腹主动脉瘤的诊断和治疗：附19例分析

报告19例腹主动脉瘤,其中14例行瘤体切除加人造血管移植,术后无并发症,生活质量与同龄健康人相当,B超示人造血管通畅,无血栓形成。5例未手术病例,有4例于随访期间死亡,死亡时累计病程/随访时间分别为4年/1年、5年/2年、7年/2年、7年/4年。腹主动脉瘤一经形成,均有足够的手术指征,并就其定性、定位诊断和治疗进行了讨论。     

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     

腹主动脉瘤破裂的临床分析(附6例报告)

目的探讨腹主动脉瘤破裂的诊断和治疗方法。方法我院从1999年10月至2004年1月期间经手术治疗腹主动脉瘤破裂6例。结果1例患者因术后失血性休克而死亡;5例患者随访4年,1例术后2年死于心肌梗死,余4例存活。结论腹主动脉瘤应早期诊断、早期治疗,一旦破裂应迅速诊断、急诊手术,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。     

腹主动脉瘤18例诊治体会

我科自1998年6月至2003年6月共收治腹主动脉瘤患者18例，现回顾总结如下。     

腹主动脉瘤的外科治疗：病例报告及文献复习

对腹主动脉瘤多主张积极手术治疗。本文报告一例腹主动脉瘤合并严重髂股动脉粥样硬化，用人造血管移置替换动脉瘤及严重动脉粥样化段血管，共５处吻合获得成功，患者存活已１年。作者认为目前血管造影、ＭＲＩ等检测技术在明确血管病损的确切范围上尚有困难；术中最大限度去除内膜病变血管是保证手术成功的关键；用体外循环泵回收肝素化的术野出血为一可行方法。     

破裂腹主动脉瘤的诊断和外科治疗

随着外科技术和围手术期治疗水平日益提高，腹主动脉瘤择期手术治疗死亡率已控制在5％以内，但破裂腹主动脉瘤（ruptured abdominal aortic aneurysm，RAAA）的死亡率一直在40％～70％，如果包括尚未到达医院的RAAA患者，死亡率可达80％～90％，RAAA被美国列为第13位死亡原因。目前，及时准确的诊断和快速有效的外科治疗仍是降低RAAA死亡率的关键。     

178例肾动脉水平以下腹主动脉瘤手术治疗经验

自１９６０年１月至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（ＤＳＡ）极有帮助。手术操作术的改进使腹主     

腹主动脉瘤——附10例报告

1991～1997年,我院收治了10例腹主动脉瘤。年龄61～83岁,平均70.7岁。男8例,女2例。2例经择期手术治愈,3例来院后因发生破裂死亡。2例合并恶性肿瘤半年内死亡。2例因脑血管意外后遗症于1年内死亡。1例瘤宽3.7cm的病人2年后死于瘤体破裂。认为:提高对本病的认识,早期诊断,及早行血管移植术是使治疗获得良好效果的关键。     

腹主动脉瘤100例外科治疗分析

目的 探讨腹主动脉瘤外科治疗经验。方法 总结1979年6月至1998年12月手术治疗的腹主动脉瘤100例,其中肾上型腹主动脉瘤8例,91例行腹主动脉瘤切除,人工血管移植术;涤纶片瘤体包裹术8例,术中死亡1例。结果 14例腹主动脉瘤破裂,,急诊手术手术死亡率50%（7例）,其余未破裂者手术死亡率3.5%(3/86)。结论 术前诊断和手术时机的掌握是提高手术成功率的关键,对腹主动脉瘤应积极择期手术,手术技术和麻醉监护水平的不断改进提高和围手术期的正确处理使腹主动脉瘤手术更为安全、快捷,术后恢复更快更好。     

彩色B超在诊断腹主动脉瘤的价值(附32例分析)

目的探讨彩色多普勒B超在诊断腹主动瘤的价值。方法对我科从1995年1月～2004年10月收集32例经彩色B超诊断为腹主动脉瘤进行回顾性分析。结果本组32例彩色B超检查中,诊断为单纯腹主动脉瘤21例,夹层腹主动脉瘤是11例。与此同时,26例行CT强化扫查,13例行MRI检查,其诊断结果与彩色B超结果完全相符。彩色B超的正确诊断率为100％。结论彩色多普勒在诊断腹主动脉瘤中具有操作简便、费用低廉,诊断率高,值得临床推广使用。     

