Abdominal aortic aneurysm

The most common site for an arterial aneurysm, i.e. the focal dilatation of the original blood vessel, is the abdominal aorta. Studies have suggested that abdominal aortic aneurysms (AAAs) are rare in women under the age of 55 and in men under the age of 60. However, in men older than 60, AAAs are nearly 10 times more common in men than in women, and many of these affected men will be asymptomatic. This article reviews the prevalence, diagnosis, including screening guidelines, and treatment options for AAA, with reference to a case study of a 72 year old male smoker diagnosed with an AAA.     

Abdominal aortic aneurysm repair

Options for abdominal aortic aneurysm (AAA) repair include both open and endovascular approaches. Patient selection for each of these requires careful consideration relating to patient health, fitness and anatomy. This article aims to provide an overview of the essential aspects of both open surgical repair (OSR) and endovascular AAA repair (EVAR), focussing upon decision making, the procedures, follow-up and long-term outcomes. Consideration is also given to more complex AAA repairs, including fenestrated/branched stent grafts and open juxta-renal aneurysm repairs. AAA epidemiology, screening, and work up for repair are covered in the previous article.     

Abdominal aortic aneurysm repair

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.     

Abdominal aortic aneurysm in Chinese patients

From 1975 to 1983, 120 Chinese patients with infrarenal abdominal aortic aneurysm were seen, 72 of whom underwent aneurysmectomy; 45 were performed electively and 27 as emergencies. The operative mortality in the former was 4.4 per cent and the latter 33.3 per cent. All 27 patients who presented with rupture were operated on. However, only 45 of 93 patients (48.4 per cent) with intact aneurysm underwent surgery; the remainder were either unwilling (35) or unfit (13). Peptic ulcer disease was noted in 26.4 per cent of patients.     

Abdominal aortic aneurysm in women.

OBJECTIVE: The purpose of this study was to compare abdominal aortic aneurysm (AAA) associations in men and women. METHODS: Veterans aged 50 to 79 years without a previous history of AAA underwent ultrasound screening for AAA after completing a questionnaire on demographic information and potential risk factors. RESULTS: A total of 122,272 men and 3450 women were successfully screened. An AAA of 3.0 cm or greater in diameter was found in 4.3% of men and 1.0% of women (P <.001). Contrary to a previous report, we did not find suprarenal aortic enlargement accompanying AAA to be more common in women. The principal associations that we have previously reported for AAA in this cohort (age, smoking, family history of AAA, and a negative association with diabetes) were all similar in women compared with men. In age- and smoking-adjusted models, the interaction terms indicated that black race and cancer were more strongly associated with AAA in women than men (P <.05). Height and cerebral vascular disease were also more strongly associated with AAA in women than in men, but these interaction terms did not reach statistical significance (P <.10). Although the other differences were unexpected and require confirmation, the trend toward a stronger association of cerebral vascular disease with AAA in women is consistent with two previous reports. CONCLUSIONS: Despite the much lower prevalence of AAA in women, the most important associations with AAA are similar to those seen in men. Our data provide some support for a previous finding that cerebrovascular disease may be more closely associated with AAA in women than in men.     

Abdominal aortic aneurysm in south-west Scotland

Between 1977 and 1988, 155 patients with abdominal aortic aneurysm in the Dumfries and Galloway health region were traced. One hundred and six patients underwent surgery; 57 elective operations for non-leaking aneurysms were performed locally without mortality, and of the 49 patients operated on with ruptured aneurysm, 11 were transferred to a major vascular centre with four deaths (36% mortality rate). The remaining 38 patients were treated locally. Twenty-three of these were operated on by a surgeon with vascular interest with nine deaths (39% mortality rate) and of the remaining 15 patients operated on by a surgeon without a vascular interest, ten died (66% mortality rate). These findings emphasize that patients presenting at a district hospital with leaking abdominal aortic aneurysm should be transferred to a major vascular unit if there is no local vascular expertise available, and our figures suggest that transfer of such patients does not prejudice survival. Further, of those patients who died of leaking aneurysm in hospital without undergoing surgery (25 patients), 15 were in hospital for longer than 3 h without the correct diagnosis. A significant improvement in mortality could follow prompt and accurate diagnosis at hospital level, with the most common error in diagnosis being renal colic.     

Abdominal aortic aneurysm repair after pancreaticoduodenectomy

We present two cases of patients with coincidental pancreatic disease and abdominal aortic aneurysm. Initial pancreaticoduodenectomy was followed by staged abdominal aortic aneurysm repair via a retroperitoneal approach in both cases. We recommend the retroperitoneal approach over the transperitoneal approach as an easier and safer method of aortic aneurysmorrhaphy after the Whipple procedure. (J VASC SURG 1995;21:537-9.)     

