between groups. During operation, whereas Holter and ECG abnormalities were comparable, more patients undergoing aortic procedures suffered ischemia as determined by transesophageal echocardiography (26% vs 10%, p = 0.019). After operation there were 21 (24%) outcome events in patients having infrainguinal bypasses compared with 15 (28%) patients having aortic procedures (p = NS). Ischemia by Holter monitoring (n = 133) occurred after operation in 46 (57%) patients having infrainguinal operations compared with 16 (31%) patients having aortic reconstructions (p = 0.005). Because preoperative cardiac disease and adverse cardiac outcomes occurred with similar or even greater frequency in both groups of patients, we conclude that the risk for postoperative cardiac ischemic events in lower extremity vascular operations is at least as great as for aortic operations.     

Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer.

The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.     

The role of intraaortic balloon counterpulsation in patients undergoing cardiac operations.

Intraaortic balloon counterpulsation (IABC) was used to assist 60 patients undergoing cardiac operations for reasons of acute left ventricular failure (18 patients) or electively for indications in high-risk coronary and valvular heart disease (42 patients). Nine of 18 patients achieved hemodynamic stability when treated for acute perioperative or postoperative cardiogenic shock. Four of these died from problems unassociated with postoperative left ventricular failure and 5 were long-term survivors, indicating a potential salvage of 50%. In 42 high-risk patients, IABC was used electively to control preinfarction angina before operation (21 patients) and prophylactically to prevent postoperative low-output failure in another 21 patients with severe coronary and valvular heart disease. Thirty-nine, or 93%, of these patients survived. There were no deaths in the preinfarction angina group, 1 death in the group with coronary disease and ejection fractions less than 30%, and 2 deaths in those with valvular heart disease and congestive failure. Seven patients developed thrombotic or ischemic complications, but no permanent damage resulted. IABC is an important form of assistance for any patient with preoperative, intraoperative, or postoperative left ventricular failure and adds safety and hemodynamic stability for the high-risk patient with preinfarction angina or poor ventricular function.     

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??Non-occlusive mesenteric ischemia: diagnosis and management ZHANG Jian. Department of Vascular Surgery, First Affiliated Hospital of China Medical University, Shenyang 110001, China
Abstract Non-occlusive mesenteric ischemia (NOMI) is a rarely occurred disease and compromises all forms of mesenteric ischemia with patent mesenteric arteries. It generally affects patients over 50 years of age suffering from myocardial infarction, congestive heart failure, aortic insufficiency, renal or hepatic disease and patients following cardiac surgery. Acute abdominal pain may be the only early presenting symptom of mesenteric ischemia. Non-invasive imaging modalities, such as CT, MRI, and ultrasound, are able to evaluate the aorta and the origins of splanchnic arteries. Despite the technical evolution of those methods, selective angiography of mesenteric arteries is still the gold standard in diagnosing peripheral splanchnic vessel disease. In early NOMI, as opposed to occlusive disease, there is no surgical therapy.     

Conventional repair of abdominal aortic aneurysm in the high-risk patient: a plea for abandonment of nonresective treatment

Recent reports in the literature have promulgated nonresective treatment of abdominal aortic aneurysm as a safer procedure than conventional aneurysmectomy with graft replacement in high-risk patients. This review of 106 high-risk patients who underwent conventional aneurysm repair between 1980 and 1985 was undertaken to compare the relative risks, perioperative morbidity, and operative mortality of these patients to that reported for patients treated by nonresective therapy. Excluded were those patients who had rupture initially or underwent a concomitant renovascular procedure. Patients were considered to be at high risk if they met one or more of the following criteria: age equal to or greater than 85 years; receiving oxygen at home, PO2 less than 50 torr, or forced midexpiratory flow less than 25% of predicted; serum creatinine equal to or greater than 3 mg/dl; biopsy-proven cirrhosis with ascites; retroperitoneal fibrosis; or New York Heart Association functional class III-IV angina, left ventricular ejection fraction less than 30%, recent congestive heart failure, complex ventricular ectopy, large left ventricular aneurysm, severe valvular disease, recurrent congestive heart failure or angina after coronary artery bypass grafting, or severe unreconstructed coronary artery disease confirmed by angiography. The mortality rate for conventional aneurysm repair in high-risk patients was 5.7%, compared with a reported 7% mortality rate for nonresective therapy. In those patients with severe cardiac dysfunction, intraoperative pharmacologic manipulation and the selective use of intra-aortic balloon counterpulsation appeared helpful in achieving survival.(ABSTRACT TRUNCATED AT 250 WORDS)     