QUALITY OF LIFE AFTER EMERGENCY ABDOMINAL AORTIC ANEURYSM REPAIR

Background : Quality of life issues following surgical procedures, especially those with high mortality, should be of prime importance. There have been few studies on the quality of life of patients following emergency abdominal aortic aneurysm repairs. The decision to continue to offer surgery to these patients, especially with present monetary constraints, should rely heavily on quality of life issues. Audits of major surgical procedures should be undertaken and quality of life included. Methods : All patients in the Hawkes Bay area who had undergone emergency abdominal aortic aneurysm repairs since 1981 were identified and their quality of life assessed by means of the short form-36 (SF-36) questionnaire. Results : One hundred and fifteen patients were identified as having had an abdominal aortic aneurysm repaired as an emergency. Sixty patients died peri-operatively and 19 subsequently. There were 28 patients available to complete the questionnaire, of whom 75% rated their global quality of life as good to excellent. Using the SF-36 questionnaire, there was no statistically significant difference between those patients who had undergone surgery (whether proven leak or not) and the age-matched healthy population. Conclusions : Quality of life remains good to excellent in the majority of patients following emergency abdominal aortic aneurysm repairs. This may help justify surgery being offered to patients with this condition. Quality of life should be considered as an important outcome rather than mortality only.     

ACUTE AORTO-CAVAL FISTULA: A COMPLICATION OF ABDOMINAL AORTIC ANEURYSM

Three patients, with acute spontaneous aorto-caval fistulae, are described. The important aspects of the diagnosis and treatment of these fistulae are discussed and the recommended anaesthetic and surgical management presented.     

SCREENING FOR ABDOMINAL AORTIC ANEURYSMS IN WESTERN AUSTRALIA

A study of ultrasound screening for abdominal aortic aneurysms (AAA) was performed. During a 6 month period, 1225 men and women aged 60–80 years were screen at a variety of community venues. Screening was well received by the public and logistically simple to perform. Thirty-three AAA were detected with sizes between 30 and 81 mm. In the 60–80 year age group, the prevalence of (AAA) > 30 mm in diameter was 4.7% in men and 0.35% in women, and the prevalence of AAA > 50mm was 0.6% in men and 0.17% in women. Cigarette smoking, but not hypertension or diabetes, was found to be a significant risk factor for AAA. This study confirms that screening for AAA is feasible and yields high prevalence rates in major population centres.     

RUPTURED ABDOMINAL AORTIC ANEURYSM: A COMPLICATION OF SALMONELLA BOVIS-MORBIFICANS INFECTION

A clinical report is presented of a patient who developed Salmonella bovis-morbifcans infection and ruptured an abdominal aortic aneurysm as a complication. The management is discussed and treatment suggested.     

ABDOMINAL AORTIC ANEURYSM AND ASSOCIATED COLORECTAL CARCINOMA: A MANAGEMENT PROBLEM

The increasing age of the population has led to the more common occurrence of multi-organ disease. Colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) in the same patient is a difficult management problem. Over 10 years, 23 patients with CRC and AAA were treated at Concord Hospital. The management and outcome of these patients was reviewed to identify an optimum plan for patients with both conditions. The average age of patients was 71 years, ranging from 52 to 90 years. There was only one female patient in the series. In 19 of the patients, the AAA and CRC were synchronous, while in the other four patients the AAA and CRC were remote events. Within the group of patients with synchronous AAA and CRC, 12 had the diagnosis of both conditions made pre-operatively. However, in seven cases an unexpected AAA or CRC was found at operation for the other condition. Sixteen patients underwent resection of the CRC, while only eight underwent repair of the AAA. There were three deaths following CRC resection, two following AAA resection, and one following simultaneous CRC resection and AAA repair. Two of 10 patients with large (> 6cm) AAA, who underwent CRC resection, ruptured the AAA in the postoperative period. A further patient ruptured 10 months following CRC resection. Colorectal cancer was given priority over AAA when these conditions were found simultaneously. The present study suggests that a large AAA (> 6cm) should be either given preferential treatment, or resected simultaneously, in view of the high risk of rupture.     

AN INFECTED ABDOMINAL AORTIC ANEURYSM AND HEPATIC ABSCESSES DUE TO STREPTOCOCCUS MILLERI

The case of a 78 year old man who presented with fever and hepatic abscesses is reported. He was found to have an infected abdominal aortic aneurysm and the organism cultured was Streptococcus milleri. He was treated with an in situ Dacron graft and high-dose intravenous penicillin. This may be suitable treatment when Gram-positive organisms are involved and there is no gross peritoneal soiling.     

