Abdominal aortic aneurysm resection in patients more than 80 years old

Improvement in anesthetic and surgical techniques has prompted a more aggressive approach to repair of abdominal aortic aneurysms in patients more than 80 years old. In order to determine if surgical treatment is justified, all of the patients who were more than 80 years old admitted to the hospital during the ten year period from 1974 to 1983 with the diagnosis of abdominal aortic aneurysm were reviewed. A total of 90 patients were available for analysis. The mortality of the 18 patients treated conservatively for ruptured aortic aneurysms was 100 per cent. Ten of the 27 patients operated upon for a ruptured aneurysm died yielding a mortality of 37 per cent. Eleven patients with symptomatic aneurysms had urgent repair with a mortality of 27 per cent. Only one of the 34 patients undergoing elective aneurysm repair died. There was no difference in the size of aneurysms among the groups. Although the ruptured aneurysms required more blood (10.2 +/- 3.7 units), there was no difference between the other two groups (symptomatic 4.5 +/- 3.1 units, elective 4.6 +/- 2.8 units). There was significantly fewer myocardial and renal complications in the elective group, although the sole death in this group was from myocardial infarction. Based upon these observations, we recommend aggressive elective therapy for selected patients who are more than 80 years of age with asymptomatic abdominal aortic aneurysms. Although the mortality is higher in those patients with symptomatic or ruptured aneurysms, it is not formidable, and therefore, repair should not be ruled out on the basis of age alone.     

A twenty-two year review of elective resection of abdominal aortic aneurysms.

The clinical presentation and history of abdominal aortic aneurysm has changed little in the last 22 years. The improved results of elective resection of these lesions have occurred subsequent to advances in various aspects of treatment of this disease as well as increased experience in surgical management. The operative mortality associated with elective resection of abdominal aortic aneurysms has dropped to such a level that elective intervention is reinforced as the treatment of choice for this lesion. It is hoped that, with the continued improvement in the diagnostic phase resulting in earlier detection and surgical intervention, there may be a further reduction in the incidence of rupture of abdominal aortic aneurysms and further prolongation of life in those patients in whom such lesions develop.     

Two year prospective analysis of the Oxford experience with surgical treatment of abdominal aortic aneurysm

During the two years from 1 November 1985 to 31 October 1987, 177 patients were admitted to a hospital in Oxford with the diagnosis of abdominal aortic aneurysm (AAA). The aneurysm had ruptured in 88 patients, of whom 75 underwent emergent surgical treatment, yielding an operative mortality rate of 36 per cent. Of the 13 patients who did not have surgical treatment, two died before transfer to the operating room; in the other 11 patients, a deliberate decision was made not to undertake surgical treatment--in ten patients, the reason was an age of 85 years or more and in one patient, severe debilitating Parkinson's disease. Emergent operations were done upon another 15 patients--11 who had acute aneurysm and four in whom symptoms were not caused by an aneurysm. Emergent operations for ruptured or acute aneurysms represented 55 per cent of all operations for AAA. This high proportion and large number of emergent operations is in marked contrast with the experience of comparable specialist vascular surgical units in the United States. The 24-fold difference in mortality rates between surgical procedures performed electively and for ruptured aneurysm suggests that a considerable impact on over-all mortality could be achieved by a substantial increase in referral of patients     

Factors affecting survival of patients with ruptured abdominal aortic aneurysm in a West Virginia community

The hospital records for patients treated for ruptured abdominal aortic aneurysms in southern West Virginia during a recent five year period were reviewed. The over-all mortality rate was 62 per cent. Patients with intraperitoneal rupture had a higher mortality rate (97 per cent) than patients with retroperitoneal rupture (25 per cent). Patients at increased risk were more than 80 years of age, presented with syncope, experienced a short duration of symptoms before seeking medical attention, had preoperative systolic blood pressure levels of less than 90 millimeters of mercury and had a preoperative hemoglobin level of less than 8. Other factors associated with death were a delay in beginning surgical treatment, a larger total blood loss and amount of blood transfused. The results of multivariate analysis demonstrated that preoperative blood pressure, preoperative hemoglobin, presence of syncope and the amount of blood loss were, in large part, reflections of the type of rupture and had only slight independent relationship to mortality. The most effective method of preventing fatal outcome is elective resection of the aneurysms before rupture occurs.     

