IgG4-positive plasma cells in inflammatory abdominal aortic aneurysm: the possibility of an aortic manifestation of IgG4-related sclerosing disease

Inflammatory abdominal aortic aneurysm (IAA) is associated with autoimmune disease. However, the precise mechanism of IAA remains unclear. There is increasing evidence that IgG4 is involved in the autoimmune mechanism of various idiopathic sclerosing lesions, including sclerosing pancreatitis and retroperitoneal fibrosis. The present study investigated the hypothesis that the IgG4-related autoimmune reaction is involved in the formation of IAA. The study group consisted of 11 cases of IAA (69.2 +/- 8.59y) and 12 age-matched cases of atherosclerotic abdominal aortic aneurysm (AAA, 69.6 +/- 5.94y), which were used in the previous report. A clinicopathologic examination of these lesions was performed, including histology and immunohistochemistry, in relation to the involvement of IgG4-positive plasma cells in the formation of IAA. No difference in the incidence of risk factors for atherosclerosis was observed between the patients with IAA and AAA. Autoimmune diseases were diagnosed in 2 patients with IAA, including rheumatoid arthritis and polyarteritis nodosa. A patient with IAA had pulmonary fibrosis. In contrast, autoimmune diseases were absent in patients with AAA. However, there was no significant difference in the incidence of autoimmune diseases between the patients with IAA and AAA. Lymphocyte and plasma cell infiltration and fibrosis were significantly more intense and extensive in IAA than in AAA. In addition, lymph follicle formation and vasculitis of small veins and arteries were frequently found in the affected lesions of IAA. Immunohistochemically, IAA showed a significant increase in the number of infiltrating IgG4-positive plasma cells and the incidence of a disrupted follicular dendritic cell network in lymph follicles, in comparison with AAA. These findings suggest that IAA may be an aortic lesion reflecting the presence of IgG4-related sclerosing disease, and not a simple inflammatory aneurysm of the aorta.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

Simultaneous Open and Endoluminal Repair of Ruptured Abdominal and Thoracic Aortic Aneurysms: Report of a Case

A 66-year-old woman was transferred to our hospital for emergency treatment of a ruptured abdominal aortic aneurysm (AAA) and impending rupture of a descending thoracic aortic aneurysm (TAA) caused by a Stanford type-B dissection. She had severe coronary artery disease and a highly calcified aorta, and had been taking long-term steroids for rheumatoid arthritis. Endovascular repair of the TAA failed because the femoral artery was too small, so we performed simultaneous repair of the TAA and the AAA. A temporary axillofemoral bypass was constructed and the AAA was replaced with a bifurcated prosthetic graft. A thoracic stent graft was delivered successfully through a chimney graft of the abdominal graft. About 4 months later, the TAA extended proximally, causing hemoptysis, which was stopped by placing a new stent graft proximal to the previous one. This case report shows that a combination of open and endovascular repair is useful for treating a TAA with an AAA, especially in a small or frail patient.     

Extra-anatomic arterial reconstruction with ligation of common iliac arteries and embolization of the aneurysm for the treatment of abdominal aortic aneurysms in high-risk patients

PURPOSE: The mortality of an unrepaired abdominal aortic aneurysm (AAA) generally exceeds the mortality associated with surgical repair. However, as our longevity increases, more frequently we see patients whose risk of surgical repair approximates the risk of rupture. We present an extra-anatomic bypass graft with complete aneurysm exclusion by iliac ligation and coil embolization of the aneurysm as an alternative for these high-risk patients. METHODS: An extra-anatomic bypass graft, followed by bilateral iliac artery ligation (retroperitoneal approach) and complete coil embolization of the AAA, was performed in eight patients (mean age, 77 years) found to be at prohibitive operative risk because of multiple comorbidities (American Society of Anesthesiologists class IV). Most patients (5 of 8) were symptomatic on presentation with a mean AAA diameter of 7 cm (range, 6.7-9.5 cm). We repair approximately 30 infrarenal aneurysms per year electively at our institution. RESULTS: All patients tolerated the surgical procedures. The average hospital stay was 8 days. All but two aneurysms demonstrated complete thrombosis by 48 hours. After 48 months there was no incidence of graft thrombosis, peripheral ischemia, visceral ischemia or thrombus infection. There was one perioperative death from aspiration pneumonia. Seventy-five percent (6 of 8) of patients have survived at least 1 year without surgical complications. No patient has had a ruptured aneurysm. CONCLUSION: Combining an extra-anatomic bypass graft and complete exclusion of the AAA by ligation of the common iliac arteries and a coil embolization is an effective, less invasive treatment option for patients with AAA and prohibitive operative risk. We emphasize the need for complete embolization documented by decreased aneurysm size.     

