Total laparoscopic infrarenal aortic aneurysm repair: preliminary results

OBJECTIVES: We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. MATERIAL AND METHODS: Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. CONCLUSION: These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.     

Total laparoscopic abdominal aortic aneurysms repair

AIM: The aim of the study was to describe our experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. METHODS: Between February 2002 and September 2004, we performed 49 total laparoscopic AAA repair in 45 men and 4 women. Median age was 73 years (range, 46-85 years). Median aneurysm size was 52 mm (range, 30-95 mm). ASA class of patients was II, III and IV in 16, 32 and 1 cases, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 47 patients. Seven patients were operated via a tranperitoneal left retrorenal approach and one patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 19 and 30 patients, respectively. Median operative time was 290 min (range, 160-420 min). Median clamping time was 81.5 min (range, 35-230 min). Median blood loss was 1800 cc (range, 300-6900 cc). Mortality was 6.1% (3 patients). In our early experience, two patients died of myocardial infarction. The 3rd death was due to a multiple organ failure. Thirteen major non lethal postoperative complications were observed in 9 patients (18%). Four patients had local/vascular complications, which required reintervention (8%). Nasogastric tube is now removed at the end of procedure. Median duration of ileus, return to general diet, ambulation and hospital stay were 2, 3, 3 and 10 days. With a median follow-up of 19 months (range, 8-39 months), complete recovery with patent graft was observed in 44 patients. Two patients needed a crossover femoral graft for one iliac dissection and one graft limb occlusion. CONCLUSIONS: These results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. It remains technically demanding and a previous training in videoscopic sutures is essential. Initial learning curve in laparoscopic aortic surgery with aortoiliac occlusive lesions is preferable before to begin laparoscopic AAA repair.     

Surveillance of small aortic aneurysms does not alter anatomic suitability for endovascular repair

OBJECTIVE: Small abdominal aortic aneurysms (AAAs; 4-5.4 cm) are more likely to be suitable for endovascular aneurysm repair (EVAR) than large aortic aneurysms (>5.5 cm). The purpose of this study was to determine whether small AAA growth is associated with the development of morphologic characteristics that decrease eligibility for EVAR. METHODS: We studied 54 patients who underwent 2 or more computed tomography scans with 3-dimensional reconstruction during surveillance of small AAAs. Morphologic aortic aneurysm features and changes were measured according to Society for Vascular Surgery reporting standards. Suitability for EVAR was determined by neck anatomy (diameter, length, and angulations), iliac artery morphology, and total aortic aneurysm angulation and tortuosity. RESULTS: The median age of the study cohort was 73 years (interquartile range [IQR], 65-77 years). The median follow-up period was 24 months (IQR, 15-36 months). The median small AAA diameter increased from 44.5 mm (IQR, 41-48 mm) to 48.9 mm (IQR, 45.7-52.0 mm). The median aortic neck diameter increased from 23.0 to 24.0 mm (P = .002), whereas median neck length decreased from 26.5 to 20.0 mm (P = .001). Aortic aneurysm median tortuosity index increased from 1.09 to 1.11 (P = .05). No significant changes in iliac artery morphology occurred. Overall, the anatomic suitability for endovascular repair did not significantly change during the study period (74% vs 69%; McNemar test; P = .25). CONCLUSIONS: Changes in aortic morphology are frequently associated with small AAA growth at mid-term follow-up, but such changes are minor and do not affect overall anatomic suitability for EVAR. These data reveal that continued surveillance of small AAAs does not threaten the window of opportunity for EVAR.     

The use of statins and fate of small abdominal aortic aneurysms

The aim of this study was to evaluate the value of statins in reducing abdominal aortic aneurysm (AAA) growth rate and improving freedom from aneurysm repair or rupture. One hundred and twenty-one patients with AAA undergoing ultrasonographic surveillance for at least one year were included in this retrospective study. Patients treated with statins had a decreased linear aneurysm growth rate than those not receiving statins (1.9+/-1.8 mm/year vs. 2.6+/-2.4 mm/year, P=0.27), but this difference did not reach statistical significance. Statin users had a better survival freedom from aneurysm repair or rupture (at 5 years: 72.3% vs. 52.5%, P=0.048). The impact of treatment with statins was even more evident in patients with a baseline aneurysm diameter<40 mm (at 5 years: 84.0% vs. 58.8%, P=0.022). When adjusted for age, coronary artery disease and baseline aneurysm diameter, treatment with statins had significantly better survival freedom from aneurysm repair or rupture (P=0.012, RR 0.34, 95% CI 0.14-0.78). The use of statins seems to slightly decrease the AAA growth rate and to significantly improve freedom from aneurysm repair and rupture.     