Acute acalculous cholecystitis complicating aortic aneurysm repair

In a series of 374 consecutive abdominal aortic aneurysmal repairs, the incidence of acute acalculous cholecystitis was 1.1 per cent. This complication occurred in only one of 352 patients (0.3 per cent) after elective aneurysmorraphy, as compared with three of 22 (13.6 per cent) after emergency repair of a ruptured aneurysm. This difference proved highly significant (p = 0.0001). All of the patients who had postoperative acute cholecystitis after aortic aneurysmal repair had acalculous disease. A mortality rate of 50 per cent was noted for this complication. Technetium cholescintigraphy proved the most valuable diagnostic study when acute cholecystitis was suspected.     

Incidence of ischemic colitis following abdominal aortic reconstruction.

The incidence of ischemic colitis following abdominal aortic reconstruction was determined by postoperative colonoscopy during a three year period. The over-all incidence of colitis was 11 of 163 patients who underwent elective or urgent reconstruction of the abdominal aorta for aneurysmal and occlusive diseases. The incidence of ischemic colitis for patients who survived resection of ruptured abdominal aortic aneurysms was higher, although the colonoscopy rate was lower. The incidence might have been even higher if all patients surviving resection of ruptured abdominal aneurysms had undergone colonoscopy.     

The risk of ligation of the left renal vein in resection of the abdominal aortic aneurysm

The left renal vein can be ligated during aortic operation to attain better access to the perirenal aorta. This maneuver has been considered safe, with a low incidence of postoperative renal complications. This study was done to evaluate the risk of left renal vein ligation and its influence on renal function in patients with elective resection of abdominal aortic aneurysms. The records of 332 patients undergoing elective repair of abdominal aortic aneurysms during a five year period were reviewed. The clinical and operative data of patients who had left renal vein ligation and those who did not were similar. Left renal vein ligation was not associated with an increased mortality rate but was strongly associated with an increase in serum creatinine level and a clinical diagnosis of postoperative azotemia. Nine of 13 patients who had left renal vein ligation had postoperative azotemia compared with 21 of 319 patients without left renal vein ligation (p less than 0.001). The mean change of preoperative and postoperative creatinine value was an increase of 1.92 milligrams per deciliter in patients with left renal vein ligation in contrast with 0.26 milligram per deciliter in patients without ligation (p less than 0.00075). Thus, ligation of the left renal vein increases the risk of postoperative renal complications and its use should be selective.     

Altered aortic protease and antiprotease activity in patients with ruptured abdominal aortic aneurysms

Aortic elastase, antiprotease (a-1-antitrypsin) and total protein were assayed in 37 patients who underwent an operation on the abdominal aorta for ruptured abdominal aortic aneurysms (AAA), an elective procedure for AAA or aortofemoral bypass for occlusive disease. Aortic elastase modified by local antiprotease activity (elastase/a-1-antitrypsin) was significantly higher in patients with a ruptured AAA compared with patients with an elective AAA or occlusive aortic disease: 241 nanograms per milligram of tissue in AAA-rupture versus 57 nanograms per milligram of tissue in AAA-elective versus 32 nanograms per milligram of tissue for occlusive (p less than 0.003). Patients with a ruptured AAA had the highest elastase activity (354 nanograms per milligram of tissue) and the lowest a-1-antitrypsin (1.07 nanograms per milligram of tissue) compared with patients with an elective AAA and occlusion (p less than 0.05). These data suggest that the homeostatic balance between elastase and antiprotease may be significantly altered in the aortic wall at the time of aneurysm rupture. Increased elastase unchecked by low antiprotease results in increased elastin breakdown which may be the inciting event for rupture of a compromised, thin aortic aneurysm wall.     