Impact of chronic obstructive pulmonary disease on elective and emergency abdominal aortic aneurysm repair

OBJECTIVE: Chronic obstructive pulmonary disease (COPD) is associated with abdominal aortic aneurysm (AAA) expansion and is considered by some to be a relative contraindication to conventional aortic surgery. This study was undertaken to determine if COPD increases operative death, morbidity, intensive care unit (ICU) length of stay (LOS), and hospital LOS, after AAA repair. METHODS: Data from national administrative records supplemented with laboratory data previously obtained for a system-wide study were analyzed in a retrospective review of 1053 consecutive patients (264 with and 789 without COPD) undergoing operation for intact or ruptured AAAs in Veterans Administration Hospitals from 1997 to 1998. Bivariate comparisons and multivariate regression were used to evaluate the impact of COPD on the number of days of ventilation, ICU LOS, total hospital LOS, and death, while controlling for other known risk factors, including acute myocardial infarction, renal failure, and age. RESULTS: The mortality rate in elective aneurysm patients did not differ (P =.99) between patients with (3.7%) or without COPD (3.7%). However, elective AAA repair was associated with longer hospital LOS (14.4 vs 12.3 days, P =.01), longer ICU LOS (6.5 vs 5.4 days, P =.01), and a higher incidence of requiring 96 hours or more ventilation (6.9% vs 3.6%, P =.02) in patients with COPD. Ruptured AAA affected 4.9% of patients and was strongly associated with COPD (P =.02); however, COPD did not result in a statistically significant increase in death (P =.25). CONCLUSIONS: Although COPD does not appear to increase operative death, it is associated with an increased risk of rupture. Elective repair of AAA should not be deferred in patients with COPD despite their higher LOSs and need for postoperative ventilation.     

Identifying Patients With AAA With the Highest Risk Following Endovascular Repair

Introduction: It has been demonstrated that endovascular repair of arterial disease results in reduced perioperative morbidity and mortality compared to open surgical repair. The rates of complications and need for reinterventions, however, have been found to be higher than that in open repair. The purpose of this study was to identify the predictors of endograft complications and mortality in patients undergoing endovascular abdominal aortic aneurysm (AAA) repair; specifically, our aim was to identify a subset of patients with AAA whose risk of periprocedure mortality was so high that they should not be offered endovascular repair. Methods: We undertook a prospective review of patients with AAA receiving endovascular therapy at a single institution. Collected variables included age, gender, date of procedure, indication for procedure, size of aneurysm (where applicable), type of endograft used, presence of rupture, American Society of Anesthesiologists (ASA) class, major medical comorbidities, type of anesthesia (general, epidural, or local), length of intensive care unit (ICU) stay, and length of hospital stay. These factors were correlated with the study outcomes (overall mortality, graft complications, morbidity, and reintervention) using univariate and multivariate logistic regression. Results: A total of 199 patients underwent endovascular AAA repair during the study period. The ICU stay, again, was significantly correlated with the primary outcomes (death and graft complications). In addition, length of hospital stay greater than 3 days, also emerged as a statistically significant predictor of graft complications in this subgroup (P = .024). Survival analysis for patients with AAA revealed that age over 85 years and ICU stay were predictive of decreased survival. Statistical analysis for other subgroups of patients (inflammatory AAA or dissection) was not performed due to the small numbers in these subgroups. Conclusions: Patients with AAA greater than 85 years of age are at a greater risk of mortality following endovascular repair. In addition, patients who are expected to require postprocedure ICU admission are also at an increased risk of mortality following endovascular repair.     

