Surgical treatment of aneurysms of the abdominal and thoracic aorta

The danger of an arteriosclerotic abdominal aortic aneurysm is clearly related to the size of the aneurysm. From available clinical data it seems logical to recommend elective surgical excision and graft replacement of abdominal aneurysms 6 cm or greater in diameter because of the considerable danger of rupture of untreated aneurysms of this size. Although small aortic aneurysms do rupture, most patients with small abdominal aneurysms may be safely followed with examination at regular intervals. Surgery is reserved for those who demonstrate evidence of aneurysm expansion. The operative mortality rate for elective surgical excision of abdominal aortic aneurysms is by no means negligible but has probably diminished recently to levels of approximately 5% in the hands of experienced surgeons. Achievement of an operative mortality rate in this range requires sensible case selection, expeditious operative management and skillful postoperative care with particular attention to problems of hypoxemia in the early postoperative period.Patients with ruptured abdominal aortic aneurysms require immediate aneurysm resection for survival. Of those patients with ruptured abdominal aneurysms who reach the hospital alive, approximately 60% should be salvaged at present by emergency surgery.The prognosis of the patient with a thoracic aortic aneurysm depends upon the etiology of the aneurysm. Syphilitic aneurysms of the thoracic aorta are now fortunately rare but appear to have a high incidence of rupture. The prognosis of patients with arteriosclerotic aneurysms, which characteristically involve the descending thoracic aorta, appears to be considerably better than that of patients with aneurysms of the abdominal aorta for unknown reasons. Since the removal of thoracic aneurysms ordinarily requires extracorporeal bypass and is associated with an operative mortality rate in the range of 20%, considerable judgment must be exercised in case selection for elective resection of such aneurysms.The surgery of dissecting aneurysms of the thoracic aorta has recently been modified by the widespread acceptance of antihypertensive drug therapy for acute dissection. Surgery may be reserved, hopefully on an elective basis, for those patients with significant aortic valvular insufficiency, significant aneurysmal dilatation of the dissected aorta, or symptomatic involvement of a major aortic branch in the dissection.     

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms.

Suprarenal or supraceliac aortic clamping during repair of infrarenal abdominal aortic aneurysms can be complicated by renal, hepatic, and intestinal ischemia. To determine whether suprarenal or supraceliac clamping increases morbidity and mortality we retrospectively reviewed our recent nonrandomized experience. Between January 1993 and December 1998, 716 patients underwent elective (n=682) or urgent (n=34) infrarenal abdominal aortic aneurysm repair. Infrarenal clamping was used in 516 (72. 1 %) and suprarenal or supraceliac clamping in 200 (279%). The suprarenal/supraceliac group had significantly more older patients (> or = 70 years of age) (65.5% vs 477%) and a higher incidence of preoperative renal insufficiency (75% vs 5.5%). Suprarenal or supraceliac clamping was used during repair of ruptured (n=25), juxtarenal (n=7), or inflammatory abdominal aortic aneurysms (n=4); during concomitant renal or visceral revascularization (n=43); in other difficult settings (n=13); or at the surgeon's discretion (n=108). The decision for such clamping was always made during surgery In treating ruptured aneurysms, suprarenal/supraceliac clamping (25/200) was used more often than infrarenal clamping (9/516) (12.5% vs 1.74%). Operative times were similar in both groups, but transfusion requirements and length of hospital stay were slightly greater in the suprarenal/supraceliac group. Perioperative mortality was 3.1% overall, but higher in the suprarenal/ supraceliac group than in the infrarenal (75% vs 1.4%). Postoperative complications developed in 26 (13%) of patients who underwent suprarenal/supraceliac clamping. Abdominal re-exploration was required in 9 other patients. We conclude that, despite associated comorbidities, elective suprarenal/supraceliac clamping during infrarenal abdominal aortic aneurysm repair is safe, facilitates repair, and does not significantly increase mortality.     