A suggested classification and reappraisal of mortality statistics for ruptured atherosclerotic infrarenal aortic aneurysms

A retrospective review of 80 ruptured infrarenal abdominal aortic aneurysms with classification of the patients into clinical groups based upon the findings at laparotomy was undertaken. Patients with small hematomas confined to the area of rupture were uniformly salvaged. Those with free intraperitoneal blood almost invariably died. Intermediate groups had mortalities od 37.5 and 62.5 per cent. It is concluded that operative mortality is related to the clinical group to which the patient belongs. Attention must be focused upon the potentially salvageable intermediate groups, with regard to early laparotomy and prompt, effective proximal and distal control of the aorta before entering the retroperitoneal hematoma. Major improvements in survival have occurred with smaller ruptures but little has been achieved with larger ruptures during the past 25 years.     

Zero operative mortality rate in 109 consecutive elective aortic operations performed by residents

One hundred and nine consecutive elective abdominal aortic operations were performed at the Veterans Administration Medical Center San Diego between 1984 and 1987. All of the operating surgeons were residents in general surgery who were assisted by attending staff. The mean age of the patients was 66.1 years and 34 patients were 70.0 years or older. The indication for operation was aortic aneurysm in 69 and aortoiliac occlusive disease in 40. Fifteen patients underwent highly complex procedures. The mean duration of operation was 5.6 hours, mean aortic clamp time was 72 minutes and mean volume of blood replacement was 1,186 milliliters. There was no operative mortality. Twenty-nine patients had 32 nonfatal complications. Patency of the graft was 100 per cent at discharge. We conclude that excellent clinical results with complex elective aortic operations can be achieved by surgical residents with appropriate supervision.     

Clinical observations and lessons learned in the treatment of patients with thoracoabdominal aortic aneurysms

Thoracoabdominal aortic aneurysms can be repaired successfully with acceptable rates of morbidity and mortality. Twenty-three men and seven women (an average age of 67 years) underwent 23 elective and seven emergency operations. Pulmonary complications were the most common, but renal insufficiency and paraplegia were the most serious postoperative problems. The average time of suprarenal aortic occlusion was 47 minutes, but neither renal insufficiency nor paraplegia was directly related to suprarenal clamp time. Four deaths occurred after elective procedures, two from postoperative bleeding (one death from a technical error) and two deaths from multisystem organ failure. Four late deaths were caused by myocardial infarction. The remaining patients are alive at two to 79 months after infarction. DeBakey's technique (multiple sidearm grafts from the main aortic graft) was used in the first three procedures, and the graft inclusion technique of Crawford, in the remainder. The graft inclusion technique reduced operating time and loss of blood by 50 per cent and intraoperative fluid requirements by 33 per cent. Hypothermia was minimized by extraperitoneal, rather than intraperitoneal, abdominal aortic exposure, heated ventilation and warmed intravenous fluids. Selective renal cooling was performed by catheter perfusion of the renal arteries. Extreme care must be taken in making openings and attaching grafts to visceral arteries to avoid troublesome hemorrhage. In contrast with patients with infrarenal aneurysms, those with thoracoabdominal aneurysms require prolonged ventilatory support and have considerably higher fluid requirements. Precise surgical technique is mandatory.     

Abdominal aortic aneurysm and the pseudorupture syndrome

A consistently high mortality for ruptured abdominal aortic aneurysm has given rise to an aggressive approach in the management of these patients. However, there is a group of patients who present with signs and symptoms suggesting a ruptured abdominal aortic aneurysm but instead have other life threatening conditions. These patients and their management are presented herein.     