A screening program to identify risk factors for abdominal aortic aneurysms.

BACKGROUND: We aimed to explore the feasibility of a nurse-supervised aneurysm screening program to identify any independent risk factors for abdominal aortic aneurysm (AAA) formation in high-risk patients. METHODS: We conducted a prospective observational study of 90 male patients in a university- affiliated hospital in southern Ontario. The patients were prospectively evaluated and all underwent abdominal ultrasonography, with the main outcome measure being detection of an AAA. RESULTS: AAAs were identified in 18 patients (20%) and had a mean diameter of 3.6 (range 2.8-6.0) cm. A separate analysis was performed to identify risk factors for the presence of an aneurysm. The presence of carotid artery disease proved to be the only statistically significant independent predictor of the presence of AAA (odds ratio 2.23, 95% confidence interval 1.76-2.56). CONCLUSIONS: This study confirms the feasibility of a nurse-supervised AAA screening program, and on the basis of these results we recommend ultrasonographic screening for AAA in patients with a history of carotid artery disease.     

Peripheral aneurysms and arteriomegaly: Is there a familial pattern?

Purpose: Studies have shown that 11% to 18% of patients with an abdominal aortic aneurysm (AAA) have a first-degree relative with an AAA. A familial pattern among patients with peripheral arterial aneurysms and arteriomegaly has not been reported. The objective of this study was to examine familial patterns among patients with peripheral arterial aneurysm and arteriomegaly and compare them with patterns among patients with AAA. Methods: Pedigrees were constructed for first-degree relatives of patients who received the diagnosis of peripheral arterial aneurysm, arteriomegaly, or AAA from 1988 through 1996. The presence of aneurysms and risk factors was confirmed for patients and relatives by means of telephone interviews and review of hospital and physician records. Results: Seven hundred three first-degree relatives older than 50 years were contacted for 140 probands with peripheral arterial aneurysm, AAA, or arteriomegaly. There were differences in risk factors for hernia and diabetes mellitus among the probands with peripheral arterial aneurysm, AAA, or arteriomegaly but none for relatives. Patients with peripheral arterial aneurysm (n = 40) had a 10% (4/40) familial incidence rate of an aneurysm, patients with AAA (n = 86) had a 22% (19/86) familial incidence rate, and patients with arteriomegaly (n = 14) had a 36% (5/14) familial incidence rate. AAA (24/28, or 86%) was the aneurysm diagnosed most commonly among first-degree relatives. Most aneurysms (85%) occurred among men. Conclusion: There appears to be a gradation of familial patterns from peripheral arterial aneurysm to AAA to arteriomegaly among patients with degenerative aneurysmal disease, and there appears to be a predominance among men. Relatives of patients with any of the 3 lesions—peripheral arterial aneurysm, AAA, arteriomegaly—most frequently have AAA. Relatives of patients with AAA, peripheral arterial aneurysm, or arteriomegaly may be screened by means of a physical examination for peripheral aneurysmal disease. Screening by means of ultrasound examination of the aorta should be limited to first-degree relatives of patients with aortic aneurysms or arteriomegaly. (J Vasc Surg 1998;28:599-605.)     

