Probability of rupture of an abdominal aortic aneurysm after an unrelated operative procedure: a prospective study

It has been assumed by some authors that patients with abdominal aortic aneurysms may be at increased risk of rupture after unrelated operations. From July 1986 to December 1989, 33 patients (29 men, 4 women) with a known abdominal aortic aneurysm underwent 45 operations. Twenty-eight patients had an infrarenal abdominal aortic aneurysm, and five patients had a thoracoabdominal aneurysm. The abdominal aortic aneurysm ranged in transverse diameter from 3.0 to 8.5 cm (average 5.6 cm). Twenty-seven patients underwent a single operation, and six patients had two or more (range of 1 to 6). Operations performed were abdominal (13); cardiothoracic (9); head/neck (2); other vascular (11); urologic (7); amputation (2); breast (1). General anesthesia was used in 29 procedures, spinal/epidural in 6, and regional/local in 10. One postoperative death occurred from cardiopulmonary failure. One patient died of a ruptured abdominal aortic aneurysm at 20 days after coronary artery bypass (1/33 patients [3%]; 1/45 operations [2%]). Fourteen patients had repair of their abdominal aortic aneurysm at a later date, an average of 18 weeks after operation. Four patients had abdominal aortic aneurysm considered too small to warrant resection (average 3.6 cm). Four patients were considered at excessive risk for elective repair. The five thoracoabdominal aneurysm were not repaired. Four patients are awaiting repair. During this same 40-month period, two other patients, not known to have an abdominal aortic aneurysm, died of a ruptured abdominal aortic aneurysm after another operative procedure, at 21 days and 77 days. All three ruptured abdominal aortic aneurysms were 5.0 cm or greater in transverse diameter.(ABSTRACT TRUNCATED AT 250 WORDS)     

Inflammatory abdominal aortic aneurysm

The inflammatory abdominal aortic aneurysm has received little attention in the literature. To date only four reports have addressed the subject specifically. Controversy remains as to whether this is a variant of the usual atherosclerotic aneurysm or a separate entity. The operative reports of 24 patients with inflammatory abdominal aortic aneurysms are reviewed; 21 were intact and 3 ruptured. Intact aneurysms ranged in diameter from 5 to 12 cm and the ruptured ones from 5 to 10 cm. Nine patients with intact aneurysms had symptoms of abdominal or back pain. Of 13 patients who underwent excretory pyelography before operation, only 3 had evidence of obstruction. Nine patients had tube grafts placed, 10 had aortoiliac grafts and 5 aortofemoral grafts. There was one intraoperative duodenal injury and in another patient it was necessary to divide the left renal vein for proximal exposure. No attempt was made to expose the ureters at operation. All patients were discharged from hospital. The authors believe that the inflammatory aneurysm is a variant of the abdominal aortic arteriosclerotic aneurysm. Intraoperative complications can be avoided by the recognition of the pathological features.     

Rupture of a small fusiform thoracic aortic aneurysm

We report a case of ruptured aortic aneurysm of the distal aortic arch. This aneurysm was fusiform and only 4.0 cm in maximum diameter: Emergency total aortic arch replacement was successful. Rupture of a thoracic aortic aneurysm of this shape and size is possible but extremely rare.     

A case of ruptured aortic arch aneurysm into the lung]

Successful surgical treatment of aortic arch aneurysm ruptured into the left lung was reported. The patient was a 74-year-old man suffering from recurrent hemoptysis. Computed tomography and aortic angiography demonstrated a giant aortic arch aneurysm. Emergency operation was performed. Arch reconstruction by a Dacron graft was performed with hypothermic circulatory arrest. The post operative course was uneventful and there was no evidence of cerebral complication. In the emergency operation for ruptured aortic arch aneurysm, hypothermic circulatory is very useful method for cerebral protection.     