The impact of coronary artery disease on carotid endarterectomy.

In a series of 531 CENDX, preoperative cardiac risk was categorized by clinical criteria. Patients with CAD (history of previous MI, angina, congestive heart failure, and/or electrocardiographic evidence of CAD were selected for more invasive studies based on clinical criteria. The overall incidence of postoperative myocardial infarction was 2.5% and increased slightly to 4% in patients with symptomatic cardiac disease. More importantly, the overall mortality was 0.9% and only 3 of 13 (23%) postoperative myocardial infarctions were fatal. Neurologic complications averaged 1.4% and approximately 70% were related to preceding cardiac events. Twenty-two patients or 4% of the entire series underwent carotid endarterectomy combined with coronary artery bypass graft and this approach was associated with one death and one stroke. Therefore, we conclude that a selective approach to coronary arteriography and subsequent CABG based on clinical criteria is associated with an acceptably low mortality and cardiac morbidity.     

Myocardial damage in high-risk patients undergoing elective endovascular or open infrarenal abdominal aortic aneurysm repair.

OBJECTIVE: Dobutamine stress echocardiography (DSE) provides an objective assessment of the presence and extent of coronary artery disease. Therefore we compared cardiac outcome in patients at high-cardiac risk undergoing open or endovascular repair of infrarenal AAA using preoperative DSE results. METHODS: Consecutive patients with >or=3 cardiac risk factors (age >70 years, angina pectoris, myocardial infarction, heart failure, stroke, renal failure, and diabetes mellitus) undergoing infrarenal AAA repair were reviewed retrospectively. All underwent cardiac stress testing using DSE. Postoperatively data on troponin release and ECG were collected on day 1, 3, 7, before discharge, and on day 30. The main outcome measures were perioperative myocardial damage and myocardial infarction or cardiovascular death. RESULTS: All 77 patients (39 endovascular, 38 open) had a history of cardiac disease. The number and type of cardiac risk factors were similar in both groups. Also DSE results were similar: 55 vs 56%, 24 vs 28%, and 21 vs 18% had no, limited, or extensive stress induced myocardial ischemia respectively. The incidence of perioperative myocardial damage (47% vs 13%, p=0.001) and the combination of myocardial infarction or cardiovascular death (13% vs 0%, p=0.02) was significantly lower in patients receiving endovascular repair. CONCLUSION: In patients with similar high cardiac risk, endovascular repair of infrarenal aortic aneurysms is associated with a reduced incidence of perioperative myocardial damage.     

Aortic valve replacement in the elderly. Risk factors and long-term results.