Outcome of cardiac and thoracic aortic operation in patients over 80 years old

A retrospective analysis was performed to determine the early outcome of cardiac and thoracic aortic surgery in patients over 80 years old. Between 1994 and 2000, 41 octogenarians (mean age, 82.6 +/- 2.5 years) underwent coronary artery bypass grafting (25), valve surgery (8), thoracic aortic aneurysm repair (7), or combined valve and bypass surgery (1). Overall hospital mortality was 9.8%. Mortality rates for specific procedures were 12% for coronary bypass, 0% for valve surgery, and 14% for thoracic aortic aneurysm repair. Major postoperative complications affected 27% of patients and included severe low cardiac output, respiratory failure, and acute renal failure, with a low incidence of perioperative stroke (2.4%). Cardiac and thoracic aortic operations can be performed with acceptable mortality and morbidity when appropriately applied in selected octogenarians.     

Screening, diagnosis and advances in aortic aneurysm surgery

BACKGROUND: Aortic aneurysms are common in the elderly and a frequent cause of sudden death. As elective aneurysm repair has a mortality drastically lower than that associated with rupture, the emphasis must be on early detection and repair free from complications. Recent advances include ultrasound screening for asymptomatic abdominal aortic aneurysm (AAA) and clinical trials on the size of AAA that require repair. Pre-operative assessment, management of cardiac risk, autologous blood transfusion strategies, and endovascular stent graft technology to avoid major open surgery are all issues to be addressed. METHODS: Following a computerized Medline search for publications on the detection and treatment of abdominal and thoracic aortic aneurysm, the publications identified were then read and the references within those publications examined for further publications on this topic. We have reviewed these publications without attempting a meta-analysis. RESULTS: Randomized population studies have addressed ultrasound screening for AAA. Attendance for screening was good and AAA detection inexpensive. Screening men from 65 years reduces the mortality from rupture and is cost-effective. Open thoracic and abdominal aneurysm repair has a mortality of around 8%, with myocardial infarction being a frequent cause of death. Pre-operative reduction of cardiac risk by cardiac investigations and beta-blockade may reduce this mortality. Autologous transfusion techniques such as acute normovolaemic haemodilution and interoperative cell salvage reduce the need for allogeneic blood and the complications associated with open surgery. Minimally invasive endovascular repair is now possible for 40% of the AAA and an increasing proportion of thoracic aneurysms. CONCLUSIONS: The combination of screening, reduced pre-operative risk, and new minimally invasive techniques extends aortic aneurysm treatment into an increasingly elderly population. The combination of these techniques will reduce mortality from ruptured aortic aneurysm in the elderly and also reduce the stress associated with aneurysm surgery.     

Proximal clamping levels in abdominal aortic aneurysm surgery

In the surgical treatment of abdominal aortic aneurysm, the single proximal cross-clamp can be placed at 3 alternative aortic levels: infrarenal, hiatal, and thoracic. We performed this retrospective study to evaluate the advantages and disadvantages of the 3 main aortic clamping locations. Eighty patients presented at our institution with abdominal aortic aneurysms from March 1993 through May 1998. Fifty of these patients had intact aneurysms and underwent elective surgery, and 30 had ruptured aneurysms that necessitated emergency surgery. Proximal aortic clamping was applied at the infrarenal level in 24 patients (22 from the intact aneurysm group, 2 from the ruptured group), at the hiatal level in 34 patients (22 intact, 12 ruptured), and at the thoracic level (descending aorta) via a limited left lateral thoracotomy in 22 patients (6 intact, 16 ruptured). Early mortality rates (within 30 days) were 4% (2 of 50 patients) among patients with intact aneurysms and 40% (12 of 30 patients) among those with ruptured aneurysms. In the 2 patients from the intact aneurysm group, proximal aortic clamps were applied at the hiatal level. In the ruptured aneurysm group, proximal aortic clamps were placed at the thoracic level in 10 patients, the infrarenal level in 1, and the hiatal level in 1. According to our study, the clinical status of the patient and the degree of operative urgency--as determined by the extent of the aneurysm--generally dictate the proximal clamp location. Patients who present with aneurysmal rupture or hypovolemic shock benefit from thoracic clamping, because it restores the blood pressure and allows time to replace the volume deficit. Infrarenal placement is advantageous in patients with intact aneurysms if there is sufficient space for the clamp between the renal arteries and the aortic aneurysm. In patients with juxtarenal aneurysms, hiatal clamping enables safe and easy anastomosis to the healthy aorta. Clamping at this level also helps prevent late anastomotic aneurysm formation, which is frequently encountered after inadvertent anastomosis of the graft to a diseased portion of the aorta. Further studies are needed in order to confirm these results.     