Ten-year outcome of patients with very small abdominal aortic aneurysm

BACKGROUND: The long-term fate of very small abdominal aortic aneurysms (AAA) is not well known. METHODS: Forty-one patients with asymptomatic small AAA (range 25 to 40 mm) underwent ultrasonographic surveillance. RESULTS: The median follow-up period was 7.3 years. The median linear aneurysm expansion rate was 2.0 mm/year (range 0 to 8.4). Three patients experienced aneurysm rupture (7.3%) which resulted in 1 patient'death. Thirteen patients underwent aneurysm repair (31.7%) and 1 patient died postoperatively (7.7%). The survival rate at 10-year follow-up was 59.0%. The survival rate free from aneurysm rupture and repair at 10-year follow-up was 69.9%. The median time for occurrence of aneurysm rupture was 4.9 years (range 1.8 to 10.5) and the need for aneurysm repair was 4.5 years (range 1.4 to 10.4). CONCLUSIONS: The fate of very small AAA is to slowly enlarge in size, sometimes threatening the patient's life. These observations underline the importance of continuous surveillance and the potential benefits of any medical treatment in this patient population.     

Ruptured inflammatory abdominal aortic aneurysm: insights in clinical management and outcome

BACKGROUND: Ruptured inflammatory abdominal aortic aneurysm (AAA) is relatively rare, and little has been written on the outcome of operative treatment. METHODS: Patients undergoing attempted repair of ruptured inflammatory AAA between 1995 and 2001 were included in a retrospective case-cohort study. Demographic, clinical, and operative factors were analyzed, together with in-hospital morbidity, in-hospital mortality, and duration of postoperative hospital stay. RESULTS: Of 297 patients who underwent attempted operative repair of ruptured AAA, 24 (8%) had an inflammatory aneurysm. Twenty-two patients were men, and two were women; median age was 69 years (range, 51-85 years). Operative findings revealed a contained hematoma in 16 patients (70%), free rupture in 3 patients (13%), aortocaval fistula in 4 patients (17%), and aortoenteric fistula in 1 patient (4%). Of 273 noninflammatory ruptured AAAs, only 2 AAA (1%) were associated with primary aortic fistula. Ten patients (42%) with inflammatory AAA died in hospital, compared with 117 of 273 patients (43%) without inflammation. Median postoperative stay was 10 days (range, 0-35 days). Of the 14 patients with inflammatory lesions who survived, 11 had postoperative complications; 4 patients had acute renal failure, three of whom required temporary renal replacement therapy. CONCLUSIONS: Ruptured inflammatory AAA is associated with a higher incidence of aortic fistula than is ruptured noninflammatory AAA. Repair of ruptured inflammatory AAA is not associated with increased operative mortality compared with repair of ruptured noninflammatory AAA.     

The impact of gender on presentation, therapy, and mortality of abdominal aortic aneurysm in the United States, 2001-2004

INTRODUCTION: The elective repair of abdominal aortic aneurysms (AAA) may decrease a patient's risk of rupture and confers a significantly lower in-hospital mortality rate than emergency repair. Previous works have shown that AAA rupture rates are higher in women compared to men, and that women have higher associated in-hospital mortality rates. This study was performed to evaluate, currently, to what extent patient gender influences presentation and treatment of AAA and the associated outcomes in the United States. METHODS: The Nationwide Inpatient Sample was used, with pertinent ICD-9 codes, to identify all patient-discharges that occurred with the primary diagnosis of intact (iAAA) or ruptured/dissecting (rAAA) abdominal aortic aneurysms between the years 2001 and 2004. Univariate and multiple logistic regression analyses of variables were performed. RESULTS: An estimated 220,403 AAA patient-discharges were identified during the study period. 37,016 (17%) patients presented with rAAA. A higher percentage of women with AAA presented with rupture compared to men (21% vs 16%; odds ratio [OR] 1.40, 95% confidence interval [CI], 1.27-1.54). This rupture rate did not significantly change from 2001 to 2004 (P = .85 for trend). For iAAA, women had higher odds of in-hospital mortality than men (OR 1.60; 95% CI, 1.24-2.07). Compared to men, in-hospital mortality rates for women with iAAA were higher for both endovascular (2.1% vs 0.83%, P < .0001) and open repairs (6.1% vs 4.0%, P < .0001). For iAAA, fewer women underwent endovascular repair (32.4% vs 46.7%, P < .0001; O.R. 0.59, 95% CI, 0.52-0.67). For patients who presented with rAAA, women were less likely to undergo surgical intervention compared to men (59% vs 70%, P < .0001). For those that underwent repair, women had higher in-hospital mortality rates than men (43% vs 36%, P < .0001; OR 1.49, 95% CI, 1.16-1.91). CONCLUSION: A higher percentage of women currently present with aneurysm rupture. They have higher in-hospital mortality rates for both iAAA and rAAA. This gender difference in the outcomes following repair of abdominal aortic aneurysm has persisted over time, the cause of which is not explained by these or previous data, a fact that warrants further investigation.     

