Myocardial Injury and Systemic Fibrinolysis in Patients Undergoing Repair of Ruptured Abdominal Aortic Aneurysm: a Preliminary Report

BACKGROUND: ruptured abdominal aortic aneurysm (AAA) is associated with inhibition of systemic fibrinolysis. Hypofibrinolysis is a risk factor for ischaemic myocardial injury, one of the commonest complications of ruptured AAA repair. Cardiac troponin I (cTnI) is one of the most sensitive and specific marker of myocardial injury currently available. OBJECTIVE: To examine, for the first time, the relationship between fibrinolytic activity and myocardial injury in patients operated for ruptured AAA. METHODS: Twenty patients (18 men and 2 women of median age 74, range 65-86 years) undergoing repair of ruptured AAA were prospectively studied. Plasma tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI-1) activity were measured pre-operatively, immediately before and five minutes following aortic clamp release. Serum cTnI was measured pre-operatively, 6 and 24 h following clamp release. Results cTnI was detectable at one or more sample points in 13 (65%) patients, and in 7 out of 8 patients who suffered major cardiac complications. There was a significant negative correlation between pre-operative t-PA activity and cTnI before operation (r =-0.55, p = 0.01) and 6 h ( r =-0.51, p =0.02) after clamp release. There was a significant positive correlation between pre-operative PAI activity and cTnI before operation (r =+0.50, p =0.03), 6 h ( r =+0.47, p =0.04) and 24 h ( r =+0.50, p =0.03) after clamp release. There was no correlation between pre- and intra-operative hypotension or blood transfusion requirement and cTnI release. CONCLUSIONS: Hypofibrinolysis during ruptured AAA repair is associated with the development of peri-operative myocardial injury. The causal mechanisms underlying this state are not clear but treatment of this prothrombotic/hypofibrinolytic diathesis may help to limit myocardial cell necrosis.     

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.     

Aneurysm rupture is independently associated with increased late mortality in those surviving abdominal aortic aneurysm repair

PURPOSE: The aim of this study was to define whether veterans who survived repair of ruptured abdominal aortic aneurysms (AAA) experienced late survival rates similar to those surviving repair of intact AAA. METHODS: All veterans undergoing AAA repair in DRGs 110 and 111 during fiscal years 1991-1995 were identified using the Veterans Affairs (VA) Patient Treatment File (PTF). Late mortality was defined using VA administrative databases including the Beneficiary Identification and Record Locator System and PTF. Illness severity and patient complexity were defined using PTF discharge data that were further analyzed by Patient Management Category software. Veterans were followed up to 6 years after AAA repair. RESULTS: During the study, 5833 veterans underwent repair of intact AAA while 427 had repair of ruptured AAA in all VA medical centers. Operative mortality was defined as that which occurred within 30 days of surgery or during the same hospitalization as aneurysm repair. For those undergoing repair of intact AAA, operative mortality thus defined was 4.5% (265/5833). Operative mortality was 46% (195/427) after repair of ruptured AAA. Overall mortality (including operative mortality) during 2.62+/-1.61 years follow-up was 22% (1282/5833) with intact AAA versus 61% (260/427) for those with ruptured AAA (P<0.001). Further analysis of survival outcomes was performed in patients who survived AAA repair (i.e., those who were discharged alive and lived 30 days or more after surgery). Of those who initially survived repair of ruptured AAA, 28% (65/232) died during follow-up versus 18% (1017/5568) who initially survived repair of intact AAA (odds ratio 1.74; 95% confidence limits 1.30-2.34; P<0.001). In those initially surviving AAA repair, stepwise logistic regression analysis revealed that increasing age, illness severity, patient complexity, as well as AAA rupture and aortic graft complications were increasingly and independently associated with late mortality. Mean survival time was 1681 days for those who survived >30 days and who were discharged alive after repair of ruptured AAA versus 1821 days for those who initially survived repair of intact AAA (P< 0.001). CONCLUSIONS: In addition to higher postoperative mortality rates with ruptured AAA, mortality during follow-up for survivors of AAA repair was also greater for those who survived repair of ruptured AAA. The toll taken by ruptured abdominal aortic aneurysms did not end in the immediate postoperative period.     