Trends and Outcomes of Elective Thoracic Aortic Repair and Acute Thoracic Aortic Syndromes in the United States

BackgroundThere is a paucity of data on the contemporary outcomes and trends of elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome.MethodsWe queried the National Inpatient Sample (NIS) database years 2012-2016 to identify hospitalizations for elective thoracic aortic aneurysm repair and aneurysm-associated acute aortic syndrome. The main study outcome was in-hospital mortality.ResultsThe analysis yielded 24,295 hospitalizations for elective thoracic aortic aneurysm repair and 8875 hospitalizations for aneurysm-associated acute aortic syndrome. The number of hospitalizations for elective aortic repair significantly increased from 4375 in 2012 to 5450 in 2016 (P_trend = .01). The number of hospitalizations for acute aortic syndrome numerically increased from 1545 in 2012 to 2340 in 2016 (P_trend = .10). Overall in-hospital mortality for elective aortic repair was 2.4% with no change over time. In-hospital mortality for acute aortic rupture was 39.4% and for acute aortic dissection was 6.2% with no change over time. Hospitalizations for elective aortic repair had lower incidence of complications compared with those for aneurysm-associated acute aortic syndrome, including cardiogenic shock, cardiac arrest, acute stroke, and shorter length of stay. Factors associated with higher mortality among admissions undergoing elective aortic repair included older age, heart failure, valvular disease, and chronic kidney disease. Older age, coagulopathy, and fluid/ electrolytes disorders were associated with increased mortality among those with acute aortic syndrome.ConclusionContemporary elective thoracic aortic aneurysm repair is associated with lower in-hospital mortality and morbidity when compared with a clinical presentation for an aneurysm-associated acute aortic syndrome. This should be taken into account when deciding the timing of elective aortic aneurysm repair and balancing the risks and benefits.     

Personal experience of the treatment of ruptured aortic aneurysms. The prognostic evaluation of some parameters

BACKGROUND: The rupture of an aortic aneurysm is the most frequent and most severe complication, with an incidence of approximately 20-40/100,000 persons each year. The aim of this study was to identify the preoperative, intraoperative and postoperative factors that may influence the mortality rate. METHODS: Between January 1996 and December 1999 145 patients underwent emergency abdominal aortic repair surgery. One hundred and twenty-three patients represented a ruptured AAA and 22 a fissured aneurysm. One hundred and thirty-one patients were males and 14 were females; their mean age was 75+/-5.06 years. We selected a number of parameters after a review of the international literature and these were analysed in the two classes of survivors. No statistical analyses were performed on fissured aneurysms owing to the scant number of cases examined. RESULTS: Mortality was 41.4% (44.7% in ruptured aneurysms alone). The following were negative preoperative prognostic factors: old age, hypertension, ASA V, intraoperative anuria and platelet count <100,000. Intraoperative factors included: hypotension, cardiac arrest, onset of anuria, aortic clamping in more than one site, duration of surgery, quantity of RBC and plasma transfused. The main postoperative variables correlated to mortality were: hypotension, hypothermia, onset of anuria, need for further transfusions, high creatinine levels. CONCLUSIONS: Rapid intervention can minimise mortality in structures with expert teams of surgeons and anesthetists experienced in treating this type of pathology.     