Operation for late complications of aortic grafts

In a period of seven years, 120 revision operations were performed for complications occurring in 1,284 aortic bifurcation grafts. The reasons cited for operation were: graft limb occlusion or stenosis in 82 patients, false aneurysm in 28 and symptomatic disease distal to the graft in ten. Preferred operations were replacement of the graft and distal anastomosis for occlusion or complete reconstruction of the anastomosis with fresh graft material for a false aneurysm. The operative mortality rate was 1.6 per cent and three patients (2.5 per cent) underwent amputation after multiple procedures. This group of 120 patients with complications was compared with a random sample of 300 patients with aortic bifurcation grafts with no complications. In the group with complications, there were significantly fewer patients who underwent sympathectomy or profundaplasty and significantly more with an iliac rather than a femoral artery graft insertion. Those patients who had graft complications develop also had a significantly higher hematocrit level at the first procedure.     

Repeat hepatic resection for primary and metastatic carcinoma of the liver

During the last 15 years, 19 patients underwent repeated hepatic resections for malignant lesions of the liver. The first hepatic resection had been performed four to 40 months earlier for treatment of hepatocellular carcinoma (nine patients) or hepatic metastases (ten patients), eight of which were of colorectal origin. Repeat resection was an extensive hepatectomy in six, a segmentectomy in six and a local excision in seven. In one patient, three wedge resections and, finally, hepatic transplantation were subsequently performed after an initial extended right lobectomy. The operative mortality rate was 5.2 per cent. The three year actuarial survival rate was 64 per cent after the second resection.     

Salmonella infections of the abdominal aorta.

Salmonella accounts for up to one-third of all primary abdominal aortic infections. During the past ten years, we have treated three patients with this disease and have reviewed an additional 61 instances found in the English literature. The overall survival rate was 46 percent. Fever and back or abdominal pain were present in more than 90 percent of the patients, while a pulsatile mass was present in only 42 percent of those reported. Blood cultures were positive in 73 percent of patients. Computed tomography and angiography were helpful in delineating the presence of aneurysms and defining the extent. Twenty-two patients were treated without undergoing aortic resection; there were no survivors. One patient had an aortic resection without reconstruction and survived. Twenty-eight patients were treated with aortic resection and anatomic reconstruction. Six patients in this group died of graft sepsis and an additional six patients required graft removal for persistent infection. In contrast, 18 of 19 patients treated with extra-anatomic grafting and aneurysm resection survived, with only one death from aortic stump sepsis. No patient has required graft removal for sepsis. These results suggest that aneurysm resection and extra-anatomic bypass is the treatment of choice in patients with Salmonella infections involving the infrarenal aorta.     

Review: spontaneous rupture of splenic artery aneurysm in pregnancy

Splenic artery aneurysms (SAA) occur predominantly in women and a majority of the aneurysms are asymptomatic until rupture. Over half of those that rupture occur during pregnancy or in women who have had children. Rupture during pregnancy is associated with a very high maternal and fetal mortality rate. Although this condition is uncommon, good materno-fetal outcome can only be achieved by early diagnosis and prompt treatment. It is therefore important to increase awareness of this condition so that obstetricians and other frontline staff can entertain the diagnosis of a ruptured splenic artery aneurysm in any pregnant woman who presents with severe upper abdominal pain. This article reviews the aetiology, clinical features, diagnosis and treatment of this potentially lethal condition.     

Inflammatory abdominal aortic aneurysm

Between January 1976 and December 1982, 181 patients with abdominal aortic aneurysms were treated surgically, and in 13 patients the aneurysms were found to be inflammatory. Inflammatory aneurysms of the abdominal aorta (IAAA) share important characteristics with typical atherosclerotic abdominal aortic aneurysms. Diagnosis and surgical management of IAAA are distinctive which suggests that IAAA should be considered separately, as a varient of typical abdominal aortic aneurysms. IAAA occur predominantly in males. The presenting symptoms are often idiosyncratic and include severe abdominal or back pain, or both, and ureteral obstruction; the diagnosis of IAAA should be considered when these symptoms are present. Although grossly and microscopically, the perianeurysmal fibrosis resembles idiopathic retroperitoneal fibrosis, the two conditions can be differentiated. At the present time, ultrasonography and computed tomography appear to offer reliable means for diagnosing IAAA. The presence of IAAA, whether established preoperatively or discovered unexpectedly at operation, necessitate certain modifications in the surgical approach, in order to avoid injuring the duodenum and the venous structures. Most patients can be successfully treated by resection and graft replacement. Rupture of the aneurysm in IAAA appears to be less frequent than in typical atherosclerotic abdominal aortic aneurysm.     

