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.     

Transperitoneal approach and right retroperitoneal dissection for abdominal aortic aneurysm

Most abdominal aortic aneurysms can be resected through a standard transperitoneal approach. In patients with large aneurysms, supra-renal extension of the aneurysm, those requiring renal reconstructive procedures and in patients who have had previous extensive intra-abdominal operations, alternative approaches have been recommended. We exposed the abdominal aorta in ten of these difficult patients using a midline transperitoneal incision and right retroperitoneal dissection that provided excellent exposure of the suprarenal aorta. We recommend this technique for performance of complicated abdominal aortic aneurysm resections.     

Retroperitoneal in-line aortic bypass for treatment of infected infrarenal aortic grafts.

Since 1970, we have treated 43 patients with infected aortic grafts. Early in the series, four patients were treated with resection of the fistula or erosion and systemic and topical antibiotics without removal of the graft. All four patients died. Thirty-two patients were treated by conventional therapy; there were 13 deaths (40 percent). More recently, seven patients were managed by the left retroperitoneal placement of a new in-line polytetrafluoroethylene (PTFE) aortic graft through clean tissue planes, followed by the immediate transperitoneal removal of the infected graft without cross-contamination. Patients were maintained postoperatively on antibiotics for a minimum of two weeks. All seven patients survived without septic complications, with a mean follow-up time of 36 months (six months to four years). The surgical technique consists of initial suprarenal control of the aorta, followed by infrarenal division and oversewing of the distal aorta. A PTFE bifurcation graft is placed connecting the proximal aorta and the appropriate femoral vessels, the right limb tunneled through the space of Retzius. After closure of the incisions, through the space of Retzius. After closure of the incisions, the patient is placed in the supine position and the infected graft is removed transperitoneally. We believe that retroperitoneal in-line aortic bypass for treatment of an infected aortic graft offers a favorable alternative to conventional therapy by avoiding the use of an extra-anatomic bypass and associated risk of stump blowout.     

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.     

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.     

Twenty-one years' experience with ruptured abdominal aortic aneurysms.

The surgical experience with 107 ruptured abdominal aortic aneurysms at this hospital during the years 1953 to 1975 has been reviewed. The operative mortality rate during the first ten years of this study was 86 per cent, but since 1966, it has fallen to 40 per cent. These improved mortality statistics are related primarily to improved techniques for controlling operative blood loss and minimizing the time of aortic cross clamping. The use of an intra-aortic balloon has been useful in this regard. Twenty-four additional patients died from ruptured aneurysms without undergoing operation, all before 1966. Only seven had a correct diagnosis prior to death, and these seven serve to emphasize the importance of being alert to the diagnosis of ruptured aneurysm which often masquerades as urologic or orthopedic problems because of the frequent symptoms of back, abdominal, flank or groin pain. Since the operative mortality rate for elective resection of the aneurysm has been less than 1 per cent at this institution during the last eight years, we believe we are justified in encouraging prompt resection of aneurysms on an elective basis to eliminate the high mortality rate that still accompanies rupture of the aneurysm.     

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.     

The hemodynamics of extra-anatomic bypass grafts.

The hemodynamics of extra-anatomic bypass were studied with the use of right to left iliac artery bypass grafts. An arteriovenous fistula on the recipient side was used to increase the flow through the graft. Flow measurements in this model under normotensive conditions showed proportionate increases in the suprarenal aortic blood flow and in the blood flow through the segment of donor artery proximal to the bypass graft anastomosis. Stealing of blood was not observed even when the graft flow was increased to approximately 11 times the normal flow in the donor artery. Arfonad was used for producing hypotension through vasodilatation. In the presence of peripheral vasodilatation, adequate blood flow can be expected after such bypass grafts at blood pressures as low as 80 millimeters of mercury and hypotension per se does not produce vascular steal.     

Hemoaccess site infection.

Infectious complications involving a hemoaccess graft or fistula are a significant cause of morbidity in patients on chronic hemodialysis. A review of 274 consecutive hemoaccess procedures identified 28 infections (an incidence of 10 per cent). Infections occurred in 27 polytetrafluoroethylene (PTFE) grafts. The predominant organism was Staphylococcus aureus. Partial excision resolved 14 of the 27 graft infections. The remaining 13 required complete removal. Surgical management required six arterial ligations and seven autogenous reconstructions. No limb ischemia or mortality was directly attributable to these procedures. One infection occurred in 48 autogenous fistulas (an incidence of 2 per cent). Although partial removal of an infected prosthesis was often sufficient, brachial artery ligation was well tolerated when required to control anastomotic infection.     