Growth rate and associated factors in small abdominal aortic aneurysms.

OBJECTIVE: To study the growth rate and factors influencing progression of small infrarenal abdominal aortic aneurysms (AAA). DESIGN: Observational, longitudinal, prospective study. PATIENTS AND METHODS: We followed patients with AAA <5 cm in diameter in two groups. Group I (AAA 3-3.9 cm, n = 246) underwent annual ultrasound scans. Group II (AAA 4-4.9 cm, n = 106) underwent 6-monthly CT scans. RESULTS: We included 352 patients (333 men and 19 women) followed for a mean of 55.2+/-37.4 months (6.3-199.8). The mean growth rate was significantly greater in group II (4.72+/-5.93 vs. 2.07+/-3.23 mm/year; p<0.0001). Group II had a greater percentage of patients with rapid aneurysm expansion (>4 mm/year) (36.8 vs. 13.8%; p<0.0001). The classical cardiovascular risk factors did not influence the AAA growth rate in group I. Chronic limb ischemia was associated with slower expansion (< or = 4 mm/year) (OR 0.47; CI 95% 0.22-0.99; p = 0.045). Diabetic patients in group II had a significantly smaller mean AAA growth rate than non-diabetics (1.69+/-3.51 vs. 5.22+/-6.11 mm/year; p = 0.032). CONCLUSIONS: The expansion rate of small AAA increases with the AAA size. AAA with a diameter of 3-3.9 cm expand slowly, and they are very unlikely to require surgical repair in 5 years. Many 4-4.9 cm AAA can be expected to reach a surgical size in the first 2 years of follow-up. Chronic limb ischemia and diabetes are associated with reduced aneurysm growth rates.     

Abdominal aortic aneurysm as an incidental finding in abdominal ultrasonography

The difference between the mortality rate from ruptured abdominal aortic aneurysm (overall mortality rate 85-95 per cent and operative mortality rate 23-63 per cent), and that for elective aneurysm repair (less than 5 per cent) is dramatic. Awareness of the existence of an abdominal aortic aneurysm is therefore essential. Of 1800 consecutive patients aged greater than or equal to 50 years referred for their first abdominal ultrasonography, 113 who had been referred specifically for suspected abdominal aortic aneurysm or vascular screening were excluded. The remaining 1687 patients (693 men and 994 women) form the study group. Apart from the symptom-directed examination, the entire abdomen of every patient was routinely studied by ultrasonography. The definition of an abdominal aortic aneurysm was a local dilatation of the aorta with an anteroposterior diameter greater than 30 mm or greater than 1.5 times the anteroposterior diameter of the proximal aorta. In 82 cases (4.9 per cent) an abdominal aortic aneurysm was disclosed; 61 were in men (8.8 per cent) and 21 were in women (2.1 per cent). The prevalence of abdominal aortic aneurysm as an incidental finding in men aged greater than or equal to 60 years was 11.4 per cent. In every patient aged greater than or equal to 50 years undergoing their first abdominal ultrasonography examination, the aorta should be screened for the presence of an aneurysm.     