Diagnostic and surgical management of patients with aneurysms of the thoracic aorta with various causes. Echocardiography and contrast enhanced computed tomography in prophylactic replacement of the ascending aorta

Sixty eight patients with aneurysms of the thoracic aorta were studied. Forty one had aortic dissection, 24 had dilatation only, and three had transverse aortic rupture. Sixteen had Marfan's syndrome; 17 had hypertension; and in eight there were other causal factors. In 17 the cause of the aneurysm was unknown. Histological examination did not help to establish the cause of aneurysm. Echocardiography failed to detect dissection of the ascending aorta in four (21%) out of 19 cases studied. The mortality rate in the whole series was 26%. Early (operative and hospital) and late deaths occurred in 20% and 6% of patients respectively. The early mortality rate was 40% in the 24 emergency cases of dissection of the ascending aorta, 9% in patients operated on for dilatation of the ascending and transverse aorta without dissection, and 8% in patients with chronic dissection of the ascending aorta who had elective operation. Early and late mortality rates were no higher in patients with Marfan's disease than in any of the other groups. It is suggested that contrast enhanced computer tomography should be performed in all patients with pronounced aortic root dilatation and in patients with Marfan's disease with symptoms which suggest dissection, even if they have only slight aortic root dilatation. Preventive replacement of the ascending aorta should be considered in more patients to reduce the number of emergency operations, in which the mortality rate is high. There is no definite limit of aortic root dilatation above which preventive replacement of the ascending aorta should be routinely considered.     

Diagnostic and surgical management of patients with aneurysms of the thoracic aorta with various causes. Echocardiography and contrast enhanced computed tomography in prophylactic replacement of the ascending aorta.

Sixty eight patients with aneurysms of the thoracic aorta were studied. Forty one had aortic dissection, 24 had dilatation only, and three had transverse aortic rupture. Sixteen had Marfan's syndrome; 17 had hypertension; and in eight there were other causal factors. In 17 the cause of the aneurysm was unknown. Histological examination did not help to establish the cause of aneurysm. Echocardiography failed to detect dissection of the ascending aorta in four (21%) out of 19 cases studied. The mortality rate in the whole series was 26%. Early (operative and hospital) and late deaths occurred in 20% and 6% of patients respectively. The early mortality rate was 40% in the 24 emergency cases of dissection of the ascending aorta, 9% in patients operated on for dilatation of the ascending and transverse aorta without dissection, and 8% in patients with chronic dissection of the ascending aorta who had elective operation. Early and late mortality rates were no higher in patients with Marfan's disease than in any of the other groups. It is suggested that contrast enhanced computer tomography should be performed in all patients with pronounced aortic root dilatation and in patients with Marfan's disease with symptoms which suggest dissection, even if they have only slight aortic root dilatation. Preventive replacement of the ascending aorta should be considered in more patients to reduce the number of emergency operations, in which the mortality rate is high. There is no definite limit of aortic root dilatation above which preventive replacement of the ascending aorta should be routinely considered.     

Ascending aorta or arch surgery: is previous cardiac surgery a risk factor?

Surgery on the ascending aorta +/- arch is a challenge. The risks involved in such operations after previous cardiac surgery were assessed in elective and emergency settings in a single institution. Over a 10-year period, 29 patients underwent replacement of the ascending aorta +/- arch following previous cardiac surgery. In 12 patients (41.4%), the procedure was carried out on an emergency basis. Thirteen had previous replacement of the ascending aorta and 16 had previous valve replacement with or without coronary artery bypass; 4 patients were undergoing a 3rd cardiac operation. Concomitant procedures included coronary artery bypass in 2, arch replacement in 4, and descending aortic replacement in one. The overall in-hospital mortality was 13.8% (4/29) vs. 12.4% (33/267) in primary procedures. Mortality in elective repeat surgery was 5.9% (1/17) vs. 25% (3/12) in emergency re-operations. The incidences of permanent stroke (3.4%) and renal failure (3.4%) were similar to first-time operations. Elective re-operation for ascending aorta +/- arch repair can be accomplished with acceptable mortality and morbidity. Outcomes in emergency cases carry a higher early mortality but still conform to contemporary expectations and are similar to emergency first-time aortic surgery.     