分次阻断胸腹主动脉重建术13例

目的 总结胸腹主动脉瘤（TAA）分次主动脉阻断法胸腹主动脉重建的经验,探讨该手术方式对降低手术病死率、减少严重并发症－肾衰、截瘫等的作用。方法 运用改良的Crawford法行胸腹主动脉分支重建术13例。其中男性9例,女性4例。TAA分型为I型1例,Ⅱ型1例,Ⅲ型2例,Ⅳ型3例（Crawford分型）;主动脉夹层Debakey I型1例,主动脉夹层DebakeyⅢ4例（其中2例为动脉瘤破裂急诊手术病例）;主动脉缩窄1例。结果 13例手术均成功完成,1例于手术即将结束时因心脏意外死亡,手术病死率为7．7％（1／13）。本组病例手术并发症：急性坏死性胰腺炎1例,ARDS 1例,胸腔出血2例,截瘫、急性肾功能衰竭发生率各为7．7％。结论 分次主动脉阻断法行胸腹主动脉重建术降低了手术病死率及凶险并发症发生率,减少了脏器的缺血性损伤,是常温全身麻醉下行主动脉置换较为合理的方式。     

Incidence of rupture of aortic aneurysms after coincidental operation

The clinical course of 76 patients with aortic aneurysmal disease undergoing 107 coincidental surgical procedures was analysed in order to examine the relationship between aortic aneurysmal rupture and coincidental treatment. Additionally the incidence of aneurysmal rupture was assessed following 82 endoscopic procedures in 42 patients with aortic aneurysms. Two patients ruptured an aortic aneurysm after operation, one after colonoscopy (maximal transverse diameter 7cm) and one after coronary artery bypass grafting (maximal transverse diameter 5.6cm). The mean maximal transverse diameter of aneurysms in 76 patients was 5.08cm (95% confidence interval 4.7–5.4 cm). Both patients with ruptured aortic aneurysms were outside these confidence limits and were known hypertensives whose perioperative control of hypertension was questionable. The present series of patients is discussed with reference to induction of collagenase activity as a precipitating cause for postoperative rupture of aortic aneurysms, perioperative control of hypertension, transverse aneurysm diameter as a predictor of postoperative rupture and conduct of coincidental procedures in the presence of aneurysmal disease.     

Thoracic Aortic Aneurysm: Reading ttable he Enemy’s Playbook

Background The purpose of the present study was to use the clinical database at the Yale University Center for Thoracic Aortic Disease to shed light on the pathophysiology of thoracic aortic aneurysm (TAA), the clinical behavior of thoracic aortic aneurysm, and the optimal clinical management. Materials and Methods The Yale database contains information on 3,000 patients with thoracic aortic aneurysm, with 9,000 patient-years of follow-up and 9,000 imaging studies. Advanced statistical techniques were applied to this information. Results Analysis provided the following observations: (1) TAA is a genetic disease with a predominantly autosomal dominant mode of inheritance, (2) matrix metalloproteinase (MMP) enzymes are activated in the pathogenesis of TAA, (3) wall tension in TAA approaches the tensile limits of aortic tissue at a diameter of 6 cm, (4) by the time a TAA reaches a clinical diameter of 6 cm, 34% of affected patients have suffered dissection or rupture, (5) extreme physical exertion or severe emotion often precipitate acute dissection, and (6) single nucleotide polymorphisms (SNPs) are being identified which predispose a patient to TAA. Conclusions The “playbook” of TAA is gradually being read, with the help of scientific investigations, positioning practitioners to combat this lethal disease more effectively than ever before.     

An evaluation of new methods of expressing aortic aneurysm size: relationship to rupture.

The diameter of aortic aneurysms were standardized to measures of patient size and normal aortic size in an effort to define indexes that might be more predictive of aneurysm rupture than raw aneurysm diameter alone. Normal aortic diameters were measured in 100 patients undergoing abdominal CT scans for other reasons, and an average infrarenal aortic diameter of 2.10 +/- 0.05 cm was observed. Normal aortic diameter was dependent on both age and sex, ranging from 1.71 +/- 0.06 cm in women below age 40 years to 2.85 +/- 0.04 cm in men above age 70 years. Overall, 11 (5.1%) of the ruptures occurred in aneurysms less than 5 cm in diameter, and four (1.9%) occurred in aneurysms less than 4.0 cm in diameter. When the CT scans of 100 patients undergoing elective aneurysm resection were compared with those of 36 patients with ruptured aneurysms, no threshold diameter value accurately discriminated between the two groups. However, standardization of the aneurysm diameter to the transverse diameter of the third lumbar vertebral body as an index of patient body size produced an accurate predictor of rupture when a threshold ratio of 1.0 was used. No aneurysm ruptured below this ratio, but 29% of elective aneurysms were smaller than the vertebral body diameter. Receiver operating characteristic curve analysis confirmed the superiority of the aneurysm to vertebral body diameter ratio as a discriminator of ruptured aneurysms. It appears that aneurysm diameter alone is not sufficiently predictive of rupture to be used as the sole indication for elective resection.     