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.     

Functional outcome after open repair of ruptured abdominal aortic aneurysm

BACKGROUND: Outcome after operative repair of ruptured abdominal aortic aneurysm (AAA) has traditionally been assessed in terms of survival. This study examines the functional outcome of patients who survive operation. METHODS: Consecutive patients who survived open repair over an 18-month period were entered into a prospective case-control study. Age- and sex-matched controls were identified from patients undergoing elective AAA repair. The Short Form-36 health survey was administered to both groups of patients at 6 months after operation. Results were compared with the expected scores for an age- and sex-matched normal UK population. RESULTS: Fifty-seven patients underwent open repair of a ruptured AAA, and 30 survived; no patient was lost to follow-up. There were no significant differences in quality of life between patients who had an emergency repair and those who had an elective repair. Both of these groups had poorer health-related quality of life outcomes than the matched normal population. Surprisingly, compared with the normal population, patients after elective repair had poorer outcomes in more health domains than patients who survived emergency operation. CONCLUSIONS: Survivors of ruptured AAA repair have a good functional outcome within 6 months of operation.     

The long-term survival rates of patients after repair of abdominal aortic aneurysms

This study was undertaken to examine the longterm survival rates of patients following abdominal aortic aneurysm (AAA) repair in comparison with an age-matched normal population, and to determine by multivariate analysis the factors influencing long-term survival. Of 125 patients who underwent AAA repair prior to July 1986, 13 died during hospitalization. Of these 13 patients, 6 who suffered aneurysmal rupture all died within 30 days. The survival rate of patients with ruptured aortic aneurysms was significantly lower than that of those with nonruptured aneurysms. Of the 112 patients surviving hospitalization, 85 died within 0.48 to 24 years after their operation. The long-term survival rate of patients who had suffered a preoperative cardiovascular event was significantly lower than that of those who had not suffered a preoperative cardiovascular event. The actual survival rate was significantly lower than the expected survival rate. According to a multivariate analysis, the significant predictors of late survival were age, aneurysmal rupture, and chronic renal failure in all the patients, and age, chronic renal failure, and pre- and postoperative cardiovascular events in patients who did not die in hospital. These findings indicate the importance of improving immediate perioperative management of ruptured AAA and that cardiovascular events should be prevented, or treated during long-term follow-up.     

A randomised trial of endovascular and open surgery for ruptured abdominal aortic aneurysm - results of a pilot study and lessons learned for future studies.

INTRODUCTION: EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations. METHODS: An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited. RESULTS: Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group. CONCLUSIONS: Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.     

Mortality from ruptured abdominal aortic aneurysm in Wales.

BACKGROUND: The aim of this study was to identify the incidence of, and mortality in, patients with a ruptured abdominal aortic aneurysm (AAA) reaching hospital alive in Wales. METHODS: Patients who presented with a ruptured AAA between September 1996 and August 1997 were analysed. Data were collected prospectively by an independent body, observing strict confidentiality. RESULTS: Some 233 patients with a confirmed ruptured AAA were identified, giving an incidence of eight per 100 000 total population. Some 133 patients (57 per cent) underwent attempted operative repair; 85 (64 per cent) of these died within 30 days. Of the 233 patients, 92 were admitted under the care of a vascular surgeon and 141 under a non-vascular surgeon. Vascular surgeons operated on 82 patients (89 per cent), of whom 50 (61 per cent) died, whereas non-vascular surgeons operated on 51 patients (36 per cent), of whom 35 (69 per cent) died. DISCUSSION: This study is unique as it is an independent prospective study of mortality in patients with a ruptured AAA who reached hospital alive. Mortality was independent of the operating surgeon, but vascular surgeons turned down significantly fewer patients than non-vascular surgeons (11 versus 64 per cent, P < 0.001).     

