Complex Abdominal Aortic Aneurysm Repair

Vascular surgery is a challenging discipline and complex aneurysms can present an entire range of technical difficulties. To overcome these problems good technical skills are mandatory. However, it is also worth remembering a few basic rules:

? The simplest solution is often the best.

? All cases need careful planning, including that of the approach

? A successful anastomosis requires good aortic tissue

? Minimal dissection reduces morbidity.     

Perioperative Anaesthesiological Management and Outcome of the Ruptured Abdominal Aortic Aneurysm

Summary BACKGROUND: While constant advances in surgical and anaesthesiological procedure have dramatically improved the outcome of elective surgery for abdominal aneurysm, no progress has been made in the management of the ruptured abdominal aortic aneurysm. METHODS: Review of recent literature. RESULTS: While most patients survive surgery, perioperative mortality remains between 40 % and 60 %. Many patients surviving surgery develop a systemic inflammatory response syndrome, often leading to sepsis and/or multiple organ failure and requiring prolonged treatment in the intensive care unit that includes mechanical ventilation, tracheostomy, and haemofiltration. The need for and the duration of such treatment were correlated with an unfavourable prognosis. Mortality was described to reach 38 % without organ failure, 42 % with single organ failure, 58 % with two organs failing, and 67 % with three. CONCLUSIONS: Improved outcome can only be expected if the development of systemic inflammatory response syndrome and organ failure is hindered.     

Minilaparotomy Abdominal Aortic Aneurysm Repair Versus the Retroperitoneal Approach and Standard Open Surgery

Purpose We evaluated the surgical results of minilaparotomy abdominal aortic aneurysm (AAA) repair in comparison with those of standard open repair and retroperitoneal approach repair.Methods Between February 2000 and January 2003, 30 patients with AAA underwent minimal incision laparotomy repair (MINI) through an abdominal incision 7–12cm long. Their clinical characteristics and in-hospital outcome were then compared with those of patients who had undergone repair of AAA by a standard open technique (OPEN) or retroperitoneal approach technique (RETRO).Results There were significant differences between the MINI, OPEN, and RETRO groups in the time until the patient was able to resume eating (2.4 ± 1.0 vs 4.4 ± 2.4* vs 2.8 ± 1.9 postoperative days [PODs], respectively; *P < 0.05), the time until ambulation outside the room (2.1 ± 0.7 vs 3.5 ± 1.3* vs 2.5 ± 1.9 PODs, respectively; *P < 0.05), and the operation times (188 ± 43* vs 256 ± 77 vs 238 ± 59min, respectively; *P < 0.05).Conclusion Minilaparotomy repair is a feasible technique, which combines the benefits of a small incision with those of conventional open repair. With the exception of patients with an iliac artery aneurysm extending to the external or internal iliac artery, MINI repair should be considered for the elective treatment of patients with aortic disease.     

腔内修复术治疗破裂型腹主动脉瘤的效果评价

目的分析破裂型腹主动脉瘤(ruptured abdominal aneurysm,r AAA)行腔内修复术(endovascular aortic aneurysm repair,EVAR)与开放手术早期结果,评价EVAR治疗的效果。方法回顾性收集我院2004年1月~2014年1月收治的48例r AAA患者临床资料,根据其手术与否、手术方式的不同分为术前死亡组(n=20)、EVAR组(n=14)和开放手术组(n=14),三组性别、年龄等一般资料比较无统计学差异(P0.05),EVAR组和开放手术组在瘤体直径、收缩压、舒张压方面比较差异均无统计学意义(P0.05)。结果 EVAR组入院至检查时间为(1.2±0.8)h,与开放手术组(7.5±7.1)h比较差异有统计学意义(P=0.006);EVAR组检查至手术时间为(1.8±1.3)h,与开放手术组(16.8±17.7)h比较差异有统计学意义(P=0.007)。死亡组入院至死亡时间与EVAR组比较差异有统计学意义(P0.009)。EVAR组手术时间为(2.3±0.7)h,与开放手术组(5.6±2.0)h比较差异有统计学意义(P0.001);EVAR组的术中出血量为(142.9±279.3)ml,与开放手术组的(3 528.6±3 252.3)ml间差异有统计学意义(P0.001);EVAR组的输血量为(985.7±2 148.7)ml,与开放手术组的(3 100.0±2 285.1)ml间差异有统计学意义(P=0.018);EVAR组的住院时间为(7.1±2.7)d,与开放手术组的(13.7±4.9)d间差异有统计学意义(P0.001);EVAR组的总费用为(20.9±5.8)万元,与开放手术组的(10.1±11.5)万元间差异有统计学意义(P=0.005)。两组并发症率比较,差异无统计学意义(P=0.430)。结论缩短院内抢救准备时间,是r AAA成功救治的要点。EVAR应作为r AAA的一线治疗方案。     

