Aneurysm of the thoracic aorta. Review of 260 cases

In a 1980 review of the natural history and treatment of 176 thoracic aortic aneurysms, we noted the high incidence of rupture (47% overall) in 135 patients not treated surgically. Since that original study we have added another 84 patients to our series and have noted a complete change in management such that most patients are now treated surgically. We now have 260 patients in our series, 126 of whom were treated surgically. Sixty-seven were emergency operations and 59 were elective. Surgical mortality was 8% for elective resection and 33% for emergency operation. Over the past 5 years these figures have improved to 5% surgical mortality for elective resection and 16% surgical mortality for emergency resection. The 5 year survival rates for the entire series were 50% for patients treated with elective operation, 30% for combined emergency and elective operation groups, and 21% for nonsurgically treated patients. Abdominal aortic aneurysm was present in 74 patients (28%) and 23 of these patients had undergone a prior resection of an abdominal aortic aneurysm. This series documents the improved survival of patients with aneurysms of the thoracic aorta who are treated with prompt surgical intervention. It also further substantiates earlier findings of a high incidence of aneurysms of the abdominal aorta in this patient population.     

An evaluation of new methods of expressing aortic aneurysm size: relationship to rupture.

The diameter of aortic aneurysms were standardized to measures of patient size and normal aortic size in an effort to define indexes that might be more predictive of aneurysm rupture than raw aneurysm diameter alone. Normal aortic diameters were measured in 100 patients undergoing abdominal CT scans for other reasons, and an average infrarenal aortic diameter of 2.10 +/- 0.05 cm was observed. Normal aortic diameter was dependent on both age and sex, ranging from 1.71 +/- 0.06 cm in women below age 40 years to 2.85 +/- 0.04 cm in men above age 70 years. Overall, 11 (5.1%) of the ruptures occurred in aneurysms less than 5 cm in diameter, and four (1.9%) occurred in aneurysms less than 4.0 cm in diameter. When the CT scans of 100 patients undergoing elective aneurysm resection were compared with those of 36 patients with ruptured aneurysms, no threshold diameter value accurately discriminated between the two groups. However, standardization of the aneurysm diameter to the transverse diameter of the third lumbar vertebral body as an index of patient body size produced an accurate predictor of rupture when a threshold ratio of 1.0 was used. No aneurysm ruptured below this ratio, but 29% of elective aneurysms were smaller than the vertebral body diameter. Receiver operating characteristic curve analysis confirmed the superiority of the aneurysm to vertebral body diameter ratio as a discriminator of ruptured aneurysms. It appears that aneurysm diameter alone is not sufficiently predictive of rupture to be used as the sole indication for elective resection.     

Long-term survival following emergency abdominal aortic aneurysm repair

Survival following emergency surgery for ruptured abdominal aortic aneurysm remains poor and is in stark contrast to that for elective repair. We have carried out a 5-year retrospective observational study to determine the long-term (5-year) survival of patients following emergency surgery for ruptured abdominal aortic aneurysm at a district general hospital in East Anglia. A total of 99 patients presented to the operating theatre for emergency repair of ruptured abdominal aortic aneurysm in this 5-year study period. In-hospital mortality was 70% and was unchanged over the 5 years. Overall long-term survival in those patients discharged from hospital was good. The ICU cost per long-term survivor was calculated to be pound sterling 36750.     

Ruptured abdominal aortic aneurysm: factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed.     

Ruptured abdominal aortic aneurysm: Factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed. Presented at the Fifteenth Annual Meeting of the Japanese Association for Cardiovascular Surgery, Kanazawa, Japan, May 17–18, 1985.     

The impact of walking impairment,cardiovascular risk factors,and comorbidity on quality of life in patients with intermittent claudication