Abdominal aortic aneurysm surgery for octogenarians

Purpose  To define the indications for abdominal aortic aneurysm (AAA) surgery in octogenarians. Methods  We reviewed septuagenarians and octogenarians with a nonspecific AAA diagnosed at our hospital between January, 1990 and June, 2006. Results  Among a total 628 patients seen, 306 were in their 70s (group A) and 108 were in their 80s or older (group B). The mortality rate associated with elective surgery was 1.9% in group A and 7.0% in group B. Of the survivors, 12 (5.7%) of 210 in group A and 8 (15.1%) of 53 in group B died within 2 years. Of the patients who did not undergo surgery, 8 of 53 in group A and 8 of 31 in group B had AAAs greater than 6 cm in diameter. The rupture-free rates of AAAs greater than 6 cm in diameter were 64% at 1 year and 0% at 4 years in group A, and 88% at 1 year and 26% at 3 years in group B. The rupture-free rates of AAAs smaller than 6 cm in diameter were 95% at 3 years and 85% at 5 years in group A, and 100% at 5 years in group B. Conclusions  We concluded that AAAs over 6 cm in diameter were an appropriate indication for surgery in octogenarians.     

Abdominal aortic aneurysm and pelvic kidney

Abdominal aortic aneurysm associated with a pelvic kidney was recognized and treated successfully in a 66-year-old male by keeping renal ischemia time to less than 40 minutes and implanting the renal arterial supply as a cuff with common iliac arterial anastomoses to each Dacron limb of the graft.     

Abdominal aortic aneurysm screening in Sweden

A large body of evidence from four international randomised controlled trials (RCT) on abdominal aortic aneurysm (AAA) screening indicate that ultrasound-based screening in elderly men with a high prevalence (4?%–7?%) reduces AAA-related mortality by 40?% through early AAA detection and increased preventive elective repair and subsequently halves rupture incidence. Coinciding with the planned launch of national AAA screening programs, a dramatic change in AAA epidemiology became evident: a lower AAA prevalence in the targeted population of men and falling mortality rates, most likely related to a drop in rates of smoking, and a paradoxical increase in elective AAA repairs. These changes have called AAA screening in today’s context into question. Sweden was the first country to provide national coverage with an AAA screening program targeting 65-year-old men. The scientifically evaluated screening initiative, started in 2006, reported the lower than expected prevalence (1.7?%) in 65-year-old men early on. Cost-effectiveness seems to be maintained despite the altered epidemiology, as shown in a health-economic study. The current prevalence of AAA among Swedish women is very low, and general population-based screening of women is likely to be futile, although targeted screening among female smokers should be evaluated. Sub-aneurysmal aortas detected at screening are likely to progress to a true AAA within 5 years, indicating a need for continued surveillance in this group. Differences in screening compliance seem to be linked to socio-economic factors. The aim of this topical review is to highlight AAA screening within a Swedish context and point to areas where information is lacking and further research is needed.     

Abdominal aortic aneurysm neck remodeling after open aneurysm repair

PURPOSE: Proximal endovascular aortic graft fixation and maintenance of hemostatic seal depends on the long-term stability of the aortic neck. Previous investigations of aortic neck dilation mostly focused on the infrarenal aortic diameter. Fenestrated and branched stent grafts facilitate suprarenal graft fixation and may thereby improve the long-term integrity of the aortic attachment site. For these devices, the natural history of the suprarenal aortic segment is also of interest. We investigated the natural history of the supra- and infrarenal aortic segment after open abdominal aortic aneurysm (AAA) repair. METHODS: For this retrospective analysis, we reviewed the preoperative and the initial postoperative as well as the most recent CT series that were obtained from 52 patients undergoing conventional repair of an infrarenal abdominal aortic aneurysm between January 1998 and December 2002. Measurements were performed using electronic calipers on a "split screen", allowing direct comparison of subsequent CT series at corresponding levels along the vessel. Main outcome measures were changes in postoperative measures of the supra- and infrarenal aortic diameters. RESULTS: The first postoperative exam was at a mean (+/-SD) of 7.0 +/- 3.5 months, and the final exams were at 44.4 +/- 21 months. Over this time period, the estimated rate of change in suprarenal diameter was 0.18 mm/ y with 95% confidence interval (CI) from 0.08 to 0.27. The estimated rate of change for the infrarenal diameter was 0.16 (95% CI: 0.05 to 0.27). A clinically relevant diameter increase of >or=3 mm was observed in seven patients (13%). There was evidence of larger diameter increases associated with larger AAA diameters (P = .003 and <.001 for suprarenal and infrarenal diameters), an inverted funnel shape (P = .002 and <.001), and marginal evidence of association with a history of inguinal hernia (P = .043 and .066). CONCLUSIONS: Although there is statistically significant evidence of increases in the supra- and infrarenal aortic diameters after conventional AAA repair, mean annual increases tended to be small and clinically relevant increases of 3 mm or more were observed in only a small proportion of cases.     