Predictors of aneurysmal formation after surgical correction of aortic coarctation

OBJECTIVES: We sought to identify the predictors of aneurysmal formation after surgical correction of aortic coarctation. BACKGROUND: In 9% of patients, aneurysms develop late after corrective surgery of coarctation of the aorta, with a 36% mortality rate if left untreated. However, the predictors of postsurgical aneurysmal formation are unknown. METHODS: Of 25 aortic aneurysms requiring corrective surgery 152 +/- 78 months after the initial coarctation repair, 8 were located in the ascending aorta (type A) and 17 at the site of previous repair (local type). Seventy-four patients without progression of the aortic diameter within 189 +/- 71 months after coarctation repair were used for categorical data analysis in an attempt to identify the predictors of postsurgical aneurysmal formation. RESULTS: Advanced age at coarctation repair (p = 0.004) and patch graft technique (p < 0.0005) independently predicted local aneurysmal formation. Type A aneurysm was univariately associated with the presence of a bicuspid aortic valve (p = 0.02), advanced age at coarctation repair (p = 0.044) and a high preoperative peak systolic pressure gradient of 74 +/- 21 mm Hg (p = 0.041). Conversely, multivariate analysis confirmed only the presence of a bicuspid aortic valve (p = 0.015) as an independent predictor of type A aneurysm. Receiver operating characteristic curve analysis revealed that 72% of patients with a postsurgical aneurysm had an operation at age 13.5 years or more, whereas 69% with no postsurgical aneurysm had an operation at a younger age. CONCLUSIONS: Use of the patch graft technique and late correction of coarctation can predict aneurysmal formation at the site of coarctation repair, although patients with a bicuspid aortic valve may be at risk for an aneurysm developing in the ascending aorta, particularly after late repair of aortic coarctation with high preoperative pressure gradients.     

Diagnosis and treatment of concomitant aortic and coronary disease: a retrospective study and brief review.

Coronary arteriosclerosis seriously complicates the surgical treatment of aortic diseases. The aim of our retrospective study was to determine the incidence of coronary artery disease among our surgical patients in treatment for aortic dissection or aneurysm, and to determine whether coronary intervention before aortic surgery appears to affect outcomes. Between 1 January 1993 and 1 March 1998, our center treated 253 patients for aortic dissection or aneurysm. We examined these cases retrospectively for information on diagnostic and treatment methods, both for the aortic lesions and for concomitant coronary arteriosclerosis. Aortic dissection had been detected in 86 (33.9%) patients and aortic aneurysm in 167 (66.1%). Coronary angiography was performed to search for concomitant coronary artery disease in 29 (33.8%) patients with dissection and in 112 (67.1%) patients with aneurysm; of these, 11 (12. 7%) and 54 (32.3%), respectively, were found to have coronary disease. Among 43 patients with abdominal aortic aneurysm in whom coronary angiography was performed, concomitant coronary disease was detected in 36 (83.7%). Coronary artery bypass surgery was performed in 10 patients who had dissection and in 30 patients who had aneurysm; percutaneous transluminal coronary angioplasty was performed in 7 patients who had aneurysm. Perioperative mortality rates in the dissection and aneurysm groups, overall, were 23.2% and 13.8%, respectively Unfortunately, the prospective, random clinical study that would be necessary to prove the case for or against preoperative coronary angiography among subsets of patients in need of aortic repair would raise ethical questions, given the strength of the information already in our possession, gathered by less formal methods. Our study reinforces existing evidence that preoperative angiography can reduce mortality and morbidity in the elective repair of aortic aneurysm, especially thoracic or abdominal aneurysm. However, angiography should not be performed routinely in cases of aortic dissection and should be withheld in cases of type A dissection.     