PURPOSE: This study assessed the cardiovascular disease, perioperative results, and survival after surgical abdominal aortic aneurysm repair in young patients (< or = 50 years) compared with randomly selected older patients who also underwent abdominal aortic aneurysm repair. METHODS: We reviewed hospital records to identify young and randomly selected control patients (3 for each young patient, > or = 65 years, matched for year of operation) with degenerative (atherosclerotic) abdominal aortic aneurysms undergoing repair between Jan 1, 1988, and Mar 31, 2000. Patients with congenital aneurysms, pseudoaneurysms, aortic dissections, post-coarctation dilations, aortic infection, arteritis, or aneurysms isolated to the thoracic aorta were excluded. Mortality data and cause of death were obtained from medical records and the National Death Index RESULTS: Among 1168 patients who underwent abdominal aortic aneurysm repairs, 19 young patients (1.6%) and 57 control patients were identified. The mean age was 48.4 years in the young group and 72.2 years in the control group. There were no differences in sex or race between the two groups. When comparing existing cardiovascular disease between the groups, there were no differences in the incidence of earlier coronary revascularization (26% vs 16%) or non-cardiac vascular surgery (5% vs 9%), but aneurysms were more commonly symptomatic in young patients (53% vs 21%; P <.01). Aneurysmal disease was limited to the infrarenal aorta in similar proportions of patients (89% vs 88%). No statistically significant differences were seen in the incidence of perioperative deaths (16% young vs 9% control; P =.40) or postoperative complications (37% young vs 26% control; P =.38). The estimated survival rate of the young group was not different from that of the control group (3-year survival rate, 73% vs 69%; P =.32) or the entire cohort of patients (older than 50 years; n = 1101) who underwent repair of abdominal aortic aneurysms during the study period (3-year survival 73% vs 75%; P =.63) CONCLUSION: After abdominal aortic aneurysm repair, young patients had perioperative results and follow-up mortality rates similar to those of control patients. Cardiovascular disease was the predominant cause of death after abdominal aortic aneurysm repair in the young patients. When compared with an age older than 50 years at the time of abdominal aortic aneurysm repair, young age alone was not associated with increased survival.     

Surgical repair of aneurysms involving the suprarenal, visceral, and lower thoracic aortic segments: early results and late outcome

OBJECTIVE: The purpose of this study is to review our experience with surgical repair of lower thoracoabdominal and suprarenal aortic aneurysms to determine early and late survival rates and identify factors influencing morbidity and survival among these patients. MATERIALS: From 1989 through 1998, 165 consecutive patients underwent repair of 108 thoracoabdominal (55 group III and 53 group IV) and 57 suprarenal aneurysms. The study group consisted of 109 men and 56 women with a mean age of 70 years (median, 70 years; range, 29-89 years). Mean aneurysm diameter was 6.9 cm (median, 6.5 cm; range, 4-12 cm). There were 125 aneurysms (76%) repaired electively; 40 repairs (24%) were nonelective. The cause of 12 aneurysms (7%) was chronic aortic dissection; the remaining 153 (93%) were degenerative aneurysms. RESULTS: The early postoperative (30-day) mortality rates were 7% (9/125) for elective and 23% (9/40) for nonelective operations (P =.016). For both elective and urgent procedures, early mortality was 1.8% (1/57) for suprarenal aneurysm repair, 11% (6/53) for group IV thoracoabdominal aneurysms, and 20% (11/55) for group III thoracoabdominal aneurysms (P =.013, suprarenal vs group III). Spinal cord ischemia occurred after 6% (10/165) of aneurysm repairs (4% paraplegia, 2% paraparesis). None of the 57 suprarenal aneurysm repairs were complicated by spinal cord ischemia, whereas it occurred in 2% (1/53) of group IV thoracoabdominal aneurysms and 16% (9/55) of group III thoracoabdominal aneurysms (P =.001, suprarenal vs group III; P =. 016, group IV vs group III). Three (25%) of the 12 patients with dissection developed spinal cord ischemia; this compared with seven (5%) of 153 patients with degenerative aneurysms (P =.027). The cumulative 3-year survival rate for the entire series was 71% (95% CI, 64%-79%), and 5-year survival was 50% (95% CI, 40%-60%). CONCLUSIONS: Aneurysms involving the suprarenal, visceral, and lower thoracic aorta may be repaired with acceptable perioperative mortality and late survival rates. The risk of spinal cord ischemia is increased for patients with aortic dissection and may be stratified according to the proximal extent of the aneurysm.     

Abdominal aortic aneurysm in high-risk patients. Outcome of selective management based on size and expansion rate.

Low mortality rates for elective surgical treatment of abdominal aortic aneurysms justify an aggressive approach in most patients. However, in high-risk patients with small aneurysms and no symptoms, the decision to operate remains a delicate balance of risk and benefit. Our observations include 99 high-risk patients with asymptomatic abdominal aortic aneurysms initially measuring 3 to 6 cm in the largest transverse diameter, who have been followed 1 to 9 years (average 2.4 years) with serial echographic measurements. Elective operations were performed for aneurysmal enlargement greater than 6 cm or symptom development. An additional 11 patients with aneurysms initially greater than 6 cm, whose initial evaluation did not result in elective surgery, were also followed. Serial data documented a mean expansion rate of 0.4 cm/year for aneurysms smaller than 6 cm. Forty-one of these 99 high-risk patients with small aneurysms eventually underwent an elective resection with two deaths (4.9%). Thirty-four patients (34%) died from causes unrelated to their unoperated aneurysms, and 21 patients (21%) are alive without symptoms. Three of the 99 patients suffered aneurysm rupture and emergency operation with two deaths. Thus, of the 99 high-risk patients with small aneurysms, four have died of elective aneurysm surgery or rupture (4%). A protocol of re-echo (or computerized tomography) examination at 3-month intervals appears to define which of these high-risk patients require elective aneurysm surgery, and has limited rupture to less than 5%. Improved criteria may emerge from recent advances in high-resolution computerized tomography.     