Abdominal aortic aneurysm in liver transplant recipients

BACKGROUND AND AIMS: To analyze the incidence, clinical features, expansion rate of, and clinical approach to abdominal aortic aneurysm in patients who had undergone orthotopic liver transplantation. To our knowledge, this is the first report on this issue in liver transplant recipients. PATIENTS/METHODS: Among 172 patients undergoing 185 liver transplantations at our institution over the last 10-year period, we identified three patients (1.7%) with infrarenal aortic aneurysm. They had all undergone routine pre-liver transplant ultrasonography screening for aortic aneurysm. RESULTS: All three patients were symptom free at the time of the discovery of a mild infrarenal abdominal enlargement before ( n=2) and after liver transplantation ( n=1), and were closely monitored by ultrasonography in the follow-up period (3.1-4.3 years). The mean aneurysm expansion rate was 0.73 cm/year. All patients underwent aneurysm repair after their aneurysm expanded significantly under observation, with a mean diameter of 5.1 cm at the time of repair. All three patients are alive and well (median follow-up: 19 months). CONCLUSIONS: Our data suggest that careful ultrasonographic surveillance is warranted in any liver transplant recipient, because of the apparent propensity for a more rapid aneurysm expansion and potentially aggressive course than in the untransplanted population. Early repair of the infrarenal aneurysm is recommended in transplant recipients, given that excellent perioperative and late outcomes can be achieved.     

Abdominal aortic aneurysm screening program in Poland

Background

Screening for abdominal aortic aneurysms (AAA) is currently recommended by several vascular societies. In countries where it has been introduced the prevalence of AAAs differed greatly and was mainly related to cigarette smoking. The screening program also had an enormous impact on the decrease of AAA ruptures and reduced mortality rate. These facts have led to the introduction of the first screening program for AAAs in Poland.

Objective

The aim of the study was to determine the prevalence of AAAs among men aged 60 years and older undergoing ultrasound examination of the abdominal aorta.

Material and methods

A single ultrasonography of the abdomen was performed to assess the aorta from the renal arteries to the bifurcation and the diameter of the aorta was measured at its widest point. The cut-off value for determining an aortic aneurysm was set at a diameter of ≥?30 mm. All ultrasonography measurements were performed by physicians in outpatient departments throughout the Kuyavian-Pomeranian Province. Additionally, each subject had to fill out a questionnaire with demographic data, smoking habits, existing comorbidities and familial occurrence of AAAs. The study was conducted from October 2009 to November 2011.

Results

The abdominal aorta ultrasound examinations were carried out in 1556 men aged 60 years and older. The prevalence of AAA in the study population was 6.0?% (94 out of 1556). The average age of the men was 69 years (SD 6 years, range 60–92 years). In the study population 55?% of the men smoked or had smoked and 3?% were aware of the presence of AAAs in family members. There were three risk factors significantly associated with the presence of AAAs: age (p?Conclusion The prevalence of AAAs among men in Poland is higher than in other European countries and the USA. The screening program for AAAs is an easy and reliable method for detecting early stages of the disease and risk factors which are the driving forces for the development of AAAs.     

Abdominal aortic aneurysm in renal transplant recipients

BACKGROUND: Abdominal aortic aneurysms (AAA) requiring surgical management are encountered more frequently in renal transplant recipients, presenting an important technical problem during the repair. The aim of the present study was to analyze the epidemiology and natural evolution of AAA among renal allograft recipients. METHODS: Three hundred ninety-four renal transplant recipients were periodically evaluated with abdominal aortic ultrasound tomography for AAA. The indication for surgery was a maximal diameter >5 cm. Renal function, graft, and patient survival were evaluated after a mean follow-up of 51 months. RESULTS: Four AAA were detected in 394 renal transplant recipients, a prevalence of 1.01%. All of the AAA were found in male recipients of mean age 59.2 +/- 5.5 years and mean time posttransplantation of 82.7 +/- 77.3 months. The mean follow-up period between diagnosis and indication for surgery was 14.2 +/- 10.8 months. Two patients underwent open repair with aneurysmectomy and conventional tube graft positioning, and 2 patients refused surgical repair. To preserve renal graft function during the aortic cross-clamping phase, cold perfusion with 4 degrees C Ringer acetate and local hypothermia with sterile ice were used. Renal function did not change after the operation (preoperative serum creatinine levels were 1.2 and 1.3 mg/dL; postoperative 1.3 and 1.5 mg/dL respectively). The 2 patients who underwent surgery are alive with excellent graft functioning after a follow-up of 1.5 and 7 years, respectively. The 2 patients who refused surgical treatment are dead. CONCLUSIONS: Yearly ultrasound screening for AAA must be recommended in renal transplant recipients as part of the routine posttransplantation follow-up. De novo AAA occurs in younger subject in the transplant population and shows a faster evolution.