Plasma endothelin levels and outcome in patients undergoing repair of ruptured infrarenal abdominal aortic aneurysm

BACKGROUND: Endothelin-1 (ET-1) is the most potent known vasoconstrictor. Elevated plasma levels have been demonstrated in patients with myocardial infarction, cardiogenic and septic shock, and respiratory, heart, and kidney failure, as well as in those undergoing elective abdominal aortic aneurysm (AAA) repair. However, endothelin levels have not previously been examined in patients undergoing repair of ruptured AAA. We hypothesized that hemorrhagic shock, lower torso ischemia, and reperfusion associated with ruptured AAA repair lead to increased synthesis and secretion of ET-1, which, in turn, predispose to organ failure, one of the principal causes of death in this condition. METHODS: Fourteen patients were studied. Plasma levels of big ET-1 and ET-1 were measured immediately before operation and immediately before, 5 minutes, and 6 hours after aortic clamp release. RESULTS: All patients survived for at least 24 hours after operation. Big ET-1 levels were above the normal range at one or more sample points in all patients, and the ET-1 levels were above the normal range in all survivors and four of five nonsurvivors. Five patients who died of organ failure had significantly lower big ET-1 levels at all sample points and significantly lower ET-1 levels after 5 minutes of reperfusion when compared with survivors. Preoperative ET-1 levels were significantly lower in eight patients who subsequently developed kidney failure than in six patients who did not. CONCLUSION: Contrary to our original hypothesis, these novel data demonstrate that patients with ruptured AAA in whom fatal postoperative organ failure develops have significantly lower perioperative endothelin levels than survivors.     

Outcome and Survival of Patients Aged 65 Years and Younger after Abdominal Aortic Aneurysm Rupture

Advanced age (> 80 years) confers a survival disadvantage after operative repair of a ruptured abdominal aortic aneurysm (AAA). This study aimed to determine if young age (≤65 years) confers a survival benefit. Consecutive patients undergoing attempted repair of a ruptured AAA between 1995 and 2001 were included in the study. Demographic, clinical, and operative factors were analyzed together with in-hospital mortality, duration of postoperative hospital stay, and long-term survival. Of 378 patients admitted with a ruptured AAA, 52 (14%) were ≤ 65 years of age and 326 (86%) were > 65 years. There were 4 (8%) women in the younger cohort compared to 74 (23%) women in the older group (p = 0.015). Four (8%) patients in the younger group were thought to be unsuitable for surgical repair compared to 77 (24%) patients in the older cohort (p = 0.009). Of the 48 younger patients who underwent attempted operative repair, 22 (46%) died in hospital, compared to 108 (43%) of 249 patients > 65 years (p = 0.753). The median (range) postoperative hospital stay of survivors was 11 days (6–59 days) in the younger cohort and 15 days (6–121 days) in the older group (p = 0.005). Patients ≤ 65 years of age undergoing operative repair of ruptured AAA have no survival advantage over older patients. These data support AAA screening for the “at risk” and age-defined population. This work was presented to the 53^rd International Congress of the European Society for Cardiovascular Surgery, Ljubljana, 2004 and published in abstract form in Interactive Cardiovascular and Thoracic Surgery 2004;3(S1):81.     

Comparison of cardiac troponin I and creatine kinase ratios in the detection of myocardial injury after aortic surgery

BACKGROUND: Perioperative myocardial infarction may not be diagnosed correctly because World Health Organization criteria are often not met and creatinine kinase myocardial fraction (creatinine kinase/creatinine kinase MB isoenzyme; CK/CK-MB) ratios can be difficult to interpret. Cardiac troponin (cTn) I and cTnT are the most sensitive and specific markers of myocardial cell necrosis currently available but are not widely used in surgical practice. The aim was to compare cTnI and CK/CK-MB ratios in the detection of myocardial injury following aortic surgery. METHODS: This was a prospective study of 59 patients undergoing elective (n = 28) or ruptured (n = 24) abdominal aortic aneurysm repair or elective aortofemoral bypass (n = 7). cTnI level was measured before operation and at 6, 24 and 48 h after surgery. The CK/CK-MB ratio was measured where cTnI was detectable. RESULTS: Some 14 of 24 emergency and ten of 35 elective patients had detectable cTnI (greater than 0.5 ng/ml) at one or more time-points. The CK/CK-MB ratio was greater than 5 per cent in only four of 24 patients having an emergency operation and in none of the elective patients with detectable cTnI. CONCLUSION: Over half of patients undergoing emergency operation and more than a quarter of those having elective aortic surgery suffered myocardial necrosis as determined by detectable cTnI levels. This was accompanied by a raised CK/CK-MB ratio in less than one-fifth of patients.     