Total laparoscopic juxtarenal abdominal aortic aneurysm repair

OBJECTIVES: This study describes our experience of total laparoscopic juxtarenal abdominal aortic aneurysm (JAAA) repair. METHODS: Between February 2002 and October 2007, we performed 148 total laparoscopic AAA repairs, including a subset of 13 patients who underwent a laparoscopic JAAA repair. Median age was 70 years (range, 50-81years). Median aneurysm size was 55 mm (range, 50-80 mm). Eight patients were in American Society of Anesthesiologist class II, and five were in class III. We used laparoscopic transperitoneal left retrorenal approaches and suprarenal clamping in all patients. RESULTS: We implanted tube grafts in nine patients and bifurcated grafts in four. No conversions to open repair were required. Median operative time was 260 minutes (range, 180-355 minutes). Total median aortic clamping time was 77 minutes (range, 36-105 minutes). Median suprarenal clamping time was 24 minutes (range, 9-37 minutes). Median blood loss was 855 mL (range, 215-2100 mL). No patients died. One patient had a postoperative coagulopathy with hemorrhagic syndrome. Five patients had moderate systemic complications, including four renal insufficiencies without dialysis and one grade I ischemic colitis. Liquid diet was reintroduced after 1 day (range, 1-7 days). Most patients were ambulatory by day 3 (range, 2-17 days). Median lengths of stay were 48 hours (range, 12-336 hours) in the intensive care unit and 10 days (range, 4-30 days) in the hospital. With a median follow-up of 19 months (range, 1-36 months), patients had complete recovery without graft anomalies. CONCLUSION: Total laparoscopic JAAA repair is feasible and worthwhile for patients. Prior experience in laparoscopic aortic surgery is essential to perform these challenging procedures. Despite these encouraging results, a greater experience is required to ensure the benefit of this technique compared with open repair.     

Feasibility of preoperative computer tomography in patients with ruptured abdominal aortic aneurysm: a time-to-death study in patients without operation

INTRODUCTION: Despite advances in surgery, anaesthesia, and critical care, mortality from ruptured abdominal aortic aneurysms (AAAs) has not decreased over the last 20 years. Endovascular aneurysm repair (EVAR) of ruptured AAAs is an alternative to open repair, which may improve outcome. However, a computed tomography (CT) scan is usually required to assess the anatomic suitability of the aneurysm for EVAR. This may result in delay in transferring patients to the operating room. We evaluated all patients admitted to hospital with a ruptured AAA who died without undergoing surgery, to determine time to death after AAA rupture and thus the potential time available for obtaining a CT scan. METHODS: A retrospective case note review was conducted of 56 patients admitted to a single center with ruptured AAAs who did not undergo surgery because of advanced age or associated comorbidity over 8 years from 1995 to 2003. Statistical analysis was performed with the Fisher exact test. RESULTS: The 56 patients (33 men, 59%; 23 women, 41%) had a median age of 85 years (range, 71-98 years). Reasons for no operation being performed were shock (9%), cardiac arrest (11%), quality of life (29%), malignancy (7%), cardiac disease (15%), respiratory disease (16%) and age (14%). Median systolic blood pressure at admission was 110 mm Hg, heart rate was 88 beats per minute, and hemoglobin concentration was 10.5 g/dL. Patients were not aggressively resuscitated once a decision was made to not perform surgery. Death within 2 hours of hospital admission occurred in 7 (12.5%) patients, and 49 (87.5%) patients died more than 2 hours after admission. Median interval between onset of symptoms and admission to hospital was 2 hours 30 minutes (range, 44 minutes-36 hours), and the median interval between admission and death was 10 hours 45 minutes (range, 1 hour 1 minute-143 hours 55 minutes). The median total time to death from onset of symptoms was 16 hours 38 minutes (range, 2 hours 6 minutes-146 hours 50 minutes). CONCLUSION: Most (87.5%) patients admitted to hospital with a ruptured AAA died after more than 2 hours. These data show that most patients with a ruptured AAA who reach the hospital alive are sufficiently stable to undergo CT and consideration of EVAR.     

Late reintervention for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm repair in an Australian population

