Repair of abdominal aortic aneurysms. A statewide experience

The results of elective treatment of abdominal aortic aneurysms are excellent in many institutions. To our knowledge, however, no study has compared the results in a large geographic area in which patients were treated by a variety of surgeons and hospitals. We studied the results of repairing abdominal aortic aneurysms for all Medicare recipients during a single year in Kentucky. One hundred thirty-six operations were performed by 52 surgeons in 31 hospitals. Overall operative mortality was 18%; elective and emergency operative mortality rates were 6% and 49%, respectively. Advancing age did not affect outcome, but mortality due to ruptured aneurysms was higher in smaller hospitals than in larger hospitals. The low mortality for elective repair of abdominal aortic aneurysms in an elderly population by numerous surgeons in divergent hospitals is a strong indication for its liberal use compared with the high mortality and morbidity of emergency surgery.     

Sutureless intraluminal graft for repair of abdominal aortic aneurysm

A series of seven patients undergoing elective repair of abdominal aortic aneurysms using sutureless intraluminal aortic prostheses for infrarenal tube grafts was reviewed. Follow-up was five to seven months. There was no morbidity related to the graft and one late mortality. In the uncomplicated cases, the average total operative time was two hours 14 minutes with no bank blood transfusions. The overall average operative time was two hours 41 minutes with an average operative transfusion of 0.28 units and total transfusions of 1.70 units of bank blood per case. Based on this experience and the observation that operative time and blood loss are major determinants of mortality with emergency abdominal aortic aneurysm repairs, we believe that use of sutureless intraluminal prostheses in suitable cases of leaking or ruptured abdominal aortic aneurysms has the potential to markedly improve survival.     

Anaesthesia for abdominal vascular surgery

Abdominal vascular surgery is required for aneurysmal and symptomatic occlusive disease of the aorta. Abdominal aortic aneurysms account for more than 8,500 deaths per year in England and Wales. Most deaths occur as a result of rupture of the abdominal aortic aneurysm, which has an overall mortality of 80%. These deaths are potentially preventable because elective repair of the abdominal aorta can be performed with an operative mortality of less than 7%. This article reviews the current indications and anaesthetic practices for open and endovascular abdominal aortic aneurysm repair.     

Suprarenal abdominal aortic aneurysm managed by excision and primary repair using a lateral suture technique

Suprarenal abdominal aortic aneurysms are rare and pose special problems in diagnosis and management. These aneurysms often involve one or more visceral branches and frequently require a thoracoabdominal approach for surgical repair. The operative management of an unusual saccular suprarenal aortic aneurysm suspected to be of mycotic etiology is discussed. The diagnosis was made preoperatively with the aid of CT scanning and arteriography. Surgical repair was accomplished through an abdominal approach by excision and primary closure using a lateral suture technique.     

Current management of infrarenal abdominal aortic aneurysms

Since the concept of endovascular aneurysm repair (EVAR) was introduced more than 15 years ago, many technological advances and multiple generations of aortic stent-graft devices have been used to manage infrarenal abdominal aortic aneurysms. In this rapidly changing environment, the determination of the optimal management of patients with aneurysmal disease can be difficult. In this article, the current management of infrarenal abdominal aortic aneurysms is outlined. Consistent data revealing short-term advantages in morbidity and mortality make EVAR a very appealing option for practitioners and patients. However, mid- and long-term data proving an all-cause mortality benefit are lacking. Open repair has proven durability, and should be strongly considered in younger and lower-risk patients.     

Aortic aneurysm repair. Reduced operative mortality associated with maintenance of optimal cardiac performance.

Recent advances in the operative management of aortic aneurysms have resulted in a decreased rate of morbidity and mortality. In 1972, we hypothesized that a further reduction in operative mortality might be obtained with controlled perioperative fluid management based on data provided by the thermistor-tipped pulmonary artery balloon catheter. From 1972 to 1979 a flow directed pulmonary artery catheter was inserted in each of 110 consecutive patients prior to elective or urgent repair of nonruptured infrarenal aortic aneurysms. The slope of the left ventricular performance curve was determined preoperatively by incremental infusions of salt-poor albumin and Ringer's lactate solution. With each increase in the pulmonary arterial wedge pressure (PAWP), the cardiac index (CI) was measured. The PAWP was then maintained intra- and postoperatively at levels providing optimal left ventricular performance for the individual patient. There were no 30-day operative deaths among the patients in this series and only one in-hospital mortality (0.9%), four months following surgery. The five-year cumulative survival rate for patients in the present series was 84%, a rate which does not differ significantly from that expected for a normal age-corrected population. Since the patient population was unselected and there were no substantial alterations in operative technique during the present period, these improved results support the hypothesis that operative mortality attending the elective or urgent repair of abdominal aortic aneurysm can be minimized by maintenance of optimal cardiac performance with careful attention to fluid therapy during the perioperative period.     