Combining abdominal aortic aneurysmectomy with gastrointestinal or biliary surgery

A retrospective study was undertaken to compare the morbidity and mortality of patients who had simultaneous abdominal aortic aneurysm (AAA) resection and gastrointestinal (GI) or biliary surgery with patients who had AAA resection alone. This series consisted of 89 patients who underwent surgery over a 6-year period (January, 1980 through December, 1985) at St. Elizabeth Hospital Medical Center. The patients were separated into three groups: group 1 had elective AAA resection; group 2 had AAA resection and a GI or biliary procedure simultaneously; and group 3 had resection of a ruptured AAA. The patients in groups 1 and 2 were similar with respect to sex, age, surgeons, estimated blood loss, operative time, preoperative risk factors and hospital stay. The patients in group 3 had shorter preoperative and longer postoperative hospital stays, were older, and had greater preoperative risk. The morbidity and mortality of the patients in group 2 were consistently the same or less than that of patients in group 1, even when individual surgeons and preoperative risk factors were compared. The patients in group 3 had a significantly higher morbidity and mortality. This article reviews the literature on management of patients with simultaneous AAA and other intraabdominal pathology and presents a suggested approach to treatment.     

Outcome after Simultaneous Abdominal Aortic Aneurysm Repair and Aortocoronary Bypass

Myocardial infarction remains the leading cause of early and late death after abdominal aortic aneurysm (AAA) repair. Myocardial revascularization is staged either before or concomitant with AAA resection, but results are far from uniform. We retrospectively analyzed our experience with patients who underwent concomitant AAA resection and aortocoronary bypass (ACB) to examine the factors affecting early morbidity/mortality and early results. Forty-two patients (all men; mean age, 67.2 years) underwent simultaneous ACB grafting and AAA repair between 1975 and 1998. All were managed postoperatively in the cardiothoracic intensive care unit (mean stay, 6.1 days). The mean total hospital stay was 17.2 days. Two died in the early postoperative period (4.8%): 1 of sustained myocardial failure following a third ACB, and 1 of coagulopathy after concomitant ACB, aortic valve replacement, and AAA. One patient developed a nonfatal MI on postoperative day 3. The incidence of wound and bleeding complications was higher for patients undergoing both ACB and AAA repair than for patients undergoing AAA resection alone. On follow-up (mean, 10 years; range, 7 months to 15 years), only 2 of 10 late deaths were due to cardiovascular causes. We believe that concomitant myocardial revascularization is warranted in select patients requiring elective or urgent AAA resection in order to decrease perioperative risk and improve late survival. Cardiac failure or ischemia during aortic surgery can be prevented by proper perfusion with or without cardiopulmonary bypass. In patients undergoing simultaneous procedures, the increased risk is related to the severity of the vascular and coronary artery disease and not to the combined operations.     

Isolated iliac artery aneurysms in patients with or without previous abdominal aortic aneurysm repair.

BACKGROUND: Isolated iliac artery aneurysms (IAA) in patients with or without previous abdominal aortic aneurysm (AAA) repair are rare. We wanted to compare the presentation, distribution, treatment, outcome and patterns of subsequent aneurysm formation in these patients. METHODS: We retrospectively reviewed patients with isolated IAA over a 10-year period. Patients with primary isolated IAA (group 1) were compared with patients who presented with IAA after previous AAA repair (group 2). RESULTS: There were 23 patients in each group. Demographics and comorbidities were similar. No aneurysms were detected outside of the iliac system in group 1; 22% of patients in group 2 had other aneurysms. The mean time after AAA repair to IAA diagnosis was 8.8 +/- 3.2 years for operated on patients. The in-hospital mortality was 0% for elective cases and 50% for emergency cases for both groups. Three patients in group 2 (13%) developed new aneurysms during follow-up, whereas the only new aneurysm in group 1 was a contralateral IAA. CONCLUSIONS: Patients with new IAA after AAA repair have a greater tendency to develop further aneurysms in other sites, synchronously or metachronously. The time to detection of new IAA after AAA repair is at least 5 years in most cases. In both groups, a quarter to a third of patients present with rupture, with a resultant mortality of 30% to 50%, whereas those operated on electively have minimal morbidity and almost no mortality.     

