Ischemic complications of abdominal aortic surgery

From 1982 through 1988, 634 consecutive patients underwent abdominal aortic reconstruction for occlusive (37%) or aneurysmal (63%) disease. We studied the ischemic problems affecting the branches of the aorta, excluding the coeliac and superior mesenteric arteries. Ischemic colitis (0.6%), spinal cord ischemia (0.16%), renal insufficiency (17%), and lower limbs ischemia (6.5%) were the major problems encountered. We identified the most significant factors associated with these complications such as hypotension, emergency, hypovolemia, preoperative renal function, suprarenal clamping, the quality of the preoperative investigation, and have suggested some specific preventive measures.     

Proximal abdominal aortic aneurysms after infrarenal aortic reconstruction

The failure of infrarenal aortic open reconstruction due to sterile sovranastomotic abdominal aortic aneurysm (SS-AAA) is a rare and complex long-term complication. Even if they undergo the same treatment, is necessary to distinguish between true aneurysmal degeneration of proximal aorta and chronic proximal aortic anastomosis sterile rupture with consequent false aneurysm formation: we call proximal para-anastomotic abdominal aortic aneurysm (PPA-AAA) the first and proximal anastomotic false abdominal aortic aneurysm (PAF-AAA) the latter. The etiology of this complication is exclusively degenerative and it occurs in the absence of infection, which has totally different features. SS-AAA have been reported in 1 to 4% patients, but the available studies differ about patient selection and diagnostic methods. According to these considerations we can suppose the real incidence greater and near to 25% in over 10 years follow-up patients. Clinical findings of PPA and PAF-AAA before rupture are poor and this consideration emphasizes the necessity of a long term ultrasound follow-up. Best diagnostic tools after echographic detection of SS-AAA are spiral TC scan and MR imaging. Due to image accuracy, the short time necessary to take the images and availability spiral TC has taken the place of standard TC and arteriography. Scar tissue field and visceral vessels involvement with consequent proximal clamping are the main problems in open repair of SS-AAA. Elective open repair mortality rate varies from 0 to 17% and increases dramatically after rupture. Endovascular repair at the present is suitable only for hardly selected cases, because of frequent visceral involvement. We report our 17 patients series (8 PPA and 9 PAF-AAA), which we have observed friom 1991 to 2003 in a total amount of 1363 abdominal aortic aneurysms treated. All the patients have been treated with elective open repair with a global perioperative mortality of 6% (1/17).     

Complex abdominal and thoracoabdominal aortic aneurysm reconstruction

Complex reconstructions of the abdominal aorta are required for aneurysms that require visceral or splanchnic revascularization, when the aorta is inflammatory or infected, when a fistula to the vena cava or bowel is present, and when the aneurysm involves the juxtarenal, pararenal segments, or the full length of the abdominal aorta. The technique for full-length abdominal and thoracoabdominal aortic reconstructions has been modified to separate the visceral and spinal cord revascularization from the body of the main graft. The visceral, renal, and intercostal arteries are not directly reimplanted into the aortic graft but rather into sidearm grafts using a patch inclusion technique. The reconstruction commences distally by anastomosing the main graft to the aortic bifurcation or to the iliac arteries as appropriate. The main graft is then anastomosed to the proximal aorta after which the aortic clamps are released to perfuse the lower limbs. The intercostal arteries are reimplanted into a posterior sidearm graft followed by visceral and renal artery reimplantation into an anterior sidearm graft. This technique reduces the period of left ventricular strain to the time taken to complete the upper aortic anastomosis. It also allows separate control of the visceral and intercostal implantations should bleeding occur, without the necessity to reclamp the main body of the graft.Presented at the Asian Vascular Society Meeting, Ube, Japan, November 1994     

Ventral hernia following abdominal aortic reconstruction

An unexpectedly high frequency of ventral incisional hernia in our aortic reconstruction patients prompted us to review a recent three year period. Of 76 aortic reconstruction patients, 66 were evaluable for at least one year following their aortic procedure. In these 66 patients, ventral incisional hernias occurred in 14 (21.2%). Of statistical significance (P less than .01) was that ten of the 14 hernias occurred in the 27 aneurysm patients (37%) and four occurred in the 39 occlusive disease patients (10%). Though a comparison group of aneurysm patients is not available in the literature, the incidence of hernia in our occlusive disease population is consistent with the literature experience when careful long-term follow-up is employed. These observations may represent another manifestation of previously reported differences between aortic aneurysm and occlusive atherosclerotic populations.     