Evaluation of modified human umbilical vein as an arterial substitute in femoropopliteal reconstructive surgical procedures.

Modified human umbilical vein allografts tanned with glutaraldehyde and encased in a polyester mesh were used as arterial substitutes in 13 femoropopliteal reconstructive procedures. A cumulative patency rate of 91 per cent has been obtained for the two year follow-up period. Two grafts were lost due to patient death from myocardial infarction. The grafts were determined to be patent at the time of death, and no death was in any way associated with the graft material. One graft occluded immediately postoperatively due to the absence of any significant distal runoff to the arteries of the calf. There has been no incidence of aneurysmal formation, and based upon our previous experience with bovine artery heterograft, the modified human umbilical vein appears to be superior in this respect. Modified human umbilical vein allograft is superior to autogenous saphenous vein in that it is immediately available, valveless, branchless and may be specially constructed as to diameter and length. We have found the allograft to be flexible, easy to handle and suture, and of sufficient length, elasticity and compliance. Our cumulative patency rate for the two year follow-up period compares favorably with that of previously reported uses of autogenous saphenous vein in femoropopliteal arterial reconstruction. Those results show the modified human umbilical vein allograft to be well deserving as an alternative to autogenous saphenous vein in femoropopliteal arterial reconstructive procedures.     

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.     

Popliteal aneurysms

A 15 year experience with 50 popliteal aneurysms in 36 patients is reviewed. Forty-seven popliteal aneurysms were atherosclerotic while three were related to entrapment of the popliteal artery. Fourteen asymptomatic popliteal aneurysms were observed preoperatively during a mean period of 26 months. Ischemic complications developed in five of these. At admission, 16 limbs were asymptomatic (group 1) while the other 34 limbs presented with ischemic symptoms (group 2). No operation was performed upon three limbs, and another two were surgically explored and amputated. No operative deaths resulted from 45 vascular reconstructions. Results from follow-up study of one to 176 months (a mean of 57 months) revealed a late patency rate of 62 per cent. The late patency rate of autologous saphenous vein (ASV) was 100 per cent; polytetrafluoroethylene (PTFE) and Dacron (polyester fiber) grafts had a patency rate of 74 and 34 per cent, respectively (ASV versus PTFE, p = N.S.; ASV versus Dacron, p less than 0.002). The rate of late salvage of limbs was 88 per cent. The bypass grafts of group 1 and those performed upon limbs with good runoff fared significantly better than others (p less than 0.05 and p less than 0.001). The risk of natural complications of popliteal aneurysms and the good results from surgical treatment suggested that a revascularization procedure in the asymptomatic stage is always recommended. The use of PTFE grafts for repair of popliteal aneurysms is justified when the ASV is not available. The use of Dacron grafts is no longer indicated.     

Bovine graft fistulas in patients with vascular access problems receiving hemodialysis.

Thirty-three bovine grafts were placed in 28 patients for vascular access for hemodialysis. The indications were lack of shunt sites and anticoagulation with Coumadin in patients without vessels suitable for construction of a primary arteriovenous fistula. All but one of the grafts were loops placed in the forearm. There were 20 complications associated with the 33 procedures. Three patients required replacement of the initial graft in the early postoperative period due to thrombosis. One additional patient required two graft replacements and eventual anticoagulation with Coumadin before a successful result was obtained. There have been no serious ischemic problems. Presently, there are 27 functional bovine grafts, and 68 per cent of these are currently used for vascular access for dialysis. Patient acceptance of the fistulas has been good. The loop bovine graft fistula in the arm is an excellent means for vascular access in the patient receiving hemodialysis.     