The surgical treatment on thoracic and abdominal aortic aneurysm in elderly patients over age of 70 years

For the last 5 years from 1986 to the end of 1990, 279 and 271 surgeries were undertaken on thoracic and abdominal aortic aneurysm, respectively. The highest age distribution of the former was between 60 to 69 years old comparing to 70 to 71 years old of later group. In thoracic aortic aneurysm, overall surgical results were inferior to elderly patients, however, this poor result was mainly attributed to the surgery for ruptured-emergency cases. In eliminating these situation, mortality of elderly in elective surgery was found to be equivalent to those of patients age of less than 69 years old. The same findings were also apparent for the surgery on abdominal aortic aneurysm where the mortality was totally the same (2.3% vs 2.4%) in elective surgery but high in ruptured cases (82% vs 30%). The long term survival rates were analysed in both groups in elderly patients. It was found the survival curve in thoracic aneurysm patients was lower especially for the first 5 years following surgery comparing to that of abdominal patients, however, because of relatively small number of patients listed in this late follow up, precise result has to be waited for the future analysis.     

Ultrasound screening of first-degree relatives of patients with an abdominal aortic aneurysm

The pedigrees were constructed of 43 patients (probands) who underwent resection of an abdominal aortic aneurysm. Seven probands (16.2%) had a first-degree relative (parent, sibling, child) known to have had an abdominal aortic aneurysm (multiplex family). To determine the prevalence of undiagnosed abdominal aortic aneurysm, ultrasound screening of first-degree relatives over age 40 years was undertaken. Of 202 eligible relatives, 103 (51.0%) were screened. An occult abdominal aortic aneurysm was defined as an infrarenal aortic diameter greater than 3.0 cm or an infrarenal/suprarenal aortic diameter ratio of greater than 1.5. An incipient abdominal aortic aneurysm was defined as a clear focal bulge of the infrarenal aorta, which was less than 3.0 cm in greatest diameter. Four of 103 relatives (3.9%) were found to have an occult abdominal aortic aneurysm (age/sex: 57M, 60M, 62F, 65M), and three (2.9%) were found with an incipient abdominal aortic aneurysm (age/sex: 56M, 60M, 67F). These smaller abdominal aortic aneurysms were in patients younger than the operated probands (average age men, 67 years; women, 69 years). Six of seven individuals were in families previously considered simplex, increasing the actual multiplex family frequency from 16.2% to 27.9%. All seven new abdominal aortic aneurysms were found in the 49 siblings age 55 years or older. There were no abdominal aortic aneurysms found in the 39 relatives under age 55 years, in 14 children ages 50 to 59 years or in one parent. Therefore of the siblings age 55 years or older, 5/20 men (25.0%) and 2/29 women (6.9%) were found to have a previously undiagnosed abdominal aortic aneurysm.(ABSTRACT TRUNCATED AT 250 WORDS)     

Resection of abdominal aortic aneurysm in patients with low ejection fractions

The perioperative and long-term survival of patients who undergo resection of abdominal aortic aneurysm is often determined by coexisting cardiac disease. This study evaluates the influence of left ventricular ejection fraction on both perioperative and long-term morbidity and mortality. Preoperative ejection fraction was measured in 104 of 208 patients undergoing elective abdominal aortic aneurysm resection. Nineteen patients were found to have ejection fractions less than 0.35, and this group was compared to 85 patients with ejection fractions greater than 0.35. The two groups did not differ significantly in terms of age, sex, preoperative renal function, or smoking status. The groups were significantly different with respect to the prevalence of prior myocardial infarction (79% of the low ejection fraction group vs 31% of the high ejection fraction group) and symptoms equivalent to New York Heart Association class II or greater (47% of the low ejection fraction group vs 24% of the high ejection fraction group) but not prior myocardial revascularization procedure (42% of the low ejection fraction group vs 31% of the high ejection fraction group). Surgical factors including aneurysm size, duration of aortic cross-clamping, and extent of arterial replacement did not differ significantly between the two groups. The perioperative mortality was not significantly different (low ejection fraction, 5%; high ejection fraction, 2%). The cumulative life-table survival of the two groups was not statistically different. Two patients in the low ejection fraction group died in the follow-up period, yielding a 4-year actuarial survival of 0.74. This is compared to 10 deaths and actuarial survival of 0.63 (p = NS) in the high ejection fraction group. We conclude that patients should not be denied aneurysm resection solely on the basis of left ventricular ejection fraction.     