Intraoperative autotransfusion during abdominal aortic reconstruction

Intraoperative autotransfusion by a continuous-flow centrifuge system was used during more than 300 abdominal aortic reconstructions at the Cleveland Clinic since May 1979. Fifty consecutive patients undergoing such operations were studied prospectively. Volumes of blood lost, salvaged, and transfused during each operation were tabulated. Autologous autotransfused blood was compared with homologous bank blood with respect to oxygen-carrying capacity, coagulation factors, microaggregate levels, red cell mass, pH, and free hemoglobin concentration. Chromium-51 red cell survival studies were performed in autotransfused blood in random patients and in control subjects. Renal, hepatic, and coagulation functions were determined during the first postoperative week. Each patient received a mean volume of 1,203 ml of autotransfused blood and 1,682 ml of bank blood to replace a mean operative blood loss of 2,386 ml. Red blood cell survival of both salvaged autologous and unshed autologous blood in the control group was nearly identical. Salvaged blood had superior oxygen-carrying capacity, a lower microaggregate level, and better buffering capacity than bank blood. Although transient elevations in liver function values and free hemoglobin levels were noted, no clinically important aberration of coagulation, hepatic, or renal function was demonstrated.     

Results and complications of ruptured abdominal aortic aneurysm repair

During 1993 to 2000 85 patients were treated for a ruptured abdominal aortic aneurysm. The average age of the patients was 72.4 years (46-90). 71 patients showed an infrarenal rupture and the remaining 14 a suprenal rupture. 76 of 85 cases were covered ruptures. All patients were operated upon. A tube graft was required in 43 cases and 31 needed a bifurcated graft. In further two cases an extraanatomical bypass was necessary due to a mycotic aneurysm. The operation on 11 patients could not be completed and 21 patients died in hospital during the postoperative period. On the other hand, 53 patients survived the rupture of the aneurysm. The mortality rate was 37.6 %. The early non-surgical complications dominated during the postoperative period. Respiratory failure, renal failure and cardiac failure were responsible for the mortality rate. It is unforseeable which patients will survive the emergency operation. Therefore it is always appropriate to attempt the reconstruction of an acutely ruptured AAA.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

腹主动脉瘤开放手术围手术期并发症分析

目的 探讨腹主动脉瘤(abdominal aortic aneurysm,AAA)开放手术并发症的治疗和预防.方法 1991年1月到2009年8月手术治疗AAA329例,对围手术期并发症进行回顾性分析.结果 患者均顺利完成手术治疗,30 d围手术期死亡率为0.91%.围手术期主要并发症发生率为19.1%(63/329),包括心功能不全21例,呼吸功能不全15例,心肌梗死6例,肾功能衰竭5例,心律失常6例,脑梗死2例,下肢动脉栓塞2例,伤口裂开2例,腹壁切口疝1例,皮下血肿1例,下肢深静脉血栓2例.均给以对症治疗,1例患者死于急性心肌梗死,1例术后6 h出现肾功能衰竭,经20 d透析治疗后死亡,1例术后6 h死于频发室早和室颤,其余患者恢复良好.结论 心脏并发症及呼吸功能不全是AAA开放手术后最常见的并发症,术前全面评估、术中精细操作、术后严密监护并及时处理相应并发症是提高疗效的关键.     