OBJECTIVE: The current study was undertaken to determine long-term results of aortic valve replacement (AVR) in the elderly, to ascertain predictors of poor outcome, and to assess quality of life. SUMMARY BACKGROUND DATA: Aortic valve replacement is the procedure of choice for elderly patients with aortic valve disease. The number of patients aged 70 and older requiring AVR continues to increase. However, controversy exists as to whether surgery devoted to this subset reflect a cost-effective approach to attaining a meaningful quality of life. METHODS: This study reviews data on 247 patients aged 70 to 89 years who underwent isolated AVR between 1980 and 1995; there were 126 men (51%) and 121 women (49%). Follow-up was 97% complete (239/247 patients) for a total of 974.9 patient-years. Mean age was 76.2 +/- 4.8 years. Operative mortality and actuarial survival were determined. Patient age, gender, symptoms, associated diseases, prior conditions, New York Health Association class congestive heart failure, native valve disease, prosthetic valve type, preoperative catheterization data, and early postoperative conditions were analyzed as possible predictors of outcome. Functional recovery was evaluated using the SF-36 quality assessment tool. RESULTS: Operative mortality was 6.1% (15/247). Multivariate logistic regression showed that poor left ventricular function and preoperative pacemaker insertion were independent predictors of early mortality. After surgery, infection was predictive of early mortality. Overall actuarial survival at 1, 5, and 10 years was 89.5 +/- 2% (198 patients at risk), 69.3 +/- 3.4% (89 patients at risk), and 41.2 +/- 6% (13 patients at risk), respectively. Cox proportional hazards model showed that chronic obstructive pulmonary disease and urgency of operation were independent predictors of poor long-term survival. Postoperative renal failure also was predictive of poor outcome. Using the SF-36 quality assessment tool, elderly patients who underwent AVR scored comparably to their age-matched population norms in seven of eight dimensions of overall health. The exception is mental health. CONCLUSIONS: Aortic valve replacement in the elderly can be performed with acceptable mortality. Significant preoperative risk factors for early mortality include poor left ventricular function and preoperative pacemaker insertion. Predictors of late mortality include chronic obstructive pulmonary disease and urgency of operation. These results stress the importance of operating on the elderly with aortic valve disease; both long-term survival and functional recovery are excellent.     

Gastrointestinal complications in patients undergoing heart operation: an analysis of 8709 consecutive cardiac surgical patients

INTRODUCTION: Gastrointestinal (GI) complications following heart operation may be life-threatening. Systematic analysis of risk factors to allow early identification of patients at risk for GI complication may lead to the development of strategies to mitigate this complication as well as to optimize management after its occurrence. METHODS: Of 8709 consecutive patients undergoing heart operation during 7 years (1997-2003), 46 (0.53%) developed GI complications requiring surgical consultation. Preoperative, intraoperative, and postoperative predictors of complication and death were identified and compared with a control group. RESULTS: Significant (P < 0.05) preoperative predictors of complication were prior cerebrovascular accident (CVA), chronic obstructive pulmonary disease (COPD), type II heparin-induced thrombocytopenia, atrial fibrillation, prior myocardial infarction, renal insufficiency, hypertension, and need for intra-aortic balloon counter-pulsation. The most frequent serious GI complication was mesenteric ischemia, which developed in 31 (67%) patients. Twenty-two (71%) of these patients were explored, and 14 (64%) died within 2 days of heart operation. Of the 9 patients with mesenteric ischemia who were not explored, 7 (78%) died within 3 days of heart operation. Other complications included diverticulitis (5), pancreatitis (4), peptic ulcer disease (4), and cholecystitis (2). The mortality rate in this group of other diagnoses was lower (40%), and death occurred later (32 days) after heart operation (P = 0.03 compared with mesenteric ischemia). Predictors of death from GI complication included New York Heart Association (NYHA) class III and IV heart failure, smoking, chronic obstructive pulmonary disease, history of syncope, aspartate aminotransferase (AST) >600 U/L, direct bilirubin >2.4 mg/dL, pH < 7.30, and the need for >2 pressors. CONCLUSIONS: The most common catastrophic GI complication after cardiac surgery is mesenteric ischemia, which is frequently fatal. This complication may be a result of atheroembolization, heparin-induced thrombocytopenia, or hypoperfusion. Techniques to reduce the occurrence of and/or preemptively diagnosis postcardiotomy mesenteric ischemia are necessary to decrease its associated mortality.     