Late results of coronary bypass in patients with infrarenal aortic aneurysms. The Cleveland Clinic Study.

Cardiac catheterization was performed in a prospective series of 1000 patients under consideration for elective peripheral vascular reconstruction at the Cleveland Clinic from 1978-1982. Of these, 246 patients (mean age: 68 years) presented primarily because of infrarenal abdominal aortic aneurysms (AAA) and are eligible for subsequent evaluation 3-7 years (mean: 4.6 years) after entrance into the study. Severe, surgically correctable coronary artery disease (CAD) was documented in 78 patients (32%) in the AAA group, and 70 patients (28%) received myocardial revascularization with four fatal complications (5.7%). A total of 56 patients in this subset had staged aneurysm resection, usually during the same hospital admission after coronary bypass, with a single death (1.8%) caused by cerebral infarction. The overall operative mortality rate for 126 coronary and AAA procedures was 4%. A total of 59 additional patients (25%) died during the late follow-up interval, including 14 patients (5.9%) with cardiac events and eight patients (3.4%) with ruptured aneurysms. The cumulative 5-year survival rate (75%) and cardiac mortality rate (5%) after coronary bypass reflected traditional parameters (preoperative ventricular function, completeness of revascularization) and are nearly identical to the results calculated for patients having normal coronary arteries or only mild to moderate CAD. In comparison, the cumulative survival and cardiac mortality rates in a small subset of patients with severe, uncorrected coronary involvement currently are 29% (p = 0.0001) and 34%, respectively. These data support the conclusion that selected patients who require elective resection of AAA also warrant myocardial revascularization to enhance perioperative risk and late survival.     

The surgical experience and a one to sixteen year follow-up of 277 abdominal aortic aneurysms

Between 1960 and 1975, 277 patients with abdominal aortic aneurysms were operated on at the West Virginia University Medical Center. One hundred ninety-three aneurysms were intact lesions and eighty-four were ruptured. Operative mortality for elective resection was 8.8 per cent and for ruptured aneurysms 66.7 per cent. Mortality associated with ruptured abdominal aortic aneurysms was best related to shock and advanced age. Ninety-nine per cent of patients underwent long-term follow-up which ranged from thirteen months to thirteen years and four months (mean, 4 years and 9 months). At present 61 per cent of patients surviving elective resection and 50 per cent of those surviving operation for ruptured aneurysm are alive.     

Management of urgent intact abdominal aortic aneurysms

Fifty patients with acute and urgent but unruptured abdominal aortic aneurysms were reviewed. The mortality rate was 24.3% in 37 patients having aneurysm resection and graft replacement. The mortality rate in patients developing cardiac and renal complications after surgery was 100%. Nine patients did not receive surgery and four patients had a laparotomy but did not have their aortic aneurysms repaired. Patients presenting with urgent but stable and unruptured abdominal aortic aneurysms require careful but swift assessment before surgery, and have a higher mortality than patients undergoing elective aneurysm surgery.     

178例肾动脉水平以下腹主动脉瘤手术治疗经验

自1960年1月到1994年12月间我院施行肾动脉水平以下腹主动脉瘤切除人造血管移植术178例.其中男147例,女31例,年龄15～82岁,平均65.5岁,合并高血压者118例(66%),冠心病40例(23.0%)、糖尿病17例(9.5%).B型超声和CT有助于腹主动脉瘤的诊断.若B超与CT不能确定动脉瘤上界与肾动脉间的距离,主动脉造影或数字减影血管造影术(digital substractionangiograpby,DSA)极有帮助.手术操作术的改进使腹主动脉瘤修补术变得更为迅速、安全和方便.     

腹主动脉瘤破裂18例救治体会

１８例腹主动脉瘤破裂，１６例经手术治疗。手术方法主要为腹主动脉瘤切除人造血管植入术，围手术期死亡６例（３７５％）。为提高病人生存率，一旦腹主动脉瘤诊断成立，应积极行择期手术治疗。腹主动脉瘤破裂后，正确及时的诊断尤为重要。手术时应注意阻断腹主动脉的方法以及防止术后下肢缺血     

Exclusion of internal iliac arterial aneurysm concomitant with abdominal aortic aneurysm repair.