A 5-year review of abdominal aortic aneurysms at a VA medical center

We sought to determine the outcome of our policy of following asymptomatic abdominal aortic aneursyms until a maximal diameter of 5 cm is reached before assessing risk factors and need for operative intervention.We retrospectively reviewed the charts of all patients identified with abdominal aortic aneurysm in our hospital system by ICD code for the past 5 years. We specifically reviewed size of aneurysm, modality of assessment (computed tomography vs ultrasonography), age of patient, whether aneurysm repair had been performed, comorbidities, and current status (living or deceased).Eighty-eight patients were identified with abdominal aortic aneursyms. No ruptured aneurysms were identified in any of the patients that have been followed, regardless of size. All patients who have undergone an aneurysmorrhaphy are currently alive.Our current policy of following abdominal aortic aneursyms, as stated above, has not resulted in either ruptured aneurysm or postoperative death, and we feel that in the veteran population that this is a sound approach. (Curr Surg 57:343-345)     

Results of 101 ruptured abdominal aortic aneurysm repairs from a single surgical practice

Hypotheses The results of ruptured abdominal aortic aneurysm repairs from a solo community hospital-based practice are comparable to those reported from large university referral medical centers. Patients younger than 70 years, arriving in the emergency department with stable hemodynamics, and undergoing prompt operation have better outcome. DESIGN: A retrospective review from an ongoing vascular surgery registry. SETTING: Two midsized (300-bed) community hospitals. One hundred one consecutive patients with ruptured abdominal aortic aneurysms who were undergoing open surgical repair by a single surgeon (S.S.H.) during a 21-year period were reviewed. MAIN OUTCOME MEASURES: Operative mortality; cardiac, pulmonary, renal, and gastrointestinal complications; and coagulation abnormalities were recorded. Iatrogenic complications and length of hospital stay were noted. Preoperative and intraoperative factors affecting mortality were studied. RESULTS: Fifty-three patients survived ruptured abdominal aortic aneurysm repair (operative mortality, 47.5%). A favorable outcome was observed in patients (1). younger than 70 years, (2). with a hematocrit of more than 35% at presentation, and (3). with emergency department to operating room times of less than 120 minutes. Increasing experience of the surgeon did not result in improved survival. CONCLUSION: The results of ruptured abdominal aortic aneurysm repairs from community-based practice are comparable to those reported from university referral medical centers.     

Late results of small untreated abdominal aortic aneurysms

We report our experience with 73 patients who were initially selected for nonoperative management of an abdominal aortic aneurysm less than 5 cm in diameter. Size of the aneurysm was determined by ultrasound (34); arteriography (16); computerized tomography (17); plain x-ray (4); and magnetic resonance imaging (2). End points of the study were subsequent elective resection, rupture, death from cause other than rupture, or an intact aneurysm followed for a minimum of three years. Overall, 28 (38%) aneurysms were subsequently resected on an elective basis; four (5%) ruptured; 15 (21%) were intact at the time of the patient's death; and 26 (36%) remained intact during follow-up of 3 to 6.5 years. Indications for elective resection were aneurysm enlargement (21); symptoms suggesting impending rupture (3); and improvement in medical condition (4). In the 43 aneurysms initially less than 4 cm diameter, 16 (37%) had elective resection and one (2%) ruptured, and in the 30 that were 4–4.9 cm, 12 (40%) were resected and three (10%) ruptured. The four aneurysms that ruptured had enlarged to greater than 5 cm prior to rupture. We conclude that aneurysms less than 4 cm can be safely followed. Aneurysms 4–4.9 cm should be considered for operation, depending upon the size of the aneurysm, patient's life expectancy, and risk factors for surgery. Any aneurysm that enlarges should be resected, especially if the aneurysm becomes larger than 5 cm in diameter.Presented at the Annual Meeting of the Southern California Vascular Surgical Society, September 21–23, 1990.     

Surgical treatment for ruptured aneurysm of a coronary artery to pulmonary artery fistula; report of a case

We reported a successful operative case of ruptured coronary artery aneurysm associated with coronary artery to pulmonary artery fistula. The patient was a 74-year-old woman who was admitted for syncope and chest oppression. Echocardiogram and chest CT scan revealed cardiac tamponade. Ruptured coronary aneurysm, 3 cm in diameter, was found at emergent operation. After emergent coronary angiography, which demonstrated an aneurysm arising from the left anterior descending coronary artery and draining into the pulmonary artery, orifice of draining artery to the aneurysm was closed and coronary artery fistula was ligated. She recovered smoothly and post operative angiogram revealed disappearance of the aneurysm.     