Intra- and postoperative complications in infrarenal abdominal aortic aneurysms

Patients scheduled for operation of an abdominal aortic aneurysm are a challenge to the anesthesiologist due to multiple coexisting diseases and serious intraoperative hemodynamic changes caused by cross-clamping. The aim of this study was to investigate the incidence of intra- and postoperative complications and to analyze the coexisting diseases in order to estimate complications and risks. PATIENTS AND METHOD. The charts of 72 patients scheduled for resection of an abdominal aortic aneurysm in 1984 and 1985 were retrospectively analysed. The patients are divided into 6 groups: E: elective operation; K: without pulmonary catheterization; N: emergency operation; R: ruptured aneurysm; D: acute dissection. The statistical analysis was performed by chi-square test. RESULTS. Patients monitored by Swan-Ganz catheter suffered more frequently from chronic obstructive or restrictive pulmonary diseases and coronary heart disease or cardiac failure. INTRAOPERATIVE COMPLICATIONS. Emergency patients showed more than twice as many intraoperative cardiovascular complications than scheduled patients; 3 fatal cases were observed in this group. Renal complications (anuria) occurred in 2% during elective operations and in 30% during emergency operations. POSTOPERATIVE COMPLICATIONS. Most of the postoperative complications - 75% - were associated with the cardiovascular system, followed by disturbances of gas exchange and hypoxemia. Two patients in group E had a short-lasting renal insufficiency; 1 patient died of myocardial infarction 3 weeks postoperatively. Emergency procedures were much more risky, with a 90% incidence of cardiovascular complications; 4 patients died within 5 days, 1 other after 1 week. Patients monitored by Swan-Ganz catheter showed more arrhythmias and hypotension than the others. Atelectasis was seen on X-rays in 46% of emergency patients, 35% of group P, and 2.6% of group K. CONCLUSIONS. Retrospective studies of special and high-risk patients are very useful in assessing the individual clinical standard, despite problems with data acquisition. This study permitted the assessment of perioperative complications and risks in these patients.     

Ischemic complications after endovascular abdominal aortic aneurysm repair

OBJECTIVES: Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. METHODS: Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. RESULTS: Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, which resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. CONCLUSIONS: Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality.     

Reoperations for late complications following abdominal aortic operation

Fifty patients were identified who, following abdominal aortic operation, developed late complications affecting the vascular graft or endarterectomy and who underwent their first reoperation between 1979 and 1989. Thrombosis was the commonest complication affecting 28 (56 per cent) patients, followed by false aneurysm in 11 (22 per cent), enteric fistula in nine (18 per cent) and graft infection in two (4 per cent). The 30-day mortality rate for reoperation was 8 per cent; longer follow-up revealed mortality rates of 22, 50 and 63 per cent at 1, 3 and 5 years respectively. Thirty-four complications required reoperation within 5 years of the original surgery. Reoperation was needed for 35 patients whose original pathology was occlusive disease and for 15 whose original pathology was aneurysm. The nature of the complication was related to initial pathology; thrombosis was far commoner in those with occlusive disease, and enteric fistula and false aneurysm were commoner in those with aneurysmal disease.     

Ischemic colitis and mesenteric ischemia after abdominal aortic reconstruction

Ischemic colitis is quite a rare condition, which can be subdivided into two categories, a so-called occlusive form as a complication of various vascular diseases, and a non-occlusive form caused by exogenous administration of drugs, or i.e. higher cocentrations of various endotoxines or cytokines. Besides the most serious cases with transmural ischemia, needing operation and resection, over 50% of all cases suffer from non-transmural or mucosal ischemia which can be treated conservatively. These cases usually show a rather favourable outcome. A part of these patients will suffer from bowel stenosis or strictures later on and may need secondary resections. Ischemic colitis following aorto-iliac reconstructive surgery is a rare but well known complication. Although it should be suspected much more frequently, only 1 to 2% of the patients will present a condition of clinical importance. The complication is more frequent in patients who undergo surgery as an emergency, especially reconstruction for aneurysmal disease, and it is less frequent in patients who undergo aorto-iliac reconstruction for occlusive disease; probably because the latter have already developed collateral vessels in the visceral area. A preoperative evaluation of this specific risk is rarely possible by angiography. Intraoperative strong pulsating backflow from the inferior mesenteric artery is considered as a quite reliable prognostic factor for a sufficient mesenteric circulation. Measurement of inferior mesenteric stump pressure, fluoresceine instillation and doppler ultrasound have been proposed as more reliable predictive elements. Wherever mesenteric circulation seems to be doubtful, inferior mesenteric replantation is advisable. In the postoperative course, a thorough clinical surveillance and probably systematic sigmoidoscopy especially on patients with prolonged intubation in strongly advisable in order to detect ischemic lesions in an early stage. Early operations on transmural lesions will help to improve this otherwise very serious and life threatening complication.     