Effects of coronary insufficiency on the early and late results in patients surgically treated for aneurysm of the sub-renal abdominal aorta

Between 1973 and 1988, 200 patients underwent repair of unruptured aortic aneurysm located distal to the renal arteries. There were 181 men (90%) and the mean age was 68.8 years. The most serious associated disease was arteriosclerotic heart disease which was present in 102 patients (51%): 48 patients had angina pectoris; 59 patients had previous myocardial infarct; 8 patients had ischemic myocardiopathy. Associated cerebrovascular disease was found in 29 patients (15%). Of these 200 patients, 36% had no symptoms relating to the aneurysm. The aneurysm was associated with iliac aneurysm (19%), iliac occlusion (14%), distant femoral occlusion (14%). In patients with history of coronary arteries disease (102), 39 (18%) had a coronary angiography prior the elective resection, 18 (9%) coronary artery bypass surgery underwent elective myocardial revascularisation prior to elective resection of their aneurysm. The treatment was by graft replacement and exclusively by graft inclusion. RESULTS: Death occurred within 30 days of treatment in 5 patients (2.5%). The first cause of early death was myocardial infarct (3). Early peripheral vascular complication occurred within 30 days in these 200 patients and were thromboembolism in 12 patients and colic ischemia in 8 patients. Of the 83 patients (1975-1983) who survived operation, follow up information regarding survival was obtained in 79 patients. The overall 5 and 8 years survival rates in percentage in the series were 69% and 50%. The survival rate was greatest in patients free of associated disease and worse in patients with myocardial infarctus. Subsequently 24 vascular operations were performed in these patients: 7 iliac aneurysms, 16 occlusive lesions and 2 false aneurysms. DISCUSSION: Young (15) and associates reported an operative mortality rate of 6.3% for elective aneurysm resection but found that 20% of the patients with pre-operative evidence of coronary artery disease had post-operative myocardial infarct of which 58% were fatal. Hertzer and colleagues (6), using routine coronary angiography prior to elective aortic reconstruction, have documented a 59% incidence of significant anatomic coronary artery disease. This incidence increased to 95% in patients with abdominal aortic aneurysm and suspected coronary artery disease. Only one patient of the 68 patients with an abdominal aortic aneurysm had normal coronary arteries in their series. Thus, considering the omnious implications of coronary artery disease in patients with abdominal aortic aneurysms, routine preoperative coronary angiography has been recommended. For Brown and coll. (1), it would appear that the risk of prophylactic coronary artery revascularisation may be greater than that for elective abdominal aortic aneurysm resection alone in the older age group. For the authors, only patients which instable angina pectoris or angina pectoris with a myocardial infarct had a coronary angiography. The coronary artery bypass is recommended for left maintrunk obstruction or diffuse multivessel coronary artery disease.     

Influence of the first assistant on abdominal aortic aneurysm surgery

The hypothesis that the type of first assistant who attends the surgeon influences the course and outcome of graft replacement for abdominal aortic aneurysm was tested. Surgical results were analyzed in 179 consecutive patients (149 men and 30 women; mean age, 69 +/- 7.5 years). All the operations were performed by the author-an experienced surgeon with a practice limited to general vascular surgery. The choice of first assistant was based solely on availability; 110 (61%) patients had a board-certified surgeon as the first assistant and 69 (39%) had an experienced registered nurse as the first assistant. Patients with intact aneurysms undergoing elective surgery were in Group 1, and patients with intact aneurysms undergoing urgent surgery were in Group 2. Group 3 patients included those who had ruptured aneurysms but were hemodynamically stable, and Group 4 patients had ruptured aneurysms and were in shock. The distribution of patients was similar in each first-assistant group, as was the use of straight and bifurcated graft reconstructions, associated visceral procedures, and other adjunctive procedures. The hospital mortality was 4% (6/149) for Group 1 patients, 12% (2/17) for Group 2,20% (1/5) for Group 3, and 50% (4/8) for Group 4 patients. The morbidity and mortality rates were independent of the type of assistant, as were the operative time, blood loss, and adjusted blood transfusion volume. These results suggest that the choice of either an MD-surgeon or an experienced RN as first assistant does not influence the course or outcome of abdominal aortic aneurysm surgery.     

Ten-year results following elective surgery for abdominal aortic aneurysm.