BACKGROUND: To study the long-term outcomes after exclusion of internal iliac arterial aneurysm performed concomitantly with abdominal aortic aneurysm repair in patients with ruptured aortic aneurysm or other high-risk conditions. METHODS: The 31 patients who participated in this study underwent emergency (N = 9) or elective surgery (N = 22). The abdominal aortic aneurysm and the common iliac artery were excluded together with the internal iliac aneurysm in 7 patients. Forty-three (12 bilateral and 19 unilateral) internal iliac aneurysms were excluded: 35 by proximal ligation only, 5 by proximal and distal ligation, and 3 by partial resection of the proximal part of the aneurysm. The platelet count and fibrinogen level were evaluated pre- and postoperatively. Pelvic organ ischemia, classed as ischemic colitis, buttock claudication and sexual dysfunction, was examined. RESULTS: The inferior mesenteric artery was reimplanted in 21 patients. The platelet count dropped significantly postoperatively, but the fibrinogen level increased and no bleeding tendency was noted. Ischemic colitis occurred in 7 patients, resulting in colonic infarction in 2 patients. The operative mortality was 16%, and the postoperative observation periods ranged from 4 days to 217 months (mean, 60 months). The incidence of buttock claudication and sexual dysfunction was 12% and 39%, respectively. The excluded aneurysms were all thrombosed at discharge, and no late rupture was noted. The 5- and 10-year survival rate after surgery was 56% and 51%, respectively. CONCLUSIONS: Exclusion of the internal iliac aneurysm concomitant with abdominal aortic aneurysm repair shows acceptable outcome when performed in patients with high-risk conditions.     

肾动脉水平以下腹主动脉瘤153例手术治疗体会

本文报告１９６０年１月至１９９３年１２月间行肾动脉水平以下腹主动脉瘤切除人造血管移植术１５３例。其中男性１２４例，女性２９例。年龄最小１５岁，最大８０岁，其中４０岁以下３４例，６０岁以上６１例。合并有高血压者９８例，冠心病３５例，糖尿病１５例。Ｂ型超声和ＣＴ对腹主动脉瘤的诊断均有帮助。腹主动脉瘤诊断中最为关键乃是确定动瘤上界与肾动脉间的距离，若Ｂ超和ＣＴ不能确定的情况下，主动脉造影极有帮助。手术操     

Results of 101 ruptured abdominal aortic aneurysm repairs from a single surgical practice

Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital-based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome. DESIGN: A retrospective review from an ongoing vascular surgery registry. SETTING: Two midsized (300-bed) community hospitals. One hundred one consecutive patients with ruptured abdominal aortic aneurysms who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed. MAIN OUTCOME MEASURES: Operative mortality; cardiac, pulmonary, renal, and gastrointestinal complications; and coagulation abnormalities were recorded. Iatrogenic complications and length of hospital stay were noted. Preoperative and intraoperative factors affecting mortality were studied. RESULTS: Fifty-three patients survived ruptured abdominal aortic aneurysm repair (operative mortality, 47.5%). A favorable outcome was observed in patients (1). younger than 70 years, (2). with a hematocrit of more than 35% at presentation, and (3). with emergency department to operating room times of less than 120 minutes. Increasing experience of the surgeon did not result in improved survival. CONCLUSION: The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.     

Abdominal aortic aneurysms in Western Australia: descriptive epidemiology and patterns of rupture

All abdominal aortic aneurysms presenting to hospitals and coroners in Western Australia over an 11-year period (January 1971 to December 1981) have been reviewed. A total of 1237 abdominal aortic aneurysms were found. After age and sex standardization it was apparent that the prevalence of diagnosis of abdominal aortic aneurysms had increased from 74.8 per 100 000 to 117.2 per 100 000 for men over 55 years of age (increase of 56.7 per cent) and from 17.5 per 100 000 to 33.9 per 100 000 for women over 55 years of age (increase of 93.7 per cent) during this period. One hundred and twenty-three patients were identified by coroner's autopsy after sudden death from ruptured abdominal aortic aneurysms in whom there had been no previous diagnosis of abdominal aortic aneurysm. Between 1971 to 1981, 478 patients underwent surgery; 225 had elective resection of their aneurysm with a 4.0 per cent fatality rate, and 253 had emergency operations with a 31.2 per cent fatality rate. Seasonal variations contributing to the date of emergency presentation or death from rupture of abdominal aortic aneurysms indicated a possible influence of colder weather upon rupture. It is hoped that the information provided in this paper will be of use to surgeons and physicians involved in health care planning for similar populations.