Selective evaluation and management of coronary artery disease in patients undergoing repair of abdominal aortic aneurysms. A 16-year experience.

Reduction of cardiac mortality associated with abdominal aortic aneurysm (AAA) repair remains an important goal. Five hundred consecutive urgent or elective operations for infrarenal nonruptured AAA were reviewed. Patients were divided into three groups based on preoperative cardiac status: group I (n = 260, 52%), no clinical or electrocardiographic (ECG) evidence of coronary artery disease (CAD); group II (n = 212, 42.2%), clinical or ECG evidence of CAD considered stable after further evaluation with studies such as dipyridamole-thallium scanning, echocardiography, or coronary arteriography; group III (n = 28, 5.6%), clinical or ECG evidence of CAD considered unstable after further evaluation. Group I had no further cardiac evaluation and groups I and II underwent AAA repair without invasive treatment of CAD. Group III underwent repair of cardiac disease before (n = 21) or coincident with (n = 7) AAA repair. In all instances, perioperative fluid volume management was based on left ventricular performance curves constructed before operation. The 30-day operative mortality rate for AAA repair in all 500 patients was 1.6% (n = 8). There was one (0.4%) cardiac-related operative death in group I, which was significantly less than the five (2.4%) in group II (p less than 0.02). Total mortality for the two groups were also significantly different, with one group I death (0.4%) and seven group II deaths (3.3%), (p less than 0.02). These data support the conclusions that (1) the leading cause of perioperative mortality in AAA repair is myocardial infarction, (2) correction of severe or unstable CAD before or coincident with AAA repair is effective in preventing operative mortality, (3) patients with known CAD should be investigated more thoroughly to identify those likely to develop perioperative myocardial ischemia so that their CAD can be corrected before AAA repair, and (4) patients with no clinical or ECG evidence of CAD rarely die of perioperative myocardial infarction, and thus selective evaluation of CAD based on clinical grounds in AAA patients is justified.     

Chronic visceral ischemia. Three decades of progress.

Symptomatic visceral atherosclerosis is a major surgical challenge because of its life-threatening course and the complexity of its definitive operative treatment. Evolution in the operative approach to the visceral aorta and progress in the intraoperative management of patients undergoing complex vascular reconstructions prompted a review of the authors' cumulative experience in the surgical management of chronic visceral ischemia. Among all patients undergoing visceral revascularization at the University of California, San Francisco during the past three decades, 74 patients were identified whose primary reconstruction used transaortic endarterectomy (TA TEA) (n = 48) or antegrade bypass (AB) (n = 26), the authors' preferred revascularization techniques. The two treatment groups were comparable in gender distribution, age, presenting symptoms, and physical findings, although the amount of preoperative weight loss was greater in the AB group (35.8 +/- 19.5 versus 22.4 +/- 12.0, p = 0.003). The groups were also comparable in the prevalence of atherosclerosis risk factors, symptomatic vascular disease at other sites, and previous vascular operations. However associated renal artery atherosclerosis was slightly greater in the TA TEA group (58.3% versus 23.1%, p = 0.07) when compared to the AB group. Antegrade bypass was usually performed transabdominally (88.5%), while TA TEA was approached thoracoretroperitoneally (75.0%). Celiac revascularization was almost universal in both treatment groups, but the TA TEA group underwent significantly more frequent superior mesenteric artery (SMA) revascularization (93.8% versus 46.2%, p = 0.0001) and slightly more frequent inferior mesenteric repair (18.8% versus 3.8%, p = 0.07) than the AB group. In addition the frequency of combined renal and visceral repair (25.0% versus 0.0%, p = 0.01) as well as combined aortic, renal, and visceral repair (22.9% versus 3.8%, p = 0.03) was significantly greater in the TA TEA group. The obligatory interval of renal and visceral ischemia did not differ between the two approaches. The perioperative mortality rate was 12.2% and was the same for TA TEA (14.6%) and AB (7.7%). Overall the incidence of complications was the same with either operative approach, although patients in the TA TEA group tended to have multiple complications (17.1% versus 0.0, p = 0.03) and all significant pulmonary complications occurred in this group. Two patients were lost to follow-up. The cumulative percentage of patients who remained asymptomatic following AB or TA TEA was (respectively) 95.8% and 97.3% at 1 year and 86.5% and 86.1% at 5 years. Both of these operative approaches provide durable symptom relief with acceptable operative morbidity and mortality rates.(ABSTRACT TRUNCATED AT 400 WORDS)     

Simultaneous aortic reconstruction and renal revascularization: risk factors and late results in eighty-nine patients

From 1973 through 1984, graft replacement of infrarenal aortic aneurysms (N = 56) or occlusive disease (N = 33) was performed in conjunction with simultaneous renal revascularization in 89 patients. Isolated renal artery stenosis was corrected by unilateral reconstruction in 56 patients (63%), but the remaining 33 (37%) had diffuse involvement that required either bilateral renal artery grafts or unilateral revascularization of solitary kidneys. The incidence of hypertension (greater than 180/90 mm Hg) refractory to preoperative medical therapy (88%), severe coronary disease documented by angiography (40%), and postoperative azotemia (33%) or oliguric renal failure (15%) was significantly higher among patients with bilateral renal artery disease (p less than 0.05). In addition, this group had twice the early mortality rate (15%) of patients having unilateral renal artery lesions (7.1%). During a mean follow-up interval of 37 months, medical control of hypertension was enhanced in 46 of the 80 operative survivors (58%), and renal function improved or remained stable in 63 survivors (79%). Five-year actuarial survival presently is 65% for the entire series, with a cumulative mortality rate of 38% among patients who underwent aneurysm resection (mean age 64 years) in comparison to 15% (p = 0.03) for those patients with aortoiliac occlusive disease (mean age 60 years).     

