Aortic-caval fistula from ruptured abdominal aortic aneurysm.

Four cases of spontaneous aorto-caval fistula are reported. All cases were successfully treated by suture of the fistula from the inside of the aortic aneurysm, which was replaced by a dacron graft. All patients are alive and well at follow up after one, three, four and twelve years, respectively. In one patient pulmonary and circulatory haemodynamics were recorded preoperatively as well as in the early and late postoperative period. Preoperative high pulmonary artery and capillary wedge pressures and cardiac output were rapidly reduced to almost normal values after the operation. An intrapulmonary shunt fraction of 58 % preoperatively was reduced to 15 % shortly after closure of the fistula. Possible mechanisms causing the high pulmonary shunt fraction are discussed.     

Colon infarction after ruptured abdominal aortic aneurysm.

Colon infarction is a lethal complication of ruptured abdominal aortic aneurysm. We compared multiple anatomic, hemodynamic, and clinical features in 25 patients with ruptured abdominal aortic aneurysm who suffered colon ischemia and 25 initial survivors of ruptured abdominal aortic aneurysm in whom this complication did not develop. Prior impressions notwithstanding, preoperative shock or volume administration did not correlate with the development of colon ischemia, nor did aneurysm location, cross-clamp site, graft type, or inferior mesenteric artery patency. However, patients with colon ischemia had a significantly lower perioperative cardiac output and were significantly more likely to have received alpha-adrenergic vasoconstrictor agents. Seventeen patients (68%) with colon ischemia died compared with nine patients (36%) without colon ischemia. Perioperative maintenance of cardiac output and avoidance of alpha-adrenergic vasopressor agents are critical elements in prevention of this lethal complication.     

Endovascular repair of the ruptured abdominal aortic aneurysm.

The present knowledge on endovascular repair of ruptured abdominal aortic aneurysms (rAAA) prevents firm conclusions when to use this method in comparison to open repair. This review article briefly summarizes results from case series, and discusses how to achieve reliable information despite the absence of randomized controlled trials. At present a careful conclusion might be that dedicated centers with an adequate organization and reasonably high volume of abdominal aortic aneurysm (AAA) should use detailed registry protocols to achieve experience and data to create an as reliable basis as possible for future recommendations.     

Hypotensive resuscitation in patients with ruptured abdominal aortic aneurysm.

BACKGROUND: The technique of hypotensive resuscitation in haemorrhagic shock involves resuscitation to below normotensive blood pressures achieving the minimum perfusion pressure that will adequately perfuse vital organs until definitive arrest of haemorrhage. AIM: To summarise the evidence for the use of hypotensive resuscitation in patients with uncontrolled haemorrhagic shock and ruptured abdominal aortic aneurysm (AAA). METHODS: A MEDLINE (1966-2004) and Cochrane library search for articles relating to hypotensive resuscitation was undertaken; see text for further details. RESULTS: Several animal studies exist using an abdominal aortotomy model of ruptured AAA. These have demonstrated improved tissue perfusion, decreased blood loss and improved survival associated with hypotensive resuscitation compared with aggressive resuscitation. There are several human studies advocating delayed rather than immediate resuscitation in trauma patients but careful review of the literature reveals no prospective studies of hypotensive resuscitation in patients with ruptured AAA. CONCLUSIONS: Animal studies demonstrate superiority of hypotensive resuscitation over aggressive resuscitation but further research is required to assess its efficacy in patients with ruptured AAA.     

In-hospital mortality of ruptured abdominal aortic aneurysm

Background: New Zealand, like Australia, has a widely dispersed population in towns at long distances from the main centres. We set out to estimate the in‐hospital mortality rate for ruptured abdominal aortic aneurysms in New Zealand and identify factors associated with mortality. Methods: Data were gathered prospectively as part of the Vascular Society of New Zealand’s continuous audit programme of all member surgeons. Data collection was validated by random record audit. In‐hospital mortality of ruptured abdominal aortic aneurysms, defined as death during hospital admission irrespective of cause, was determined for the period 1993–2005. Along with other performance indicators, differences in outcomes were assessed to take into account the trend over the time period, hospital size and number of non‐operative admissions. Results: Of the 740 patients admitted with a mean age of 73.9 ± 8.5 years, 78% were men and 17.8% were declined an operation. The in‐hospital mortality was 48.3% and the operative mortality was 37.8%. With univariate analysis increasing patient age, American Society of Anesthesiology score, hospital size and female sex were predictors of in‐hospital mortality. Only age and American Society of Anesthesiology score were independent predictors of operative mortality. Women were less likely to have surgery. Conclusion: Over the past 13 years in‐hospital mortality of ruptured abdominal aortic aneurysms in New Zealand remained unchanged. In provincial hospitals the operative outcomes were satisfactory, but the reported number not offered surgery was higher.     