OBJECTIVE: 10-year results after elective operation for infrarenal aortic aneurysm considering the influence of risk factors. EXPERIMENTAL DESIGN: Retrospective study with 5-12 year postoperative follow-up. SETTING: University hospital (Klinikum Grosshadern, Munich). PATIENTS: The long-term follow-up was based on 521 (95.6%) out of 545 consecutive patients operated upon electively for abdominal aortic aneurysm between 1978 and 1987. INTERVENTIONS: The infrarenal aneurysms were excluded by aortic tube grafts (314 patients, 59%) or bifurcation grafts (231 patients, 41%). MEASURES: The birthday, operation day and eventually the day of death in the hospital were documented in the charts. The patient's state or cause of death were elicited on the phone 5 to 12 years after the operation. Kaplan-Meier survival curves were calculated based on these data and compared to age-matched normal male populations. RESULTS: Hospital mortality was 6.4%. The cumulative rate of survival following elective surgery was 65% at 5 years and 41% at 10 years, the mean survival time being 95.1 months. Age, coronary artery disease and hypertension had a significant influence on the cumulative survival. Patients with aorto-coronary bypass had a better long-term outcome than those without bypass surgery. CONCLUSIONS: The excellent long-term results within a high-risk population support elective surgery of infrarenal aortic aneurysms. Results of new interventional techniques will have to be compared with this "golden standard" follow-up.     

Risk evaluation and midterm outcome of cardiac surgery in patients on dialysis

The medical charts of 54 patients on maintenance dialysis who underwent cardiovascular surgery (37 elective and 17 urgent/emergency) from 1994 to 2004 were retrospectively analyzed. Thirty patients had coronary artery bypass grafting (17 elective and 13 urgent/emergency), 18 had valve replacement (16 elective and 2 urgent/emergency), and 6 underwent aortic surgery (4 elective and 2 urgent/emergency). The overall early mortality rate was 11.1%, comprising 2 patients (5.4%) who had elective operations and 4 (23.5%) who had urgent or emergency operations ( p = 0.049). The overall 5-year survival rate was 48.4%. The 5-year survival rate was 67.2% for elective surgery and 10.5% for urgent/emergency surgery ( p = 0.0001). The midterm clinical results after elective cardiovascular surgery were acceptable, whereas the results after urgent/emergency surgery were poor. For elective surgery, sufficient and detailed preoperative examinations might have contributed to the better operative outcome. Early diagnosis and consultation to avoid urgent/emergency operations in dialysis patients is recommended.     

Cardiac surgery in the octogenarian: perioperative outcome and clinical follow-up

The perioperative and follow-up results of cardiac operations employing extracorporeal circulation and cold cardioplegic arrest were examined in 191 consecutive patients greater than or equal to 80 years of age having surgery over a 5 year period (1982 to 1986). Most patients had severe preoperative symptoms with functional class III (39.8%) or IV (57.1%) limitation. The overall 30 day postoperative cardiac mortality rate was 15.7%. The total in-hospital mortality rate was 18.8%; the mean postoperative hospital stay was 16.4 +/- 13.3 days. The perioperative mortality rate for elective operations was as follows: coronary artery bypass (5.6%), aortic valve replacement (9.6%), aortic valve replacement with coronary bypass (17.9%) and mitral valve surgery with or without coronary bypass (21.4%). Urgent operations were performed in 39 patients (20.4%) with a total perioperative mortality rate of 35.9%; urgent coronary artery bypass was performed in 26 patients (67%) with an in-hospital mortality rate of 23.1%. Clinical evidence of left ventricular failure, functional class IV symptoms, left ventricular ejection fraction less than 50%, mitral valve repair or replacement for severe mitral regurgitation and urgent operation were associated with an increased perioperative mortality rate. Follow-up study in all 155 patients surviving postoperative hospitalization at 22.6 +/- 14.8 months showed significant improvement in symptom status in all surgical subgroups. There were 18 follow-up deaths (11.6%); 10 were noncardiac. The actuarial survival rate of the entire study group was significantly better than that in age- and gender-matched control subjects (p = 0.037).(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical techniques. Thoracoabdominal aorta