腹主动脉瘤腔内修复术后的并发症

腹主动脉瘤腔内修复术最早于1991年被报道,目前已经发展成为一项成熟可行的技术,但在术后并发症发病率及手术死亡率方面仍存在着相当高的风险。如果腹主动脉瘤腔内修复术欲在未来完全取代传统手术,降低围手术期死亡率并提高长期疗效势在必行。以下将围绕腹主动脉瘤腔内修复术并发症的产生机制、发病率及其带来的问题进行讨论。     

Abdominal Aortic Aneurysm Due to Brucella Melitensis

Purpose : To assess the effect of in or out of city residence of patients with breast carcinoma, where breast surgery unit treatment and follow-up is made postoperatively.

Method : 234 patients operated on for breast carcinoma at the Breast Surgery Unit were retrospectively studied. Patients were divided into two groups; patients living in the major city where the Breast Surgery Centre is located and patients living in smaller cities, districts, towns and villages out of the city. The distance of patients’ residences from the Breast Centre has also been determined in kilometres. The number of patients and the frequency of check-up visits were compared in both groups.

Results : The number of patients residing in the city centre where the Breast Unit is located was 156 (66.7%). Comparing the frequency of patients’ visits for check-up during the postoperative period, there were no differences between the two groups during the first four years. However, the patients living out of the city did not visit the Breast Unit for check-ups during the fifth postoperative year. Moreover, when the patients were classified into two groups with known and unknown outcomes, it was observed that those patients with unknown outcomes lived further away from the city where the Breast Surgery Unit was located compared to those with known outcomes (p = 0.002). Discussion : Living within or out of the major city centre where the Breast Surgery Unit is located does not have any effect on the frequency of follow-up visits or the number of patients applying for check ups during the first four years postoperatively. However, there were gradual decreases over the course of time in both groups and these differences became apparent during the 5th year. In addition to this, the distance was also found to be an important factor for patients with unknown outcomes in the present study. The combination of living outside the city where The Breast Unit was located and the distance may have a negative effect on follow-ups. There is a need for new, larger scale, studies with longer follow-ups to show how this difference will change over a longer time period.     

Repair of Ruptured Abdominal Aortic Aneurysm in Octogenarians

Objective

To determine whether advanced age was independently associated with prohibitive surgical risks or impaired long-term prognosis after ruptured aortic aneurysm repair.

Design

Post-hoc analysis of prospective cohort.

Materials

Consecutive patients undergoing ruptured aneurysm repair between January 2001 and December 2010 at a tertiary referral centre.

Methods

Surgical mortality (i.e., <30 days) was compared between octogenarians and younger patients using logistic regression modelling to adjust for suspected confounders and to identify prognostic factors. Long-term survival was compared with matched national populations.

Results

Sixty of 248 involved patients were octogenarians (24%) and almost all were offered open repair (n = 237). Surgical mortality of octogenarians was 26.7% (adjusted odds ratio (OR) 2.1; 95% confidence interval (CI), 0.9–5.2) and confounded by cardiac disease. Hypovolaemic shock predicted perioperative death of octogenarians best (OR 5.1; 95%CI, 1.1–23.4; P = 0.037). After successful repair, annual mortality of octogenarians averaged 13.7% vs. 5.2% for younger patients. At 2 years, octogenarian survival was at 94% of the expected ‘normal’ survival in the general population (vs. 96% for younger patients).

Conclusions

Surgical mortality of ruptured aneurysm repair was not independently related to advanced age but mainly driven by cardiac disease and manifest hypovolaemic shock. An almost normal long-term prognosis of aged patients after successful repair justifies even attempts of open repair, particularly in carefully selected patients.     