Urinary tract manifestations of ruptured infrarenal aortic aneurysms (author's transl)]

18 patients were admitted from 1969 to 1973 to the Surgical and Urological University Clinic in Mainz with ruptured infrarenal aortic aneurysms. Three patients died immediately following the operation and three during surgery from internal hemorrhage. Eight patients died later following prolonged shock. Four patients survived surgery. The classical symptoms of shock, abdominal pain and pulsating tumor was only present in three patients. The diagnosis was only made in seven patients at admission, from the clinical findings. Urological symptoms were also prominent such as unilateral flank pain, colic, dysuria, anuria and tenderness over the kidney. There is no typical clinical picture of ruptured aortic aneurysm. Acute urological symptomatology in cases of acute abdomen with unclear etiology and in connection with shock could indicate a ruptured aortic aneurysm. There is absolute indication for immediate operative intervention. The aneurysm is removed and replaced by a vascular prosthesis. Early diagnosis is important since prolonged shock and anuria will result in a poor postoperative prognosis. Abdominal exploration is therefore also indicated when a ruptured aortic aneurysm is only suspected.     

Anastomotic false aneurysms of the abdominal aorta and the iliac arteries

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a potentially lethal complication of prosthetic grafts. To study this complication, the records of 18 patients with 22 noninfected AFAs (15 aortic and seven iliac) were reviewed. Patients with an intact AFA had a pulsatile abdominal mass, abdominal pain, an occluded graft, peripheral emboli, or a femoral anastomotic false aneurysm. All patients with a ruptured AFA were in shock, but 67% (four of six) had symptoms before hemorrhage. For diagnosis, single-plane angiography was 69% accurate (11 of 16), computed tomography was 100% accurate (six of six), and ultrasound was used once and suggested an AFA. Three patients with an AFA less than 5 cm diameter were initially observed; however, all three aneurysms rapidly enlarged and one ruptured. The operative mortality rate was 8% (1 of 12) for patients with an intact aneurysm and 67% (four of six) for patients with a ruptured aneurysm. Treatment was resection of the AFA and replacement with a new graft. Retroperitoneal AFAs often appear years after the initial operation, and life-long follow-up is required for patients with an aortic or iliac graft. All retroperitoneal AFAs should be resected since the outcome of patients with a ruptured AFA is poor.     

A case of free rupture of abdominal aortic aneurysm into the peritoneal cavity during posture change after induction of anesthesia

We report a case in which posture change for radiography after induction of anesthesia caused free rupture of the abdominal aortic aneurysm (AAA) into the peritoneal cavity, resulting in shock, although in the patient an AAA had ruptured into only the retroperitoneal space and hemodynamics had been stable preoperatively. The massive bleeding was controlled with autotransfusion using a washing salvaging autotransfusion device and a roller pump for hemodialysis. In addition, international mild hypothermia was effective for protection of the brain from suspected ischemia during shock. Meticulous attention should be paid for anesthetic management of patients with ruptured AAA even if their hemodynamic status is stable.     

Endovascular repair of a ruptured thoracic aortic dissection with a right sided aortic arch: A case report

BackgroundEmergency treatment of complex aortic pathology is challenging in the setting of a right-sided aortic arch. We report the successful treatment of a ruptured thoracic aortic aneurysm (TAA) in the setting of a Stanford type B aortic dissection (TBAD) and right-sided aortic arch.Presentation of caseThe patient is a 66-year-old male with chronic kidney disease (CKD) admitted with right sided chest pain and hypotension. Computed tomography angiography (CTA) revealed a 5 cm ruptured TAA in the setting of a TBAD and right-sided aortic arch. The TBAD began just distal to the right common carotid artery and involved the origin of the left subclavian artery (SCA). Using a totally percutaneous approach, a conformable Gore^® TAG^® thoracic endoprosthesis was placed in proximal descending thoracic aorta covering the left SCA. Aside from progression of his pre-existing CKD, the patient had an uneventful recovery. CTA one-month post-procedure revealed a type IB endoleak with degeneration of the distal descending thoracic aorta. To exclude the endoleak, the repair was extended distally using a Medtronic Valiant^® thoracic stent graft. The left subclavian artery was subsequently coil embolized to treat an additional retrograde endoleak. The patient has done well with no further evidence of endoleak or aneurysm expansion.ConclusionRight-sided aortic arch presents challenges in the emergency setting. CTA and post-processing reconstructions are very helpful. While the endoleaks prompted additional interventions, the end result was excellent. This case displays the importance of careful attention to detail and follow-up in these complicated patients.     