Epidemiological study of the relationship between volume and outcome after abdominal aortic aneurysm surgery in the UK from 2000 to 2005

BACKGROUND: The aim was to assess the relationship between hospital volume and outcome after abdominal aortic aneurysm (AAA) surgery in the UK. METHODS: Hospital Episode Statistics (2000-2005) were classified as elective, urgent or ruptured AAA repair. Analysis was by modelling of mortality rate, complication rate and length of hospital stay with regard to the annual operative volume, after risk adjustment. RESULTS: There were 112,545 diagnoses, or repairs, of AAAs, of which 26,822 were infrarenal aneurysms. The mean mortality rate was 7.4, 23.6 and 41.8 per cent for elective, urgent and ruptured AAA repair respectively. Elective AAA repair undertaken at high-volume hospitals showed volume-related improvements in mortality (P < 0.001). Patients were discharged from hospital earlier (P < 0.001). The critical volume threshold was 32 elective AAA repairs per year. For urgent repair, patients at high-volume hospitals had a reduced mortality rate (P = 0.017) with an increased length of stay (P = 0.041). There was no relationship between volume and outcome for ruptured AAA repairs. CONCLUSION: Increased annual volumes were associated with significant reductions in mortality for elective and urgent AAA repair, but not for repair of ruptured AAAs.     

Adverse effects of cell saver in patients undergoing ruptured abdominal aortic aneurysm repair

A retrospective analysis of 56 patients undergoing ruptured abdominal aortic aneurysm (AAA) repair was performed to find out if cell saver had any impact on postoperative morbidity and mortality. All patients but one were male. The mean age was 68 ± 8 years (35-85 years). Cell saver was used in 40 patients (CS group) and was not used in 16 patients (NCS group). We compared the incidences of respiratory, renal, and gastrointestinal complications; reoperation; transfusion requirement; length of hospital stay; and mortality between the groups. This study demonstrated that intraoperative cell saver usage significantly increased the incidence of respiratory complications and the need for blood and fresh frozen plasma transfusion, and prolonged the hospital stay in patients with ruptured AAA, but did not have any impact on mortality. Postoperative complications were more prominent in patients who received >3000 mL cell saver blood.     

Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.     

Open aneurysm repair at an endovascular center: value of a modified retroperitoneal approach in patients at high risk with difficult aneurysms

OBJECTIVE: This study was undertaken to evaluate elective open abdominal aortic aneurysm (AAA) repair and the role of a modified retroperitoneal approach in a high-volume endovascular center. METHODS: We reviewed prospectively collected data for 175 elective infrarenal open AAA repairs performed over 6 years. A transperitoneal approach was used in 118 procedures, and a modified retroperitoneal approach was used in 57 procedures. The incisional modification, which facilitated repair in patients with massive obesity, scarring, or ventral hernia, included a higher, more posterolateral location in the ninth intercostal space. Risk factors that added to the difficulty of the repair included aneurysms with a short (<1 cm) or no aortic neck in 45 patients; large, angled or flared aortic neck in 32 patients;, tortuous and calcified iliac arteries in 6 patients; morbid obesity in 10 patients; low ejection fraction (15%-30%) in 14 patients; chronic obstructive pulmonary disease, with forced expiratory volume at 1 second less than 55% in 4 patients; previous laparotomy in 18 patients; previous left-sided colectomy in 11 patients; large right iliac aneurysm in 8 patients; large ventral hernia in 8 patients; pelvic irradiation in 4 patients; failed endovascular repair in 5 patients; and previous failed open repair attempt in 2 patients. Many of these factors occurred with significantly greater frequency (P =.04-.001) in the retroperitoneal group. All factors were correlated with outcome. RESULTS: Despite these risk factors, overall 30-day mortality was 3.5% (retroperitoneal group, 3.8%), and mean length of hospital stay was 9 days (retroperitoneal group, 8 days). There was no significant correlation between mortality or length of stay and any of the mentioned risk factors (P >.2). CONCLUSION: In the era of endovascular aneurysm exclusion, open AAA repair is generally used to treat anatomically complex or difficult aneurysms, many of which are present in patients at high risk. Despite this combination of anatomic and systemic risk factors, the modified retroperitoneal approach facilitates treatment in difficult circumstances and enables open AAA repair to be performed with acceptable mortality and morbidity.     