The role of tissue factor in patients undergoing open repair of ruptured and nonruptured abdominal aortic aneurysms

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) is associated with the development of a procoagulant and hypofibrinolytic state. Tissue factor (TF) and its naturally occurring inhibitor, tissue factor pathway inhibitor (TFPI), play a central role in the initiation and progression of such a hypercoagulable state, but their role in patients undergoing open AAA repair has not previously been examined. METHODS: A prospective study was conducted of 17 patients undergoing elective AAA repair and 10 patients undergoing emergency AAA repair. Blood was taken before induction, and 5 minutes, 24 hours, and 48 hours after aortic cross-clamp release and assayed for plasma TF, TFPI, tissue plasminogen activator (t-PA), plasminogen activator inhibitor (PAI), and thrombin-activatable fibrinolysis inhibitor (TAFI) activities. RESULTS: TF activity was significantly higher at all time points in patients with ruptured AAA compared with nonruptured AAA. The median (interquartile range, IRQ) TF activity (AU/mL) was 9.9 vs 3.2 (IRQ, 5.9 to 12.6 vs 2.0 to 7.6; P = .005) at preinduction; 10.7 vs 1.5 (IRQ, 9.2 to 18.3 vs 0.1 to 6.6; P = .003) at 5 minutes after clamp release; 9.5 vs 3.3 (IRQ, 7.0 to 13.5 vs 1.0 to 7.9; P = .013) at 24 hours, and 9.6 vs 3.9 (IRQ, 7.6 to 12.6 vs 2.4 to 8.7; P = .006) at 48 hours. TFPI levels were not significantly different between ruptured AAA and nonruptured AAA before or during operation but became significantly elevated at 24 and 48 hours in patients who had undergone repair of ruptured AAA. Ruptured AAA repair was associated with a hypofibrinolytic state compared with nonruptured AAA. CONCLUSIONS: The present study has demonstrated for the first time, to our knowledge, that ruptured AAA is associated with significantly higher perioperative levels of circulating TF compared with nonruptured AAA. Furthermore, in the immediate perioperative period, the high levels of TF are not associated with a corresponding rise in TFPI levels, indicating an unopposed prothrombotic state. Direct inhibition of TF by administration of anti-TF antibodies or recombinant TFPI remains to be evaluated in subjects presenting with hemorrhage due to ruptured AAA, but if given early enough, it may attenuate the early deleterious effects of unopposed TF expression and ultimately contribute to improved outcomes.     

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.     

Extra-anatomic arterial reconstruction with ligation of common iliac arteries and embolization of the aneurysm for the treatment of abdominal aortic aneurysms in high-risk patients