Clinical management of the symptomatic but unruptured abdominal aortic aneurysm

Pain or tenderness of an abdominal aortic aneurysm is widely believed to signify acute expansion and imminent rupture. To assess the potential benefit of emergency operation for the group of patients with an acutely expanding aneurysm, the clinical course of 19 patients with a symptomatic but unruptured expanding abdominal aortic aneurysm was compared with 117 patients undergoing elective abdominal aortic aneurysm resection, and 69 patients having operation for a ruptured abdominal aortic aneurysm. Postoperative morbidity was high in the patients with an expanding abdominal aortic aneurysm, and included a 21% incidence of myocardial infarction, a 10% incidence of stroke, a 37% risk of ventilatory failure, and a 31% incidence of acute renal failure, which was not statistically different from the results in patients having ruptured abdominal aortic aneurysm resection. Patients undergoing elective abdominal aortic aneurysm resection had only an 8% risk of myocardial infarction, and only a 2% risk of stroke, ventilatory failure, or renal failure. The mortality rate for expanding abdominal aortic aneurysm resection was 26% compared to 35% for ruptured abdominal aortic aneurysm (p = 0.31). Both emergency operations had a mortality rate more than five times greater than the 5.1% after elective procedures (p = 0.008). Our findings emphasize the need for early and aggressive treatment of abdominal aortic aneurysm in the elective setting, even in the patient at high risk, and suggest that the preoperative assessment and modification of risk factors is important to prevent the cardiac, cerebrovascular, pulmonary, and renal complications seen accompanying an emergency operation of this magnitude.     

Chronic contained rupture of an abdominal aortic aneurysm with vertebral erosion: report of a case.

A 73-year-old man had lumbago of unknown cause for several months prior to presentation. At examination prior to surgery for gastric cancer, an abdominal aortic aneurysm (AAA) of 6 cm in maximum diameter, retroperitoneal hematoma and vertebral erosion were found on abdominal computed tomography (CT). Hematological examination revealed mild anemia and stable hemodynamics. A diagnosis of chronic contained rupture of an AAA was made and knitted Dacron bifurcated graft replacement was performed. When an intraluminal thrombosis at the posterior wall was removed, a punched-out defect (3 x 2 cm) was discovered. When the old hematoma was removed, a destroyed vertebral body was found. After surgery, the lumbago was alleviated. The patient was transferred to the Department of Surgery and a gastrectomy was performed. The patient's postoperative course was uneventful.     

A ruptured thymic branch aneurysm mimicking a ruptured aortic aneurysm,with associated bronchial artery aneurysms: Report of a case

A 57-year-old woman who went into shock following an acute left hemothorax was operated on after stabilization under the diagnosis of a ruptured aortic aneurysm. A left fifth intercostal thoracotomy was done which revealed approximately 500 ml of bloody effusion in the extrapleural space and 2,000 g of clotted blood in the pleural cavity. While the aneurysm was initially thought to have originated in the isthmic or descending aorta, intraoperative findings revealed a swollen hematomatous thymus adherent to the aorta. A ruptured thymic branch aneurysm, 3 cm in diameter, was subsequently found in the resected hematomatous thymus. Histological examination also revealed several small aneurysms in the tortured bronchial arteries. Postoperative angiography showed a saccular aneurysm, 1.5 cm in diameter, and several smaller aneurysms in the bronchial artery of the left lung. The aneurysm was successfully treated by a transcatheter arterial embolization, and the patient has had no further symptoms since then. To our knowledge, there has been no other case of a ruptured thymic artery aneurysm reported in the literature, and only a few cases of bronchial artery aneurysms have been documented.     

Ileal artery aneurysm: a case report and review of literature

In a 70-year-old Japanese male who had a history of a radical operation of ruptured descending thoracic aortic aneurysm, the ileal artery aneurysm developed asymptomatically during postoperative follow up period. The aneurysm was about 10 by 4.5 by 4 cm in size and atherosclerosis microscopically. This case seemed to be the 20th case of superior mesenteric artery aneurysm and the 4th case of ileal artery aneurysm reported in Japan. Furthermore, this may be the first report of ileal artery aneurysm associated with thoracic aortic aneurysm in Japanese and English literature.