Management of an infected aneurysm of the groin secondary to drug abuse

Fifty-three infected aneurysms of the groin in known drug abusers have been treated since 1970. There was a recent history of attempted intravenous drug injection into the femoral vein in 50 patients. Twenty-three patients underwent revascularization immediately preceding or following excision and ligation of the mycotic aneurysm. Five graft infections, resulting in one death and three amputations, occurred in this group. Three grafts became occluded, resulting in one additional instance of an amputation within six months of operation. Thirty patients underwent excision and ligation only. Five extremities were amputated in the immediate postoperative period because of irreversible ischemic changes. Six patients underwent delayed reconstruction five days to two months postoperatively because of rest pain or gangrene limited to the forefoot. No deaths and no graft infections occurred in this group. In infected aneurysms of the groin from drug addiction, we recommend initial excision with ligation and delayed selective revascularization, if indicated.     

Polytetrafluoroethylene vein composite grafts across the knee

Fifteen Gore-tex vein composite femoral-popliteal artery bypass procedures were performed during the four year period of December 1975 to December 1979. Nine were performed for salvage of the limb and six, for incapacitating claudication. Preoperatively, all patients had an arteriographic evaluation of the outflow tract. CPR by the life-table method was 63 per cent at six years. Early failures were three occlusions within two months in patients with poor outflow. One late occlusion occurred at 16 months, and the limb was salvaged with a femoral tibial bypass graft. Another late occlusion was treated by thrombectomy at 24 months with continued patency. Late revision was carried out in one patient at seven months. This consisted of repair of a stenosis of the distal popliteal artery with salvage of the graft. Only two of ten grafts available for evaluation beyond one year have become occluded. All patients operated upon for claudication or with good runoff have patent grafts. On the contrary, none of the grafts to an isolated popliteal segment remained patent. When there is not sufficient autogenous saphenous vein available for femoral-popliteal bypass, the ready availability of a synthetic graft makes it an attractive choice. Nevertheless, our 63 per cent CPR at six years strongly suggests that the composite graft is a durable option.     

Initial experience with the AneuRx Stent Graft for the treatment of infrarenal abdominal aortic aneurysm.

ABSTRACT: We report our initial experience with the modular AneuRx Stent Graft System for the treatment of infrarenal abdominal aortic aneurysm (AAA) in National Taiwan University Hospital. From July 2002 to October 2003, 5 patients were recruited for stent graft repair. Patients were all male, and aged from 62 to 82 years. The stent grafts were deployed via the opened femoral arteries under fluoroscopic guidance. Endograft deployment was successful in all 5 patients. The average procedure time was 139 +/- 23 min, and mean blood loss was 310 +/- 167 mL. All patients had a smooth postoperative course. Type II endoleak was noted in 3 patients initially, which sealed spontaneously in 2 of them. One patient developed graft limb thrombosis 1 month after operation, which was treated by femoral-femoral bypass. Treatment was successful in all patients with no mortality during 1-year postoperative follow-up.     

Small artery syndrome in women

During the past four years, 106 women underwent aortography and peripheral runoff studies for peripheral vascular disease. Eleven patients presented with "small vessels" and were selected for this study. They were significantly younger than the rest of the group (a mean age of 52 versus 66 years). A clear history of claudication was elicited in all patients. Rest pain was present in four patients. Most patients were small in stature but not obese. Weak or absent femoral and distal pulses and abdominal or femoral bruits were common. Angiography demonstrated a narrow infrarenal aorta, narrow iliac and common femoral arteries and a straight course of iliac arteries. Atherosclerotic lesions involved mainly the aortoiliac segment, but were confined to the superficial femoral artery in two patients. Reconstruction was achieved by endarterectomy or transluminal angioplasty in segmental aortoiliac disease and aortobifemoral or aortobi-iliac graft in diffuse disease. Femorpopliteal or iliopopliteal graft or lumbar sympathectomy was performed in patients with significant femoral disease. In one patient, an acutely occluded femoral segment was replaced by a venous interposition graft. Two patients were treated conservatively. There were no operative deaths. Nine patients were markedly improved at follow-up examination. Graft thrombosis occurred in one patient with combined aortobi-iliac and iliopopliteal graft. The high incidence of single bifurcating lumbar arteries at the fourth and fifth lumbar vertebrae supports the hypothesis that aortic hypoplasia may result from embryonic overfusion of the dorsal aortas. Lipid abnormalities existed in 54 per cent of the patients. All women were heavy smokers and 73 per cent had a positive family history of cardiovascular disease.     