Combined Abdominal Aortic Aneurysm Repair and Coronary Artery Bypass: Presentation of 13 Cases and Review of the Literature

Coronary artery disease remains the major cause of perioperative mortality after abdominal aortic aneurysm (AAA) repair. The beneficial effect of coronary artery bypass (CAB) before AAA repair in patients with severe coronary artery disease has been proven. The coexistence of a very large or symptomatic AAA and coronary artery disease remains a therapeutic challenge since there is the risk of AAA rupture in the interval between CAB and AAA repair. Combined CAB and aortic aneurysm repair has been suggested for these cases, and results on several series of patients have been published. However, the exact indication for the combined operation remains to be clarified. We present a series of 13 patients who underwent CAB on cardiopulmonary bypass and aortic aneurysm repair as a one-stage procedure. The indication was a large AAA in seven patients and a symptomatic AAA in six patients. In four patients, the aortic reconstruction was performed without the use of cardiopulmonary bypass; in nine patients, the aortic reconstruction was performed under partial cardiopulmonary bypass. Thirty-day mortality was 15%. Major morbidity was 31%. All major complications were due to excessive bleeding and occurred in patients who had AAA repair performed with partial cardiopulmonary bypass, suggesting that prolonged bypass time represents a major source of morbidity. A detailed review of the literature is presented. From the evidence available we suggest that the combined procedure can be recommended only for patients with very high rupture risk, such as in symptomatic AAA. In all other cases, the staged approach — CAB followed by AAA repair 2-4 weeks later — is preferable. During the combined procedure, cardiopulmonary bypass support during AAA repair should be used only in patients with clear evidence of hemodynamic instability.     

Oxygen-dependent chronic obstructive pulmonary disease does not prohibit aortic aneurysm repair.

BACKGROUND: Severe oxygen-dependent chronic obstructive pulmonary disease (COPD) is considered by many to be a contraindication to open abdominal aortic aneurysm (AAA) repair. We reviewed our own experience with this patient population. METHODS: From July 1995 to March 1999, 14 consecutive patients limited by home oxygen-dependent COPD underwent elective open infrarenal AAA repair. Their medical records were reviewed. RESULTS: The mean aortic aneurysm size was 6.3 cm. The mean PaO2 = 70 mm Hg, PaCO2 = 45 mm Hg, forced expiratory volume in 1 second (FEV1) = 34% of predicted, and forced vital capacity (FVC) = 67% of predicted. All 14 patients were extubated within 24 hours, mean length of hospital stay was 5.9 days, and there were no perioperative deaths. CONCLUSIONS: Severe home oxygen-dependent COPD is not a contraindication to safe elective open AAA repair.     

The Impact of Introducing an Autologous Intraoperative Transfusion Device to a Community Hospital

The purpose of this study was to determine the benefits and disadvantages of transfusing autologous blood during abdominal aortic aneurysm (AAA) surgery at a district general hospital with an intraoperative autologous transfusion device (Haemoccel ABT 350). In this retrospective study, 128 patients underwent abdominal aortic aneurysm repair between 1992 and 1999 by a single vascular surgeon. Ninety-three patients (60 autologous and 33 allogeneic) had elective AAA repair (group A) and 25 patients (4 autologous and 21 allogeneic) had emergency AAA repair (group B). Nine group A patients (7.6%) received their own salvaged blood and no other allogeneic blood. Although the mean estimated blood loss was higher in the autologous group of patients (NS), the intraoperative autologous transfusion device did not significantly reduce allogeneic blood usage in patients who had autologous transfusion in both elective and emergency groups. There was no difference in postoperative hemoglobin and hematocrit, ICU stay or hospital stay. In this study, red cell salvage was significantly more expensive than blood bank usage (p < 0.0001), yet it did not significantly reduce the needs of allogeneic blood. We concluded that the intraoperative autologous transfusion device is underused, not cost-effective and requires formulation of local guidelines.     