Cardiac risk stratification in patients undergoing endoluminal graft repair of abdominal aortic aneurysm: a single-institution experience with 365 patients

OBJECTIVE: Patients undergoing abdominal aortic aneurysm repair have a high incidence of coexisting cardiac disease. The traditional cardiac risk stratification for open abdominal aortic aneurysm surgery may not apply to patients undergoing endoluminal graft exclusion. The purpose of this study was to examine predictive risk factors for perioperative cardiac events. METHODS: As part of multiple prospective endograft trials approved by the US Food and Drug Administration, data for 365 patients who underwent endoluminal graft repair from 1996 to 2001 were collected. Variables included for analysis were age and sex; history of smoking; presence of hypertension, diabetes mellitus, or renal insufficiency; Eagle clinical cardiac risk factors; American Society of Anesthesiologists index; type of anesthesia administered; estimated blood loss; preoperative hemoglobin level; preoperative use of beta-blocker therapy; duration of surgery; need for iliac artery conduit; and concomitant other vascular procedures. Univariate and multivariate logistic regression analysis were used to determine which variables were predictive of an adverse perioperative cardiac event, eg, Q wave and non-Q wave myocardial infarction (MI), congestive heart failure (CHF), severe arrhythmia, and unstable angina. RESULTS: The study cohort included 322 men and 43 women (mean age, 74.2 years). Fifty-two (14.2%) postoperative cardiac events occurred: severe dysrhythmia in 15 patients (4.1%), MI in 14 patients (3.8%), non-Q wave MI in 8 patients (2.2%), CHF in 8 patients (2.2%), and unstable angina in 7 patients (1.9%). Univariate analysis demonstrated that age 70 years or older (P =.034), history of MI (P =.018), angina (P =.004), history of CHF (P <.001), two or more Eagle risk factors (P <.001), and lack of use of preoperative beta-blocker therapy (P =.005) were predictors of perioperative cardiac events. Multivariate analysis identified only age 70 years or older (P =.026), history of MI (P =.024) or CHF (P =.001), and lack of use of preoperative beta-blocker therapy (P =.007) as independent risk factors for an adverse cardiac event. CONCLUSIONS: Age 70 years or older, history of MI or CHF, and lack of use of preoperative beta-blocker therapy are independent risk factors for perioperative cardiac events in patients undergoing endoluminal graft repair.     

Application of clinically valid cardiac risk factors to aortic aneurysm surgery

The operative outcome of 97 consecutive nonruptured infrarenal aortic aneurysms is analyzed regarding clinically identifiable cardiac risk factors. Clinically evident coronary artery disease was present in 45 patients (46%). Operative mortality was 4% (four cardiac deaths) with an additional 4% nonfatal postoperative myocardial infarction rate. All cardiac complications occurred in patients with clinically evident coronary artery disease, while no mortality occurred in 52 patients lacking a preoperative history of myocardial infarction, congestive heart failure, or angina. Preoperative risk factors having a significant negative influence on outcome include a history of prior myocardial infarction and compensated congestive heart failure. Few patients with aneurysms who have clinical evidence of coronary artery disease are indicated for coronary arteriography and bypass prior to aneurysm repair. Furthermore, indications for invasive cardiac screening of the patient with an aneurysm who lacks cardiac symptoms are limited.     

Does the clinical evaluation of the cardiac status predict outcome in patients with abdominal aortic aneurysms?

A cost-effective method to reduce mortality rates after abdominal aortic aneurysm repair centers on selecting and investigating only those patients at risk for cardiac-related death. All 146 patients undergoing asymptomatic abdominal aortic aneurysm repair over a 5-year period (1986 to 1990) were retrospectively placed into one of the three following groups on the basis of a clinical evaluation. Group I: no history of myocardial infarction or angina, no congestive heart failure, and no ischemic changes on electrocardiogram (ECG). Group II: history of myocardial infarction or class I-II angina or ischemic changes on ECG. Group III: presence of congestive heart failure or class III-IV angina. Patients in group I had no further cardiac work-up; patients in group II with angina had left ventricular ejection fraction assessment by multiple gated acquisition (all greater than 37%) and were cleared for operation by a cardiologist; patients in group II without angina had no further cardiac work-up; patients in group III had coronary angiography and then coronary revascularization. The overall mortality rate was 4.8%, with a cardiac mortality rate of 3.4%. The mortality rate in group I (n = 64) was 1.8%, with no cardiac-related deaths; the mortality rate in group II (n = 63) was 9.5% (8% cardiac-related deaths). No deaths occurred in group III (n = 19). The difference between the cardiac mortality rates in groups I and II was significant (p = 0.02) as was the postoperative cardiac morbidity: total myocardial infarctions (p less than 0.001); congestive heart failure (p = 0.02); tachyarrhythmias (p = 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