OBJECTIVE: To examine late reintervention rates for aortic graft-related events and new aortoiliac disease after open abdominal aortic aneurysm (AAA) repair in an Australian population. METHODS: Interrogation of a prospective computerized database identified 1256 consecutive patients (1058 men, 198 women; median age, 70 years; range, 40 to 97 years) who survived open repair of nonruptured (n = 957, group I) and ruptured (n = 299, group II) infrarenal AAA in a single institution between January 1, 1982 and December 31, 2003. Median (range) follow-up was 41 (1 to 261) months for group I and 30 (1 to 243) months for group II. RESULTS: In group I, 33 patients (3.4%) underwent 38 late reinterventions: 20 patients (2.1%) for aortic graft-related events at a median (range) interval of 36 (1 to 94) months after the index AAA repair, with a 30-day mortality rate of 15%; and 13 patients (1.4%) for new aortoiliac disease at a median (range) interval of 33 (3 to 207) months, with 30-day mortality of 8%. In group II, 15 patients (5%) underwent 16 late reinterventions: 10 patients (3.3%) for aortic graft-related events at a median (range) interval of 5 (2 to 112) months, with a 30-day mortality of 10%; and five patients (1.7%) for new aortoiliac disease at a median (range) interval of 67 (39-105) months, with a 30-day mortality of 40%. There was no significant difference in the late reintervention rate between the groups: group I, 33 (3.4%) of 957 vs group II, 15 (5%) of 299 (P = .23). For all patients, the estimated survival at 1, 3, 5 and 10-years was 90%, 79.4%, 66.4%, and 31.6%, respectively; estimated survival free from reintervention at 1, 3, 5 and 10-years was 98.7%, 97.1%, 95.1%, and 91.9%, respectively. CONCLUSIONS: These data demonstrate, for the first time, that open AAA repair has excellent long-term durability in an Australian population and the results compare favorably with previous reports from North America and Europe. These data represent an important benchmark for comparison of the results of endovascular AAA repair in this patient population.     

Abdominal aortic aneurysms following orthotopic heart transplantation

The purpose of these authors' study was to analyze their center's experience with orthotopic heart transplantation (OHT) and abdominal aortic aneurysms (AAA) with particular attention to corticosteroid dosing, hemodynamic parameters, and aneurysm growth rate. A retrospective review of all patients (453) who underwent OHT at their university-affiliated medical center over an 18-year period (1981-1999) was undertaken. Nine (2%) patients who developed AAAs were identified and aneurysm growth was correlated with corticosteroid immunosuppression and hemodynamic parameters. The mean age of OHT patients was 44.5 +/-15 years and the majority were males (371 males, 82%). Median follow-up was 5.7 years. Ischemic cardiomyopathy (IC) was the most common indication for transplantation (45.5% of patients). All AAA patients were male (p=0.157), with a mean age of 58.4 +/-4.8 years (p=0.001), and had undergone OHT for IC (p=0.001). Mean arterial blood pressure and ejection fraction in the AAA patients had increased from pretransplant values of 107 mm Hg and 14.3 +/-5.7% to 142 mm Hg (p=0.017) and 54.1 +/-14.1% (p<0.001), respectively, before aneurysm repair. Mean aneurysm diameter at the time of repair was 6.0 +/-0.8 cm, and the average growth rate was 1.2 +/-0.4 cm/year in the 4 patients in whom it could be measured. Aneurysm repair was performed urgently in 2 patients and electively in 7 patients with 1 early postoperative death (11%). The extent of corticosteroid immunosuppression, corticosteroid pulses, and total corticosteroid dosing did not correlate with the rate of aneurysm growth. Improved hemodynamics and progressive posttransplant hypertension may contribute to aneurysm formation and growth in this group of patients.     

Different disease profiles for women and men with abdominal aortic aneurysms.

OBJECTIVE: The overall aim with this study was to investigate causes of death and mortality rates for women and men treated for abdominal aortic aneurysm (AAA) in Sweden. MATERIALS AND METHOD: All patients treated for ruptured and non-ruptured AAA 1987-2002 in Sweden were identified in national registries (n=12917). Age, sex, diagnosis, surgical procedure and mortality were analysed on a patient specific level. Logistic regression and analysis of standardised mortality rates (SMR) were performed. RESULTS: Post operative mortality was similar between the sexes. Age (p<0.0001), and surgery for rupture (p=0.0005), but not gender (p=0.65) were significant risk factor for poor long term survival. SMR revealed increased risk for both sexes compared to the population with significantly higher values for women than men (2.26, CI 2.10-2.43 vs. 1.63, CI 1.57-1.68, p<0.0001). The higher risk for women could be explained by the higher risk for aneurysm related death (ie.thoracic or abdominal aorta) compared to men (Hazard ratio 1.57 vs. 1.0, p<0.0001). CONCLUSION: Women do not have an increased surgical risk compared to men, but treated women have an increased risk of premature death compared to men and women in the population. They also have a higher risk for aneurysm related death compared to men with AAA.     