Is arterial surgery advisable for patients over 80 years of age?

BACKGROUND: Recently life expectancy has become longer and longer. The purpose of this study was to analyse whether arterial surgery for patients over 80 years of age is advisable. METHODS: During the last 14 years, 527 patients, 50 of whom were over 80 and 477 of whom were under 80 years of age, received graft replacement or bypass surgery. They suffered from ruptured abdominal aortic aneurysm (R-AAA, n=21), non-ruptured abdominal aortic aneurysm (N-R AAA, n=133) or arteriosclerosis obliterans (ASO, n=373). Complications such as cerebrovascular disease, ischemic heart disease, respiratory and kidney dysfunction, and risk factors for ASO were also checked. RESULTS: All of the patients over 80 with R-AAA (n=3/3) and 50% of the patients under 80 with R-AAA (n=9/18) died during their stay in the hospital. However, none of the N-R AAA patients over 80 (n=0/7) and only one of the 126 N-R AAA patients (0.8%) under 80 died. For the patients over 80 with ASO, the graft patency rate was better than the patients survival rate. There were no age-specific factors that should condemn arterial surgery for patients over 80 years of age. CONCLUSIONS: Arterial surgery should not be ruled out on the basis of age alone.     

Endovascular versus "fast-track'' abdominal aortic aneurysm repair

Recent studies have shown that endovascular abdominal aortic aneurysm repair (EVAR) has decreased costs, as well as decreased intensive care unit and total hospital length of stays when compared to abdominal aortic aneurysm (AAA) repair using a retroperitoneal exposure. The authors hypothesized that the fast-track AAA repair, which combines a retroperitoneal exposure with a patient care pathway that includes a gastric promotility agent and patient-controlled analgesia, would have no differences when compared to EVAR. Records of 58 patients who underwent AAA repair between April 14, 2000, and July 12, 2002, were reviewed retrospectively. Demographic information, length of stay, intraoperative and postoperative complications, mortality, and costs were evaluated. Fifty-eight AAA repairs were performed with the EVAR (n=28) and fast-track (n=30) techniques. The EVAR group was slightly older (72 vs 68 years, p=0.04), had slightly smaller average aneurysm size (5.5 +/-0.13 vs 6.1 +/-0.17 cm, p=0.008), and had more patients designated American Society of Anesthesia class 4 (p<0.0001). Both groups were predominantly male. Otherwise there were no statistically significant differences in risk factors. Patients who underwent fast-track repair tended to have a longer operation (216 +/-7.4 vs 158 +/-6.8 minutes, p<0.0001), with a greater volume of blood (1.8 +/-0.29 vs 0.32 +/-0.24 units, p=0.0005), colloid (565 +/-89 vs 32 +/-22 cc, p<0.0001), and crystalloid transfusions (4,625 +/-252 vs 2,627 +/-170 cc, p<0.0001). There were no statistically significant differences in the number of intraoperative or postoperative complications between the 2 groups. EVAR patients resumed a regular diet earlier (0.21 +/-0.08 vs 1.8 +/-0.11 days, p<0.0001). Intensive care unit stay was shorter for EVAR (0.50 +/-0.10 vs 0.87 +/-0.10 days, p=0.01), but floor (2.1 +/-0.23 vs 2.6 +/-0.21 days, p=0.17), and total hospital lengths of stay (2.8 +/-0.32 vs 3.4 +/-0.18 days, p=0.07) were similar between the 2 groups. Total hospital cost was lower in the fast-track (10,205 dollars +/-736 dollars vs 20,640 dollars +/- 1,206 dollars, p<0.0001) leading to greater overall hospital earnings (6,141 dollars +/- 1,280 dollars vs 107 dollars +/- 1,940 dollars, p=0.01). Fast-track AAA repair is a viable alternative for the treatment of abdominal aortic aneurysms. Compared to endovascular repair, the fast-track method had increased transfusions of blood and intravenous fluids and increased operating room times, but equivalent lengths of floor and total hospital stay and increased total hospital earnings.