Technical aspects in the management of abdominal aortic aneurysms

During the past decade, resection of abdominal aortic aneurysms has become common. The technical aspects of the operation are now relatively standardized and simplified. With concomitant improvements in anesthesia and intensive care, the operative mortality for elective resection of these aneurysms has declined progressively; several centres report an operative mortality of less than 5%. The author considers the following principles important in managing patients with abdominal aortic aneurysms: (a) simplicity and limited dissection are critical features of the operative technique; (b) tubular grafts should be used whenever possible; (c) selected patients should be transferred to the intensive care unit preoperatively for "fine-tuning" of the cardiovascular system; (d) patients should be monitored intraoperatively and postoperatively; (e) the surgeon should be aware of special problems such as horseshoe kidney, venous anomalies, adherent duodenum and the presence of major arteries arising from the aneurysm; (f) ruptured aneurysms should be diagnosed promptly and the patient operated upon without delay. Using these principles, the author's group achieved an operative mortality of only 1.8% in 168 patients with abdominal aortic aneurysms resected electively. However, the operative mortality for their patients with ruptured aortic aneurysms was 50%, a rate that has not changed appreciably over the years.     

Inflammatory abdominal aortic aneurysm treated by endovascular stent grafting: a case report

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.     

Endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is a connective tissue disorder caused by abnormal collagen synthesis. Vascular complications, including aneurysm formation and spontaneous arterial perforations, are difficult to manage surgically and result in significant operative mortality due to blood vessel fragility. We describe the first reported successful endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome. We discuss the advantages endovascular surgery offers over open surgery in these patients. We believe that endovascular repair of abdominal aortic aneurysms preferentially over open repair merits consideration in patients with Ehlers-Danlos syndrome.     

Arteriovenous fistula secondary to rupture of atherosclerotic abdominal aortic aneurysm: Report of five cases

Five patients with an acute spontaneous arteriovenous fistula as a result of rupture of abdominal aortic aneurysms into the inferior vena cava of iliac vein are presented. A high mortality usually accompanies this rather infrequent complication of abdominal aortic aneurysms. The pathologic and physiologic aspects of this catastrophic event are discussed with emphasis on the variation of operative management necessary for a successful outcome.     

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??Diagnosis and treatment progression of inflammatory abdominal aortic aneurysms HUANG Xin-tian. Department of Vascular Surgery, Shanghai Ninth People’s Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai 200011, China
Abstract Inflammatory abdominal aortic aneurysms (iAAA) are a variant of aortic aneurysm characterized by extensive peri-aneurysmal fibrosis, thickened walls and dense adhesions and represent between 2% and 10% of all abdominal aortic aneurysms (AAA). The etiology of iAAA is understood poorly. Aneurysm development is multifactorial with important genetic and environmental factors. Computed tomography (CT) has become the mainstay of assessing iAAA. The perioperative mortality associated with open iAAA repair is increased compared with normal AAAs, largely due to intraoperative technical difficulties related to inflammation. Endovascular repair (EVAR) for iAAA results in successful management with improvement of periaortic inflammation. It is particularly useful when open repair has failed. EVAR should be considered as first-line therapy in which anatomic parameters are favorable.     

Influence of presentation on outcome in abdominal aortic aneurysm repair.

OBJECTIVES: In the absence of formal screening abdominal aortic aneurysms (AAA) are detected in an opportunistic manner. Many remain asymptomatic and undetected until they rupture. Incidentally discovered small AAAs are entered into a surveillance programme until they reach a suitable size for repair. The aim of this study was to examine trends in the management of AAA and whether the method of presentation had an effect on subsequent mortality. DESIGN: Observational study in UK district general hospital. MATERIALS/METHODS: This study reports a single surgeon case series identified using a prospectively maintained database. Data on mode of presentation, management and mortality were retrieved from case notes, PIMS hospital database and the Office of National Statistics. RESULTS: Two hundred and five patients were referred with AAAs between 1992 and 2004, 78% presenting in elective circumstances. The surveillance programme fed 33% of the operated cases. Two aneurysms ruptured whilst under surveillance. Overall elective operative mortality was 11.8% and has progressively decreased over time. Thirty-day operated mortality was significantly lower in patients having a period of surveillance than those having immediate elective repair (2.3 vs. 16.3%, p=0.018). A slight reduction in emergency AAA repairs was noted over the study period (r2=0.6) although registered aneurysm deaths continue to increase (r2=0.83). CONCLUSIONS: Elective mortality following AAA surgery decreased over the study period. Outcome was better in those patients who had surgery for aneurysms that had been under surveillance. Despite opportunistic screening the population adjusted mortality rate of aortic aneurysms showed a progressive increase. A reduction in deaths from aneurysms is unlikely without a formal screening programme.     

True juxta-anastomotic aneurysms in the residual infra-renal abdominal aorta.