Repeat revascularization versus nephrectomy in the treatment of recurrent renovascular hypertension

Between 1960 and 1983, 38 patients underwent multiple operations for treatment of recurrent renovascular hypertension. There were 23 women and 15 men who ranged in age from eight to 69 years old (a mean of 48.5 years). The cause of hypertension requiring repeat operation was determined roentgenographically, three patients had new disease of the contralateral nonoperated renal artery, 21 patients had a new lesion of the ipsilateral (previously operated) renal artery and 14 patients had new lesions of both the previously operated and nonoperated renal arteries. Thirty patients underwent a secondary unilateral operation and eight had a bilateral operation. Sixteen patients had unilateral renal artery revascularization, 14 had unilateral nephrectomy, three had bilateral revascularization and five had unilateral revascularization with contralateral nephrectomy. There were three operative deaths (an operative mortality of 7.9 per cent). At hospital dismissal, 30 of 35 patients were improved. Follow-up study ranged from seven months to 23 years (a mean of 7.2 years). There were eight (22.9 per cent) late deaths. Secondary revascularization alone produced improvement in 77 per cent. Nephrectomy alone produced improvement in 80 per cent. We conclude that secondary revascularization is the treatment of choice in patients with recurrent renal artery stenosis. Nephrectomy should be reserved for patients who cannot undergo a revascularization procedure for technical or medical reasons.     

The use of the supraceliac aorta for hepatic arterial revascularization in transplantation of the liver

Thrombosis of the hepatic artery during the early post hepatic transplant period results in massive hepatocyte necrosis, bile duct damage and subsequent graft loss. The incidence of this complication is increased when hepatic arterial reconstruction is possible only by the placement of an interposition infrarenal iliac artery graft. We describe 45 hepatic transplants with difficult arterial reconstruction in which the supraceliac aorta was used for arterial reconstruction. Indications for using the supraceliac aorta as the primary site for arterial reconstruction were inadequate inflow through a narrow recipient common hepatic artery in 51 per cent, previously thrombosed common hepatic artery in 27 per cent, mechanical obstruction of the celiac axis in 13 per cent or intimal dissection in 9 per cent. Direct anastomosis of the donor hepatic artery to the supraceliac aorta was achieved in 22 patients, reducing the need for a graft by 49 per cent. Short segments of iliac artery graft (17 patients) or aortic conduit (six patients) to the supraceliac aortas were required because of insufficient length of the donor artery. The incidence of arterial thrombosis and graft loss were zero per cent in adults and 12.5 per cent in children, both significantly less when compared with the 23.0 to 70.0 per cent thrombosis rate when graft is placed in an infrarenal position. We conclude that routine use of the supraceliac aorta for difficult hepatic arterial reconstruction decreases the need for arterial grafts, the incidence of hepatic arterial thrombosis and loss of hepatic grafts.     

A district general hospital experience of surgical treatment of gastric and duodenal ulcer from 1970 to 1982

Seven hundred and thirteen patients who had undergone 793 operations for peptic ulcer disease during the years 1970 to 1982 were subsequently referred to a gastric follow-up clinic. The indications for initial elective surgical treatment (514) were failed medical management (448), recent hemorrhage (32) and obstruction of gastric outflow (34); for initial emergency surgical treatment (199), the indications were hemorrhage (97) and perforation (102). Reoperation was required in 80 patients-previous perforation (40), recurrent ulcer (32), reperforation (three), hemorrhage (three) and obstruction of gastric outflow (two). The over-all postoperative mortality rate was 4.2 per cent (33 of 713); 15 deaths occurred after elective surgical treatment (2.5 per cent) and 18 after emergency surgical treatment (8.6 per cent). The postoperative morbidity expressed in terms of duration of postoperative stay was unaltered for each procedure throughout the study period. Follow-up attendance rates at one, three, five and ten years were 86, 85, 74 and 28 per cent, respectively. Iron deficiency anemia was detected in 13.6 per cent of gastric resection procedures and 1.6 per cent of vagotomy and drainage procedures. No instances of macrocytic anemia and only two instances of asymptomatic metabolic bone disease were recorded. By providing accurate data for surgical audit, which suggested that screening for metabolic sequelae in the first decade after surgical treatment is not indicated and which resulted in alteration of policy toward peptic ulcer perforation, a specific follow-up clinic has proved valuable in formulating the over-all management policy regarding surgical treatment for peptic ulcer.