腹主动脉瘤腔内修复与开腹切除术的麻醉管理比较

目的比较腹主动脉瘤腔内修复与开腹切除术的麻醉管理特点。方法 2010年2月~2011年1月,70例ASAⅡ~Ⅳ级,肾下型腹主动脉瘤行腔内修复术52例（腔内修复组）,开腹切除术18例（开腹切除组）。开腹切除组采用气管内插管全身麻醉。腔内修复组采用的麻醉方法包括气管内插管全身麻酔、全凭静脉麻醉（喉罩通气）和监护麻醉。气管内插管全身麻醉采用快速顺序静脉诱导,气管插管后机械控制呼吸,静吸复合方式维持麻醉;全凭静脉麻醉（喉罩通气）采用丙泊酚靶控静脉输注,经喉罩行机械通气控制呼吸;监护麻醉保留自主呼吸,适当镇静镇痛。结果开腹切除组在气管内插管全身麻醉下完成手术,术中均需要使用血管活性药物控制血压。腔内修复组有57.7%（30/52）的患者采用气管内插管全身麻醉、34.6%（18/52）的患者采用全凭静脉麻醉（喉罩通气）和7.7%（4/52）的患者在监护麻醉下完成手术。与开腹切除组相比,腔内治疗组术中血压较平稳,麻醉时间[（90±27）min vs.（210±44）min,t=13.668,P=0.000]、手术时间[（45±22）min vs.（187±36）min,t=-19.811,P=0.000]、术中输注晶体液[（750±178）ml vs.（1896±367）ml,t=17.486,P=0.000]、胶体液[（349±147）ml vs.（1257±266）ml,t=18.034,P=0.000]、异体血[（50±34）ml vs.（898±154）ml,t=-37.615,P=0.000]、术后返ICU患者比例（15.4%vs.66.7%,χ2=17.231,P=0.000）及术后住院时间[（8.5±2.1）d vs.（15.2±4.3）d,t=8.700,P=0.000]均明显降低。结论腹主动脉瘤腔内修复术的麻醉手术时间、液体出入量及血管活性药物应用水平远低于腹主动脉瘤开腹切除术,且监护麻醉、全凭静脉麻醉适用于该术式。     

Postoperative Renal Function After Elective Abdominal Aortic Aneurysm Repair Requiring Suprarenal Aortic Cross-Clamping

Purpose To examine postoperative renal function after suprarenal aortic cross-clamping performed without renal hypothermia in patients undergoing elective abdominal aortic aneurysm (AAA) surgery.Methods Between 1991 and 2000, 18 patients underwent surgery for a juxtarenal AAA, which required a suprarenal aortic cross-clamp. All AAAs were repaired with a proximal anastomosis just below the renal arteries. We divided the patients into two groups according to the duration of the renal ischemia: <45min (n = 12) and 45min (n = 6). The postoperative changes in renal function were analyzed.Results There were no hospital deaths and none of the patients needed permanent hemodialysis. The postoperative peak in the serum creatinine level after suprarenal cross-clamping for 45min was significantly higher than that after cross-clamping for <45min. The percentage changes in serum creatinine and blood urea nitrogen were correlated positively with the duration of renal ischemia, and were significantly greater in the group with renal ischemia of <45min than in the group with prolonged renal ischemia (45min).Conclusions Suprarenal aortic cross-clamp without performing renal hypothermia is safe and able to be tolerated well by the patient during elective AAA surgery, although careful attention must be paid to limiting the period of renal ischemia.     

Abdominal Aortic Aneurysm with Coexistent Horseshoe Kidney

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.     

Postoperative Renal Function After an Abdominal Aortic Aneurysm Repair Requiring a Suprarenal Aortic Cross-Clamp

(Received for publication on Sept. 28, 1998; accepted on July 13, 1999)     

Effects of Suprarenal Aortic Cross-Clamping and Adjunctive Renal Reconstruction on Outcomes of Open Abdominal Aortic Aneurysm Repair