INTRODUCTION: abdominal aortic dilatation can occur above the graft following repair of infra-renal abdominal aortic aneurysm (AAA). This study aimed to determine the incidence and possible aetiological associations of recurrent juxta-anastomotic aneurysms following open repair of AAA. METHODS: the diameter of the infra-renal aorta above the graft of 135 patients who had previously undergone open AAA repair was determined using ultrasound. In those where the diameter was greater than 40 mm a CT scan was undertaken. Co-morbid and operative details were determined from the patients and their clinical notes. RESULTS: seven patients had true juxta-anastomotic aneurysms (>40 mm) in the residual infra-renal abdominal aorta, the occurrence of which was associated with tobacco smoking and hypertension. There was no association with other co-morbid factors, surgical operative details or the development of iliac aneurysms (which occurred in 3% of patients). CONCLUSIONS: true juxta-anastomotic aneurysms develop in the residual infra-renal neck of patients following open repair of abdominal aortic aneurysm. Tobacco smoking and hypertension are significant factors associated with the development of these aneurysms. This group of patients may warrant surveillance to prevent aneurysm rupture.     

Elective aneurysm repair and the incidence of aortic rupture in an ageing population

During the period January 1984-July 1988, 191 abdominal aortic aneurysms were encountered at Gosford District Hospital, NSW, a hospital that services an ageing population. These aneurysms were either repaired or found as the cause of death at post-mortem. During the study, the rate of elective repair rose from 0.25/month during the first 2 years to 3.67/month in the latter 2.5 years. The mortality for repair of non-ruptured aneurysms was 0.9% compared with 55% for ruptured aneurysms. The 15-fold increase in elective repair resulted in the 58% reduction in the incidence of abdominal aortic rupture from 1.87/month to 0.79/month. The mortality rate from known aneurysms fell from 46% to 14% in the final 2 years. Elective aneurysm repair reduces the incidence of and death from abdominal aortic rupture in an ageing population.     

An alternative anesthetic technique for the morbidly obese patient undergoing endovascular repair of an abdominal aortic aneurysm

Abdominal aortic aneurysms have been treated by open operative repair for many years. A frequent rate of morbidity is associated with the natural history of abdominal aortic aneurysms in combination with open surgical repair. Recently a new technique that is less surgically invasive has been developed as an alternative to open repair. The present case report outlines a less invasive anesthetic technique for the morbidly obese patient. IMPLICATIONS: This case report discusses a minimally invasive anesthetic approach towards the morbidly obese patient undergoing endovascular abdominal aortic aneurysm repair. It demonstrates a safe and cost-effective means of managing a patient with numerous comorbidities. We also discuss an anesthetic/surgical approach on how to provide maximum analgesia with minimal anesthesia.     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Low-dose aspirin may prevent growth and later surgical repair of medium-sized abdominal aortic aneurysms

Experimental data suggest that aspirin-induced platelet inhibition may retard growth of abdominal aortic aneurysms. In this article, whether low-dose aspirin use is associated with reduced aneurysm progression and subsequent need for surgery is examined. In this observational cohort study within a screening trial, 148 patients with small aneurysms (maximum diameter 30-48 mm) annually are followed. Patients were referred for surgery when the aneurysmal diameter exceeded 50 mm. Median follow-up time was 6.6 years. Among patients whose abdominal aortic aneurysms were initially 40 to 49 mm in size, the abdominal aortic aneurysm expansion rate for low-dose aspirin users compared with nonusers was 2.92 mm/y versus 5.18 mm/y (difference 2.27 mm/y, 95% CI, 0.42-4.11). No difference in expansion rates and risk ratios for operative repair was found for patients with abdominal aortic aneurysms <40 mm. For medium-sized abdominal aortic aneurysms, low-dose aspirin may prevent abdominal aortic aneurysm growth and need for subsequent repair, but residual confounding cannot be excluded.     

Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery

OBJECTIVE: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. METHODS: We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. RESULTS: Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. CONCLUSION: Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.     

Current status of thoracic aortic endograft repair

The advent and success of endovascular repair of abdominal aneurysms had led to the development of catheter-based techniques to treat thoracic aortic pathology. Such diseases, including thoracic aortic aneurysms, acute and chronic type B dissections,penetrating aortic ulcers, and traumatic aortic transection, challenge surgeons to perform complex operative repairs in high-risk patients. The minimally invasive nature of thoracic endografting may provide an attractive alternative therapy especially in patients deemed unfit for thoracotomy. A worldwide review of thoracic endografting demonstrates encouraging short- and midterm outcomes with significant reductions in morbidity and early mortality.Long-term surveillance will be crucial to discover complications unique to thoracic endovascular interventions and to determine which patients are appropriate candidates for stent-graft therapy.     

Screening for clinically unsuspected abdominal aortic aneurysms in patients with peripheral vascular disease

In patients with abdominal aortic aneurysms, most fatalities occur from rupture before the patient can be brought to hospital. Even when seen in hospital the mortality is still approximately 50% in contrast to elective repair which has a substantially reduced mortality of less than 5%. In order to reduce the number of patients dying from rupture, they must be diagnosed early to allow elective intervention, hence there has been considerable renewed interest in screening for abdominal aortic aneurysms. We have studied a consecutive series of 104 patients with either claudication or ischaemic rest pain in the lower limbs to determine the incidence of aortic aneurysms in this type of patient.