Repair of large abdominal aortic aneurysm should be performed early after coronary artery bypass surgery

PURPOSE: The surgical repair (coronary artery bypass grafting [CABG]) of symptomatic coronary artery disease (CAD) in patients with co-existent large abdominal aortic aneurysm (AAA) may result in an increased rate of AAA rupture after operation. Simultaneous CABG/AAA repair has been recommended by some surgeons, but with a somewhat higher mortality rate than staged repair. We reviewed the outcome of staged AAA repair that was performed early after CABG in patients with symptomatic coronary disease and AAA. METHODS: The records of all the patients with symptomatic CAD that required CABG with large AAA (greater than 5 cm) were reviewed. In most patients, CABG was performed first, followed by AAA repair within 2 weeks. Patient demographics, severity of coronary disease, AAA size, interprocedure duration, and perioperative morbidity and mortality rates were examined. RESULTS: Between 1991 and 1998, 1105 AAA repairs were performed. Within this group, 30 patients with AAA underwent CABG for symptomatic CAD. Mean AAA size was 6.6 cm (range, 5.0-10.0 cm). The median interprocedure interval between CABG and AAA repair was 11.5 days. There was no in-hospital AAA rupture during this interval. The patient group was comprised of 24 men and 6 women with a mean age of 71 years. There was no operative death after such staged AAA repair, and nonfatal complications occurred in seven patients (23%). During this period, seven patients had AAA rupture when they were sent home after CABG for recovery and intended AAA repair at a later date. CONCLUSION: Staged elective AAA repair may be performed safely and effectively after CABG. Performance of these procedures with a short interprocedure interval may be preferable to the higher complication rate observed after combined procedures.     

Quantifying the risks of hypertension, age, sex and smoking in patients with abdominal aortic aneurysm

BACKGROUND: The prevalence of abdominal aortic aneurysm (AAA) in a community-based sample of men and women aged 65-79 years was correlated with known risk factors. In addition, the effect of high blood pressure and the use of antihypertensive medication on growth of AAAs were studied. METHODS: Aortic diameter was assessed by ultrasonography and data on risk factors were collected by self-administered questionnaire for 5356 men and women as part of a randomized controlled trial. RESULTS: Current hypertension increased the risk of having an aortic aneurysm by 30-40 per cent while use of antihypertensive medication increased the risk by 70-80 per cent, adjusting for current blood pressure. There was no clear relationship between hypertension and growth rates of existing aneurysms in this study, although these results were largely from data on small aneurysms. Men were nearly six times more likely to develop an AAA than women; the risk increased by 40 per cent every 5 years after the age of 65 years. Smoking was an independent risk factor for AAA, with level of exposure being more significant than duration. CONCLUSION: Male sex, smoking and hypertension are strong risk factors for the development of AAA. In this study hypertension did not significantly increase the growth rate of existing aneurysms. Smoking remains the most important avoidable risk factor for AAA. The analyses presented here suggest that selection for screening, other than by age and sex, is not worthwhile.     

Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks

OBJECTIVE: Our objective was to study intra-aneurysm pressure after endovascular aneurysm repair (EVAR) in shrinking, unchanged, and expanding abdominal aortic aneurysms (AAAs) with and without endoleaks. METHODS: Direct intra-aneurysm sac pressure measurement (DISP) by percutaneous translumbar puncture of the AAA under fluoroscopic guidance was performed 46 times during the follow-up of 37 patients (30 men; median age, 73 years [range, 58-82 years]; AAA diameter: median, 60 mm [range, 48-84 mm]). Three patients were included in two different groups because DISP was performed more than once with different indications. Tip-pressure sensors mounted on 0.014-inch guidewires were used for simultaneous measurement of systemic and AAA sac pressures. Mean pressure index (MPI) was calculated as the percentage of mean intra-aneurysm pressure relative to the simultaneous mean intra-aortic pressure. RESULTS: Median MPI was 19% in shrinking (11 patients), 30% in unchanged (10 patients), and 59% in expanding (9 patients) aneurysms without endoleaks. Pulse pressure was also higher in expanding (10 mm Hg) compared with shrinking (2 mm Hg; P <.0001) AAAs. Four of the nine patients with expanding AAAs underwent five repeated DISPs later in the follow-up, and MPIs were consistently elevated. Seven of the 10 patients with unchanged AAAs without endoleaks underwent further computed tomography follow-up after DISP; 2 expanded (MPI, 47%-63%), 4 shrank (MPI, 21%-30%), and 1 remained unchanged (MPI, 14%). Type II endoleaks (6 patients, 7 DISPs) were associated with wide range of MPI (22%-92%). Successful endoleak embolization (n = 4) resulted in pressure reduction. CONCLUSIONS: Intra-aneurysm sac pressure measurement is an important adjunctive for EVAR evaluation, possibly allowing early detection of failures. High pressure is associated with AAA expansion and low pressure with shrinkage. Type II endoleaks can be responsible for AAA pressurization, and successful embolization appears to result in pressure reduction.     