Purpose: To analyze our contemporary experience in open abdominal aortic aneurysm (AAA) repair. We focused on the effects of suprarenal (SR) aortic cross-clamping and adjunctive renal reconstruction (RR) on postoperative outcomes.Methods: We retrospectively reviewed our institutional data of 141 consecutive patients who received elective open AAA repair between January 2014 and December 2020.Results: Seventy-five procedures were performed with SR aortic cross-clamping, 20 of which required an adjunctive RR. Patients in the SR group had a higher incidence of postoperative acute kidney injury (AKI) (18.7% vs. 7.6%, P = 0.045). There were no significant between-group differences in other major complications. The 30-day mortality rate in the infrarenal (IR) and SR groups was 0% and 1.3%, respectively. After a median follow-up of 33 months, the rates of chronic renal decline in the IR (18.2%) and SR (21.3%) groups were similar. All reconstructed renal arteries were patent without reintervention. The 5-year overall survival rate in the IR and SR groups was 88.8% and 83.2%, respectively.Conclusions: SR aortic cross-clamping was associated with postoperative AKI but neither SR aortic cross-clamping nor RR affected the long-term renal function or mortality. Open repair remains an essential option for patients with AAA, especially those with complex anatomy.     

Infrarenal Abdominal Aortic Aneurysm Complicated by Persistent Endotension After Endovascular Repair: Report of a Case

Endoleak and endotension may prevent the successful exclusion of an aneurysm after endovascular aortic aneurysm repair (EVAR). The pressurization in the excluded aneurysm sac caused by endotension may lead to rupture of the aneurysm; however, the cause of endotension and its underlying mechanisms remain unclear. We report a case of infrarenal abdominal aortic aneurysm (AAA) complicated by persistent endotension after EVAR. Although no endoleaks were found on conventional double-phase computed tomographic scans, a thrombosed endoleak existed in the side branch and attachment site of the endograft. After treating the undetectable thrombosed endoleaks, physical examination revealed that the pressure of the excluded aneurysm had diminished, with shrinkage of the aneurysm. This case report suggests that a high-pressure undetectable type I or type II endoleak could be a major cause of endotension. Thus, postoperative evaluation of the attachment site of an endograft is important after EVAR.     

Length Measurements of the Aorta After Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND: successful endovascular repair of abdominal aortic aneurysms (AAA) generally leads to a decrease in aneurysm size. Theoretically, this may lead to foreshortening of the excluded segment. If so, vertically rigid endografts may dislocate over time and cover renal or hypogastric arteries. AIM: to assess length changes of the infrarenal aorta after endovascular AAA exclusion. PATIENTS AND METHODS: forty-four consecutive patients were scheduled for the EndoVascular Technologies endograft, a vertically non-rigid prosthesis which would potentially accommodate longitudinal changes. Twenty-four patients had completed at least 6 months of follow-up. In 18/24 patients a decrease in size was established by aneurysm volume measurements at 6 months' follow-up. Helical computer tomography (CT) angiograms were processed on a workstation. Aortic lengths were measured along the central lumen line from the lower renal artery orifice to the native aortic bifurcation. The computer tomography angiogram (CTA) reconstruction thickness of 2 mm yields at least a 4-mm error for each length measurement. RESULTS: in the shrinking aneurysm group, the median length change was 0 mm (range -9 mm to +4 mm) at 6 months' follow-up (n =18) and also 0 mm (range -7 mm to +4 mm) at 12 months' follow-up ( n =10). In 16/18 patients, length changes remained within the measurement error range of 4 mm. CONCLUSION: in this group of shrinking aneurysms after endovascular AAA repair, foreshortening of the excluded aortic segment appears not to be a clinically significant problem.     

A Shorter Skin Incision Technique for the Repair of Infrarenal Abdominal Aortic Aneurysms

Purpose We evaluated the effectiveness of a shorter skin incision technique for the treatment of infrarenal abdominal aortic aneurysms (AAA). The aim of the present study was to evaluate whether or not the difference in the length of the skin incision contributed to an early recovery after the operation. Methods Between October 2001 and December 2004, we performed 105 elective repairs for AAA. The patients were divided into three groups according to the length of the skin incision as follows: group A, less than 15 cm, group B, from 15 cm to less than 20 cm, and group C, 20 cm or more. Results There was no significant difference in the intraoperative course among the three groups. The duration of paralytic ileus was shorter in group A than in group C (2.0 ± 0.9 days versus 3.2 ± 2.3 days; P = 0.0428). Although the periods before removal of nasogastric suction and before starting a solid diet were slightly shorter in group A than in groups B and C, there were no statistically significant differences. Conclusion We define minimally invasive vascular surgery as surgery performed with a small abdominal skin incision that does not expose the intestine to air while providing a good operative field that does not place any undue stress on the surgeon.