PURPOSE: The mortality of an unrepaired abdominal aortic aneurysm (AAA) generally exceeds the mortality associated with surgical repair. However, as our longevity increases, more frequently we see patients whose risk of surgical repair approximates the risk of rupture. We present an extra-anatomic bypass graft with complete aneurysm exclusion by iliac ligation and coil embolization of the aneurysm as an alternative for these high-risk patients. METHODS: An extra-anatomic bypass graft, followed by bilateral iliac artery ligation (retroperitoneal approach) and complete coil embolization of the AAA, was performed in eight patients (mean age, 77 years) found to be at prohibitive operative risk because of multiple comorbidities (American Society of Anesthesiologists class IV). Most patients (5 of 8) were symptomatic on presentation with a mean AAA diameter of 7 cm (range, 6.7-9.5 cm). We repair approximately 30 infrarenal aneurysms per year electively at our institution. RESULTS: All patients tolerated the surgical procedures. The average hospital stay was 8 days. All but two aneurysms demonstrated complete thrombosis by 48 hours. After 48 months there was no incidence of graft thrombosis, peripheral ischemia, visceral ischemia or thrombus infection. There was one perioperative death from aspiration pneumonia. Seventy-five percent (6 of 8) of patients have survived at least 1 year without surgical complications. No patient has had a ruptured aneurysm. CONCLUSION: Combining an extra-anatomic bypass graft and complete exclusion of the AAA by ligation of the common iliac arteries and a coil embolization is an effective, less invasive treatment option for patients with AAA and prohibitive operative risk. We emphasize the need for complete embolization documented by decreased aneurysm size.     

Twelve-year experience of the management of ruptured abdominal aortic aneurysm

Background The operative mortality rate for elective repair of asymptomatic abdominal aortic aneurysm (AAA) is falling but the fate of patients with ruptured AAA may have changed little over the past decade. Methods This study was an analysis of a prospectively gathered computerized database. Results In the 12 years to 31 December 1994, 1144 patients underwent (attempted) repair of AAA. In 514 patients (44·9 per cent) who had an operation for ruptured AAA there was no significant change in the mean age, male: female ratio (418:96), or operative mortality rate (35·0 per cent) over the interval of the study. Forty-seven patients died before reaching the operating theatre, giving an ‘intention to operate’ mortality rate of 405 per cent. A further 68 patients (10·8 per cent of all patients who presented with a ruptured AAA) were not offered operation because of poor medical condition (n = 34) or extreme age (n = 34); three patients refused operation. A greater proportion of patients had surgery between 1989 and 1994 (276 of 323, 85·4 per cent) than between 1983 and 1988 (238 of 309, 77·0 per cent) (P <0·01, X² test). Conclusion The proportion of aneurysms operated on for rupture in this unit remains high (almost 50 per cent). The results of surgery for ruptured AAA have not improved in the past 12 years.     

Coagulopathy and Hyperfibrinolysis in Ruptured Abdominal Aortic Aneurysm Repair

Perioperative hemorrhage is one of the principal causes of death in patients with ruptured abdominal aortic aneurysm (AAA). This study examines perioperative coagulation and fibrinolysis in patients undergoing ruptured AAA repair complicated by coagulopathy. Eight patients (8 men of median age 74, range 69-87, years) who developed clinical and laboratory evidence of coagulopathy during attempted repair of ruptured infrarenal AAA were prospectively studied. Platelet count, fibrinogen, clotting times, prothrombin fragment (PF) 1+2, and tissue plasminogen activator (t-PA) and plasminogen activator inhibitor (PAI) activities were measured preoperatively, immediately before, and 5 min and 24 hr after aortic declamping. Six patients died, three intraoperatively, one within 24 hr, and two in the late postoperative period. All patients had thrombocytopenia and prolonged clotting times intraoperatively with evidence of increased thrombin generation (as demonstrated by elevated PF 1+2). Five patients had increased systemic fibrinolysis (as demonstrated by elevated t-PA activity) preoperatively and/or before aortic declamping and all of these patients died. Three patients had perioperative inhibition of systemic fibrinolysis (as demonstrated by elevated PAI activity) and two survived. These data demonstrate that coagulopathy in ruptured AAA repair may be associated with a hyperfibrinolytic state. Further research is required to determine if (a) a causal relationship exists between hyperfibrinolysis and coagulopathy and (b) whether antifibrinolytic agents can improve outcome if targeted at this group of patients.     