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair

BACKGROUND: The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities. METHODS: Patients admitted to a single unit with a ruptured AAA over a 2-year interval (2000-2001) were identified from a prospectively compiled database. Hospital records of all patients undergoing attempted operative repair were reviewed. The Glasgow Aneurysm Score and the Hardman Index were calculated retrospectively and related to clinical outcome. RESULTS: One hundred patients were admitted with a ruptured AAA. Of these, 82 underwent attempted operative repair and were included in the study: 68 men and 14 women, of median age 73 (range 54-87) years. Thirty (37 per cent) patients died after the operation. The Glasgow Aneurysm Score was a poor predictor of postoperative mortality. The area under the Receiver-Operator Characteristic curve was 0.606 (P = 0.112, 95 per cent c.i. 0.483-0.729). Similarly, the Hardman Index failed to predict postoperative mortality accurately (P = 0.211, chi(2) for trend). Of nine patients in this series with three or more Hardman criteria, generally held to be fatal, six survived. CONCLUSION: Contrary to previous reports, The Glasgow Aneurysm Score and the Hardman Index were poor predictors of postoperative mortality after repair of a ruptured AAA in this study.     

Influence of gender on outcome from ruptured abdominal aortic aneurysm

BACKGROUND: The aim of the present study was to compare outcomes following ruptured abdominal aortic aneurysm (AAA) in men and women. METHODS: Overall mortality from ruptured AAA was compared in men and women using the Western Australia Health Services Research Database. The linked chains of de-identified hospital morbidity and death records were selected using the ICD-9-CM (International Classification of Diseases - Clinical Modification) diagnostic and procedure codes pertaining to AAA. Cases were divided into three groups for analysis: patients who died without admission to hospital, those admitted to hospital with a ruptured AAA but who did not undergo operation, and patients who underwent operation for ruptured AAA. RESULTS: Ruptured AAA occurred in 648 men and 225 women over the age of 55 years during the decade 1985-1994. Only 50 per cent of women, compared with 59 per cent of men, were admitted to hospital. Of those admitted to hospital only 37 per cent of women underwent operation, compared with 63 per cent of men. The overall mortality rate from ruptured AAA was 90 per cent in women and 76 per cent in men (chi2 = 50.34, 1 d.f., P < 0.0001). Although women were, on average, 6 years older than men, this unfavourable pattern occurred across all age groups. CONCLUSION: Women with a ruptured AAA are more likely to die than men. More research is required to identify the causes of this sex difference.     

Intra-aneurysm pressure measurements in successfully excluded abdominal aortic aneurysm after endovascular repair

PURPOSE: This study was performed to determine intra-aneurysm sac pressure of abdominal aortic aneurysm after endovascular aneurysm repair in patients considered successfully treated with aneurysm shrinkage and absence of endovascular leakage. METHODS: In 10 patients with median aneurysm shrinkage of 12 mm (range, 7 to 22 mm) and median follow-up of 19 months (range, 14-43 months), a percutaneous translumbar intra-aneurysm pressure measurement was made with a 0.014-inch guide wire-mounted pressure sensor and compared with intra-aortic pressure. RESULTS: Median intra-aneurysm systolic/diastolic/mean pressure was 19/18/19 (range, 17-35/13-33/17-31) compared with median intra-aortic pressure of 135/75/99 (range, 126-199/60-95/84-129). Mean intra-aneurysm pressure was 20% of mean intra-aortic pressure (range, 13%-33%). Pulsatility was negligible. CONCLUSION: Successful endovascular aneurysm repair of abdominal aortic aneurysm results in considerable pressure reduction in the aneurysm sac. The ability to monitor intra-aneurysm pressure provides hemodynamic information within the sac, which can be used in conjunction with imaging to determine whether a secondary intervention is warranted.