Mortality from ruptured abdominal aortic aneurysms. A comparison of two series

Series of ruptured abdominal aortic aneurysms from a municipal teaching hospital and from a group of private surgeons practicing at four community hospitals were compared for hemodynamic status and time to operation, as well as mortality. The overall mortality rate was 61 percent for the municipal hospital series and 32 percent for the community hospital series, which was significantly different (p = 0.003). The municipal hospital series had a significantly greater number of patients in shock before operation, as well as a greater number of patients transported directly to the operating room. The community hospital series had a significantly greater number of patients with a more than 6 hour delay in diagnosis and delays in surgical exploration. When those patients in shock who were brought directly to the operating room were compared, there was no statistical difference between the two series. Further reviews of ruptured abdominal aortic aneurysms should attempt to identify groups of patients by their hemodynamic status when evaluating treatment.     

Colon ischemia accompanying ruptured abdominal aortic aneurysm

Myocardial, cerebral, and renal ischemia are recognized as serious sequelae in patients surviving repair of ruptured abdominal aortic aneurysms. Colonic ischemia, though a documented consequence of aortic reconstruction, has received less emphasis in these patients. In a 5-year review of a single hospital's experience, 50 patients underwent an emergency operation for ruptured abdominal aortic aneurysm. Ninety-six percent of the patients were in shock preoperatively. Of the 37 patients who survived the initial surgical procedure, 12 (32%) were subsequently found to have colon ischemia diagnosed by proctoscopy, repeat laparotomy, or autopsy. Among 20 of the initial survivors who later died at intervals up to 6 weeks after aneurysm repair 8 (40%) had colon ischemia as the sole or major contributing cause of death. Because of the high incidence of this serious but remediable problem in patients undergoing emergency operation for ruptured abdominal aortic aneurysm, we now routinely perform: (a) intraoperative Doppler examination of the colonic arterial tree, with consideration of mesenteric revascularization if necessary, (b) daily postoperative sigmoidoscopy and examination of the stool for blood, and (c) aggressive “second-look” laparotomy in patients exhibiting any signs or symptoms suggesting colonic infarction. Our experience suggests that large bowel infarction is a common, lethal, and underemphasized complication following successful repair of ruptured abdominal aortic aneurysms.     

破裂腹主动脉瘤的外科治疗

目的探讨急诊腹主动脉瘤切除人工血管移植术治疗破裂腹主动脉瘤的经验。方法总结1999年4月至2005年4月外科手术治疗破裂腹主动脉瘤20例，采用钳夹阻断膈下腹主动脉或Foley氏球囊管腔内阻断瘤颈上腹主动脉后行急诊腹主动脉瘤切除人工血管移植术，应用分叉型人工血管12例，直型人工血管8例。结果急诊腹主动脉瘤切除人工血管移植手术30d围手术期死亡率40％（8例），死亡原因包括急性肾功能衰竭4例，多器官功能衰竭2例，呼吸循环衰竭2例。存活12例，术后合并症包括急性肾功能不全、肺部感染、凝血机制障碍和腹泻等共11例，均经治疗后痊愈。随访观察6～60个月，无人工血管血栓形成和感染等并发症以及随访期死亡发生。结论破裂腹主动脉瘤外科手术治疗死亡率仍然很高，早期确定诊断，紧急外科手术治疗，术后加强围手术期管理是降低破裂腹主动脉瘤死亡率的关键。     

破裂性腹主动脉瘤的治疗

目的探讨破裂性腹主动脉瘤急诊救治的治疗经验。方法回顾性研究2002年5月-2013年7月救治的36例破裂性腹主动脉瘤患者的临床资料。其中25例合并高血压病,21例合并慢性阻塞性肺疾病。33例采取急诊开腹主动脉人工血管置换术;3例采取主动脉覆膜支架腔内修复术,其中1例中转开腹手术治疗。结果术后33例存活,另外3例死亡,死亡原因包括1例失血性休克和心功能衰竭,1例术中心跳骤停,1例术后多器官功能衰竭,围手术期病死率为8．3％。术后随访3～61个月,未发生人工血管感染等手术相关并发症及死亡病例。结论积极的手术治疗是提高破裂性腹主动脉瘤患者救治成功率的关键,早期明确诊断,手术中快速有效控制近端瘤颈血流,完善围手术期治疗能有效降低病死率。