Symptomatic,nonruptured abdominal aortic aneurysms: Are emergent operations necessary?

To evaluate current morbidity and mortality and to define the best strategy of management, we retrospectively reviewed the clinical histories of 36 patients (24 males and 12 females) who underwent repair of symptomatic, nonruptured abdominal aortic aneurysms (AAAs) between April 1, 1987, and April 30, 1992, at the Mayo Clinic (3.2% of 1111 patients with AAA repair). Ages ranged from 54 to 94 years (mean 75 years). All patients were hemodynamically stable and presented with abdominal and/or back pain of 1 to 60 days' duration (mean 11.6 days). The diagnosis of AAA was confirmed by CT scan in 26 patients, ultrasonogram in seven, and plain abdominal films in three. Fourteen patients (38.9%) were operated on emergently within 4 hours of admission, 11 (30.5%) between 4 and 24 hours, and 11 between 24 hours and 7 days following presentation (mean 28.9 hours). Eight (22.2%) had inflammatory aneurysm. AAAs were repaired with a straight graft in 17 patients and a bifurcated graft in 19. Complications occurred in 24 patients (66.7%). Mortality was 11.1% (4/36). The association between emergency repair (<4 hours) and 60-day mortality was significant (p<0.05).There were no deaths among those patients whose operation was delayed. Comparison to a matched control group of 72 patients who underwent elective AAA repair revealed an increased incidence of inflammatory aneurysm and female gender among our study group. The symptomatic patients had larger aneurysms (6.5 vs. 5.6 cm,p<0.05)and required more intraoperative transfusions. Intensive care unit and hospital stay was longer in the symptomatic patients (p<0.001);morbidity was markedly increased (p<0.001).We conclude that repair of symptomatic, nonruptured AAA continues to be associated with increased mortality and high morbidity in comparison to elective aneurysm repair. Emergency repair of symptomatic, nonruptured aneurysm may contribute to the higher morbidity rate.Presented at the Third Annual Winter Meeting of the Peripheral Vascular Surgery Society, Breckenridge, Colo., January 22–25, 1993.     

Embolic complications after endovascular repair of abdominal aortic aneurysms

Purpose

This retrospective study aimed to review our experiences with endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs), along with the incidence, risk factors and prognoses of associated embolic events. Our goal was to present the EVAR results and related risk factors from a single center, with a focus on embolic complications.

Methods

We retrospectively reviewed the data of 539 patients with AAAs who underwent elective EVAR at Jikei University from July 2006 to April 2009. Of these, 438 patients were selected after excluding those requiring fenestrated and branched EVAR.

Results

The technical success rate was 91.1 % (399/438) with no surgical mortality. Embolic complications occurred in nine patients (2 %), four of whom developed ischemic colitis and were successfully treated with bowel rest and hydration. Lower extremity atheroembolization and stroke occurred in three and one patients, respectively. Two patients died of cholesterol crystal embolization. Seven of the nine embolic complications (77.8 %) were associated with the use of Zenith stent-grafts. A Cox proportional-hazard regression analysis of the adjusted risk factors showed that smoking and severe arterial degeneration of the aorta, referred to as a shaggy aorta, to be independent predictors of embolic complications.

Conclusions

The presence of a shaggy aorta and a history of smoking are independent predictors of embolic complications associated with EVAR.