Patients presenting with impending rupture of a thoracoabdominal aortic aneurysm require emergency operative repair. To prevent rupture and its associated mortality, elective repair of thoracoabdominal aortic aneurysms exceeding 5.5 cm to 6.0 cm in diameter is recommended in patients with adequate physiologic reserve. Similarly, surgery should be considered for patients with smaller symptomatic aneurysms. Atypical symptoms have been associated with rupture, therefore, they require thorough evaluation. Whether the aortic conditions are caused by medial degenerative disease or chronic aortic dissection, surgical techniques allow for graft repair of thoracoabdominal aortic aneurysms with low mortality and morbidity rates. Although surgery is usually avoided in patients with acute distal aortic dissection, operative intervention is occasionally required when complications develop. Patients with acute aortic dissection complicated by impending rupture of the thoracoabdominal segment require graft repair to restore aortic integrity; although the mortality rate is acceptable, the incidence of postoperative paraplegia approaches 20% in this setting. For patients presenting with ischemic complications of acute distal aortic dissection, less-extensive surgical options have been effective in restoring perfusion. In experienced centers, overall operative survival rate following thoracoabdominal aortic surgery can exceed 92%. Retrospective data suggest that left heart bypass reduces the incidence of paraplegia following extensive thoracoabdominal aortic repairs. Although recent advances have led to improved outcomes, paraplegia continues to occur regardless of the strategy used. The prevention of spinal cord ischemia during thoracoabdominal aortic surgery, therefore, will remain a focus of controversy and investigation, just as it was more than 4 decades ago.     

Predictors of mortality after emergency or elective repair of abdominal aortic aneurysm in a Japanese population

In Japan, there has been virtually no study in a population large enough to definitively demonstrate a relationship between the preoperative clinical features and postoperative outcomes in patients undergoing abdominal aortic aneurysm (AAA) repair. The aim of this study was to determine the preoperative variables that significantly predict postoperative mortality after emergency or elective repair in Japanese patients with infrarenal AAA. In this retrospective cohort study, we assessed significant predictors of postoperative mortality in 1055 consecutive patients undergoing emergency (n = 186) or elective repair (n = 869) of an infrarenal AAA at the University of Tokyo Hospital or Sakakibara Heart Institute (Tokyo, Japan). Using logistic regression analysis, anemia (hemoglobin <9 g/dl), shock (systolic blood pressure <80 mmHg), and hypocholesterolemia (total cholesterol <120 mg/dl) were found to be independent preoperative predictors of 30-day mortality after emergency repair for ruptured AAA. The hazard ratio (HR) (95 % confidence interval) for these three predictors was 5.96 (1.70–20.84), 8.48 (1.47–49.02), and 7.31 (1.96–27.35), respectively. In the elective repair cases, no significant preoperative predictor of postoperative mortality could be identified either within or beyond 30 days of surgery. Hypocholesterolemia, anemia, and shock were found to be independent preoperative predictors of a postoperative high mortality rate in Japanese patients undergoing emergency repair for ruptured infrarenal AAA.     

Surgical treatment of pararenal abdominal aortic aneurysms

Thirty patients with juxtarenal infrarenal and 16 patients with suprarenal abdominal aortic aneurysms underwent elective (58%) or urgent (42%) repair. Twenty-three patients were hypertensive and 20 had impaired renal function preoperatively. Nineteen patients required combined aortic and renal artery reconstruction, in which reimplantation was the most common technique used. The perioperative mortality rate was 7.4% in the elective group and 36.8% in the urgent group. Rupture of the aneurysm and a preoperative high serum creatinine level were risk factors correlating to early mortality. Among survivors, 61% showed a rise in serum creatinine in the early postoperative period. In all but one the transient renal insufficiency was resolved within one month. Of the hypertensive patients 64% were cured or under control with medication following combined reconstruction. These results demonstrate that surgical repair of pararenal abdominal aortic aneurysms can be performed with an acceptable mortality and morbidity.