Urinary L-valyl proline in patients with aortic aneurysms

Recent evidence indicates that metabolism of elastin may be altered in patients with different types of infrarenal aortic disease and that the phenotypic expression of aortic disease may be dependent on the balance between aortic elastase and antiprotease activity. The dipeptide L-valyl proline (LVP) is a specific amino acid sequence for elastin and can be quantitated by high performance liquid chromatography analysis of the urine. This study was done to determine if alterations in systemic elastin metabolism could be detected in patients with different types of infrarenal aortic disease by quantitating urinary LVP. Patients were divided into one of five groups and had urine analyzed for LVP. These are control, no known aortic disease (n = 12); occlusive aortic disease (n = 10); elective abdominal aortic aneurysms (AAA) (n = 26); ruptured AAA (n = 5), and multiple aneurysms (n = 4). Urine values were correlated with aortic elastase and aortic antiprotease activity. Urinary LVP was significantly higher in patients with multiple aneurysms (1,209 micrograms per milliliter of urine) as compared with all of the other groups. Patients with elective AAA had significantly higher urinary LVP (40.5 micrograms per milliliter of urine) than patients with occlusive disease (9.1 micrograms per milliliter of urine) and those in the control group (4.2 micrograms per milliliter of urine). Patients with ruptured AAA did not have significantly elevated urinary LVP compared with other groups (18.6 micrograms per milliliter of urine). Urinary LVP increased significantly as aortic elastase and aortic elastase and antiprotease activity increased. These data suggest that elastin metabolism, as reflected by urinary LVP, is altered in patients with aortic aneurysmal disease and provide further evidence to support the concept that systemic elastin metabolism is altered in patients with different types of infrarenal aortic pathologic findings.     

Surgical treatment of hilar carcinoma of the bile duct

The operative results of hilar carcinoma of the bile duct are extremely poor and there are few long term survivors. During the past seven years and six months at our clinic, 26 of 32 patients with hilar carcinoma were operated upon and 24 of these patients underwent resection with a resectability rate of 92.3 per cent. There was one operative death and the mortality was 3.8 per cent in 26 patients operated upon and 4.2 per cent in 24 patients who underwent resection. Seven are still alive postoperatively. The longest survival time is five years and seven months without a recurrence after right trisegmentectomy for carcinoma of the intrahepatic bile duct with hilar invasion. Curative resection was performed upon ten of 26 patients who underwent operation. Of the patients who were operated upon, 12 had invasion of the parenchyma of the liver at the hilum and 11, invasion of the caudate lobe, including direct invasion in three and invasion of the bile ducts in eight. Therefore, the caudate lobe should be resected for radical operation for hilar carcinoma. In this study, the anatomy of the hilar area, including vascular structures of the caudate lobe, was evaluated in 106 cadavers, concerning radical operation for hilar carcinoma.     

Factors influencing the rupture of abdominal aortic aneurysms

The gross findings of 49,144 autopsies performed at two major hospitals in Rome were reviewed. There were 297 patients who were found to have atherosclerotic abdominal aortic aneurysm (AAA). The aneurysm was intact in 220 (74 per cent) and ruptured in 77 (26 per cent). The occurrence of aneurysm rupture was correlated to 17 variables by univariate and multivariate statistical analysis. Covariates found to be independently predictive of the rupture of AAA were the size of the aneurysm (p less than 0.001), arterial hypertension (p less than 0.001) and the presence of bronchiectasis (p less than 0.025.). Over-all, bronchiectasis was more common among patients with AAA than in the age-adjusted and sex-adjusted control population. The simultaneous presence of bronchiectasis and AAA suggests the presence of some inherited or acquired tendency to have ectasia of the connective tissue, aneurysm formation and rupture development.