Late results of operation for ventricular tachycardia.

We have analyzed results in 54 consecutive patients with recurrent ventricular tachycardia and coronary artery disease in whom we used an aggressive surgical approach involving map-directed ventricular tachycardia ablation, scar excision and left ventricular remodeling, and coronary artery bypass grafting, as well as staged mitral valve replacement when necessary. We have previously shown age greater than 65 years to be an independent predictor of mortality and have excluded such patients from this series. Average age was 56 +/- 7 years. All patients had a previous myocardial infarction; 24% of the infarctions (13/54) were posterior in location. Symptoms included syncope or presyncope in 83% of the patients (45/54), angina in 54% (29/54), and congestive heart failure in 52% (28/54). Extensive coronary artery disease was found in 78% (42/54), and 89% (48/54) had serious compromise of left ventricular function (ejection fraction < 0.40; average ejection fraction, 0.28 +/- 0.12). Only 63% (34/54) appeared to have a resectable left ventricular aneurysm on the preoperative angiogram. Ablation techniques included endocardial excision in 82% (44/54), with the addition of cryoablation in 60% (32/54), and balloon electric shock ablation in 22% (12/54); coronary artery bypass grafting was performed in 85% (46/54). There were four hospital deaths (7%). The surgical cure rate (no inducible VT at postoperative electrophysiologic study was 72% (39/54). During follow-up (mean, 50 +/- 31 months) there have been six late deaths (1 sudden death, 1 stroke, 4 congestive heart failures with or without mitral regurgitation). Four patients with progressive congestive heart failure and serious mitral regurgitation have undergone repeat operation for mitral valve replacement.(ABSTRACT TRUNCATED AT 250 WORDS)     

Evolving experience with thoracoabdominal aortic aneurysm repair at a single institution

Fifty-seven patients underwent repair of atherosclerotic thoracoabdominal aortic aneurysms between 1978 and 1990. Five patients had urgent surgery for rupture. The 30-day operative mortality rate for the entire group was 18% (10 patients). Before July 1987, 19 patients (group 1) were operated on by use of a technique previously described. In these earlier patients the peritoneum was routinely entered, the diaphragm was divided radially, and no heparin was given. Among patients in group 1 there was a 30-day operative mortality rate of 42% (8 patients), and morbidity included myocardial infarction 4 (21%), respiratory failure 9 (47%), renal failure 12 (63%), bleeding requiring reoperation 4 (21%), and intestinal ischemia 3 (16%). Since July 1987 a standardized approach to all elective thoracoabdominal aortic aneurysms has been used in 38 patients (group 2). This method uses a left thoracoabdominal incision, circumferential division of the hemidiaphragm, retronephric totally extraperitoneal aortic exposure, single lung anesthesia, full heparinization, the graft inclusion technique, and liberal use of visceral endarterectomy. Patients in group 2 sustained a 30-day operative mortality rate of 5% (2 patients) and morbidity included myocardial infarction 2 (5%), respiratory failure 10 (26%), renal failure 11 (29%), bleeding requiring reoperation 1 (3%), paraplegia 6 (16%), and paraparesis 4 (11%). Modern surgery for repair of thoracoabdominal aortic aneurysm results in acceptably low operative mortality rates. Spinal cord ischemia remains an unresolved source of morbidity.