TREATMENT OF ABDOMINAL AORTIC ANEURYSM DISEASE IN THE 9TH AND 10TH DECADES OF LIFE

Background : The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. Methods : Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentatiodno surgery; II, elective presentatiodelective surgical repair; III, emergency presentatiodsurgical repair; and IV, emergency presentatiodconservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. Results : The mean age of the total group (n = 85) of patients was 84 years (range: 80–94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2–6 cm). The diameters for group I (n= 40), II (n= 22), III (n= 16) and IV (n = 7) were 4.9 cm (4.4–5.5, 95% CI), 5.7 (4.9–6.5 CI), 7.0 (6.1–7.7 CI) and 6.2 (5.2–7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P= 0.015). and group IV had a shorter survival than the total group (P= 0,001). However, the length of survival was no different for III versus IV (P= 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2). malignancy (1); III: rupture (10), malignancy (1); and (IV): rupture (6), malignancy (1). Conclusions : Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

EXPANSION RATES OF SMALL ABDOMINAL AORTIC ANEURYSMS

Background : The present study was carried out in order to examine those factors that influence the rate of expansion of small abdominal aortic aneurysms. Methods : A retrospective study was undertaken of 112 patients who attended the St George Vascular Laboratory between 1987 and 1997. These patients had abdominal aortic aneurysms that were considered to be too small to warrant surgical repair at the time of presentation. Sequential ultrasound examinations were used to measure maximal anteroposterior aneurysm diameter. From these data, annual growth rates were calculated. Growth rate per annum was then compared with gender, age, initial aortic aneurysm diameter, presence of hypertensive disease, cardiac disease, family history of aneurysmal disease, diabetes mellitus, smoking, beta–adrenergic blockade and lipid lowering drugs. Results : Univariate analysis showed that three factors were significantly related to growth rate: the initial size of the aortic aneurysm, the presence of cardiac disease and the presence of beta–adrenergic blockade. Conclusions : The presence of beta-adrenergic blockade appeared to have an independent effect on aneurysm growth rate, and suggests a possible role for beta-adrenergic blockade as a therapeutic strategy in controlling expansion rates of small abdominal aortic aneurysms. A controlled double-blind clinical trial is required to demonstrate this conclusively.     

THE QUALITY OF SURGICAL CARE PROJECT: BENCHMARK STANDARDS OF OPEN RESECTION FOR ABDOMINAL AORTIC ANEURYSM IN WESTERN AUSTRALIA

Background: The Quality of Surgical Care Project (QSCP) was established in May 1996, to evaluate surgical outcomes and where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). The purpose of this study is to establish benchmark standards in WA for operative mortality, 5-year survival and length of stay in all patients who were surgically treated for aneurysm of the abdominal aorta (AAA) in WA. Methods: The WA Linked Database was used to link the morbidity and mortality records of all patients admitted and surgically treated for AAA in WA from 1985 to 1994. The linked chains of de-identified hospital morbidity and death records were selected using diagnostic and procedure codes pertaining to AAA. Three groups were separated for analysis: those admitted for rupture, those admitted for elective repair, and those who were admitted to hospital as an emergency without mention of rupture but who underwent repair for AAA. Independent analysis for gender and patients 80 years or more were included in the study. Patients were excluded from the study if they were less than 55 years of age. Results: A total of 1475 cases (1257 males, 218 females) were identified. The mean age in elective cases was 70.4 years in males and 72.4 years in females, and for rupture the mean ages were 71.9 and 74.8 years, respectively. Median length of stay for males was 12 days for elective cases. Admission type or age did not significantly influence length of stay. Thirty-day mortality in males was 4.4% for elective repair and 36.7% for ruptured AAA and 5-year survival was 71.7 and 47.7%, respectively. The overall case fatality rate for ruptured AAA was 79.3% which included those cases who died from rupture without being admitted to hospital. Conclusions: These community-wide data provide a realistic measure of surgical performance for open repair of AAA. The outcomes for elective and rupture repair for AAA compare favourably with standards reported by international centres of excellence. They also support the use of this procedure in patients over 80 years of age with rupture. This information can be used for ongoing audit purposes and as a benchmark for the introduction of new treatment modalities.