Abdominal aortic aneurysm surgery: Survival and quality of life in patients requiring prolonged postoperative intensive therapy

The goal of this study was to identify patients who need longer care in the ICU (more than 48 hours) following abdominal aortic aneurysm (AAA) surgery and to evaluate the influence of perioperative complications on short- and long-term survival and quality of life. AAA surgery was performed in 553 patients, 51 (9%) of whom died within the first 48 hours. Of the 502 patients who survived for more than 48 hours, 109 required ICU therapy for more than 48 hours, whereas 393 patients were in the ICU for less than 48 hours. The incidence of preoperative risk factors was similar for the two groups. The cumulated survival rates for the two groups were 68% and 92% at 1 months, 52% and 88% at 1 year, and 60% and 33% at 6 years, respectively. This significant difference was primarily related to renal, pulmonary, and cardiac complications. However, assessment of the most severe complications and risk factors combined failed to permit identification of patients in whom the perioperative survival rate was 0%. Even 20% of patients with multiorgan failure survived for 6 months. Of those patients who needed ICU therapy for more than 48 hours, 41 (38%) were alive at the end of 1988. In response to a questionnaire, 78% stated that their quality of life had improved or was unchanged after surgery and had resumed working. These data justify a therapeutically aggressive approach, including ICU therapy following AAA surgery, despite failure of one or more organ systems.     

肾下型腹主动脉瘤的外科治疗

目的总结26例肾下型腹主动脉瘤的手术治疗经验。方法回顾性分析近5年多来手术治疗26例肾下型腹主动脉瘤的临床资料，全组26例，术前均经影像检查证实诊断。行择期手术21例，破裂型腹主动脉瘤急诊手术5例。26例均行腹主动脉瘤切除，人工血管重建术。结果围手术期死亡2例，均为急症手术患者，总病死率7．7％，急诊手术病死率40．0％。随访时间1-5年。术后1，3，5年生存率分别为96％，88％，75％。死亡原因均与腹主动脉瘤和手术无关。结论CTA检查是诊断腹主动脉瘤的可靠方法。手术治疗仍是治疗腹主动脉瘤的重要方法。瘤体直径不是决定手术的唯一指征。影响手术的危险因素主要是高龄、严重的心肺疾病和肾功能不全。     

Prognostic Factors in the Surgical Treatment of Ruptured Abdominal Aortic Aneurysms

Although the operative mortality following elective aneurysmectomy has achieved satisfactory results, that following surgery for ruptured abdominal aortic aneurysms (AAAs) remains high. The purpose of this study was to identify the factors affecting the mortality rate associated with the treatment of ruptured AAAs. Between 1978 and 1999, 33 patients underwent emergency surgery for a ruptured AAA. The operative mortality was 33.3% and in-hospital mortality was 6.0%. Hypotension, defined as a systolic blood pressure <80 mmHg, was seen in 19 patients at the time of presentation, 9 of whom underwent surgery in this state. In the remaining 10 patients, it was possible to increase the systolic blood pressure to ≥80 mmHg preoperatively. Of the 11 patients who died within 30 days of surgery, 9 had hypotension at the time of induction of anesthesia and only 2 had a systolic blood pressure of ≥80 mmHg. A satisfactory outcome was achieved in patients whose condition met the following criteria: a systolic blood pressure ≥80 mmHg at the time of operation, minimal aortic cross-clamping time, less blood loss and blood transfusions, and a shorter operation time to repair the ruptured AAA. Concomitant heart disease was also found to be an important prognostic factor. Received: June 16, 1999 / Accepted: March 24, 2000     

Ruptured abdominal aortic aneurysms: a study of incidence and mortality

The incidence of ruptured abdominal aortic aneurysms (AAA) during 1980 in the Stockholm county and the clinical fate of the patients were evaluated. Eighty-eight patients with ruptured AAA were found, an incidence of 0.06 per thousand. The overall mortality was 94 per cent. Sixty-four patients reached hospital, twenty-three received a correct diagnosis; thirteen were operated upon and five survived. Autopsy or operation revealed that most ruptures were retroperitoneal (88 per cent) and that only two aneurysms (2 per cent) extended above the renal arteries. It is concluded that the high mortality rate following rupture is more dependent upon failure to operate than on operative mortality.