Abdominal aortic aneurysm repair in patients with chronic renal disease.

OBJECTIVES: To assess the outcome of AAA repair in patients with established renal failure (RF), including patients on dialysis. DESIGN: Retrospective case-control study in a teaching hospital. Methods. All patients with established RF undergoing AAA repair were identified during the last eight years. Data was collected from patient notes on operative difficulty, hospital mortality, survival time and future dialysis requirements. For comparison, 28 consecutive patients undergoing AAA repair without RF were studied prospectively. RESULTS: Thirteen RF patients were identified. Three were receiving Continuous Ambulatory Peritoneal Dialysis (CAPD), three were receiving Haemodialysis (HD) and seven had established RF, but were not receiving dialysis. Compared with the control patients, RF patients had a longer total hospital stay (p=0.03, 95% CI for median stay -24.3 to -4.0 days), more postoperative complications (p<0.01, 95% CI 26.4-73.7%) and had an increased in-hospital mortality (p=0.02, 95% CI 4.6-54.3%). Four of the six survivors who were non-dialysis-dependent required long-term dialysis postoperatively. CONCLUSIONS: AAA repair in RF patients is associated with increased postoperative morbidity and mortality. Previously non-dialysis-dependent patients have a high risk of subsequent long-term dialysis.     

Glasgow aneurysm score predicts the outcome after emergency open repair of symptomatic, unruptured abdominal aortic aneurysms.

OBJECTIVE: To determine the predictor factors of in-hospital postoperative mortality in patients presenting with symptomatic but not ruptured abdominal aortic aneurysm (AAA) at our institution. PATIENTS AND METHODS: Forty-two patients who underwent urgent open repair for symptomatic, non-ruptured AAA were evaluated retrospectively. RESULTS: Five patients (11.9%) died during the in-hospital stay. History of coronary artery disease (p=0.014), cerebrovascular diseases (p=0.015), renal failure according to Glasgow Aneurysm Score (GAS) criteria (p=0.001), serum creatinine concentration (p=0.026), and the GAS (p=0.008) were predictive of postoperative death. The ROC curve analysis showed that the Glasgow Aneurysm Score had an area under the curve of 0.870 (95%C.I. 0.71-1, S.E. 0.08, p=0.008), and its best cut-off value in predicting postoperative death was 90.0 (specificity 89.2%, sensitivity 80.0%). The postoperative mortality rate of patients with a Glasgow Aneurysm Score below 90 was 2.9%, whereas it was 50% for those with a score >or=90 (p=0.003, O.R. 33.0). CONCLUSION: This study shows that the Glasgow Aneurysm Score is a good predictor of postoperative mortality and morbidity after urgent repair of symptomatic, non-ruptured AAA and can be useful in identifying those patients whose operative risk is prohibitive. Its simplicity makes it a clinically important tool, particularly, in the emergency setting. Patients having a score less than 90 can safely undergo urgent open repair. Thorough evaluation and improvement of preoperative status followed preferably by an endovascular repair is indicated for those with a score >or=90.     

Epidemiology of surgically treated abdominal aortic aneurysms in the United States, 1988 to 2000

Abdominal aortic aneurysm (AAA) repair is a complex procedure about which little information exists regarding trends in surgical practice in the United States. This study was undertaken to define benchmark data regarding performance and outcomes of conventional AAA repair that might be used in comparisons with endovascular AAA repair data. Patients undergoing repair of intact (n = 87,728) or ruptured (n = 16,295) AAAs in the Nationwide Inpatient Sample (NIS) for 1988 to 2000 were studied. The NIS represents a 20% stratified random sample of all discharges from US hospitals. Unadjusted and case mix-adjusted analyses of in-hospital mortality and length of stay were performed. The overall frequency of intact AAA repair remained relatively stable during the study period, ranging from 18.1 to 16.3 operations/100,000 adults between 1988 and 2000, respectively. The operative mortality rate for intact AAA repair decreased significantly (p < .001) from 6.5% in 1988 to 4.3% in 2000. Length of stay following intact AAA repair also declined significantly (p < .001) from a median of 11 days in 1988 (interquartile range [IQR] 9-15 days) to 7 days in 2000 (IQR 5-10 days). The incidence of ruptured AAA repair decreased significantly (p < .001) from 4.2 to 2.6 operations/100,000 adults between 1988 and 2000, respectively. Mortality for ruptured AAA repair, averaging 45.6%, did not decrease significantly during the study period. Intact AAA repair by conventional means has become increasingly safe, with decreased operative mortality and shorter hospital stays. Ruptured AAA repair by conventional means has not become safer but has decreased in incidence, suggesting possible reductions in risk factors contributing to rupture, coupled with more timely intact AAA repairs.     

Transperitoneal versus retroperitoneal suprarenal cross-clamping for repair of abdominal aortic aneurysm with a hostile infrarenal aortic neck

Infrarenal abdominal aortic aneurysms (AAAs) with a hostile infrarenal aortic neck unfit for endovascular aneurysm repair (EVAR) are more likely to require open repair with suprarenal aortic cross-clamping. We compared the results of the transperitoneal versus retroperitoneal approaches for repair of infrarenal AAA requiring suprarenal cross-clamping and the relative frequency of such techniques after incorporating EVAR into our clinical practice. From January 1998 through September 2005, 478 elective infrarenal aortic aneurysms were repaired. There were 160 (33%) open repairs (71% transperitoneal and 29% retroperitoneal) and 318 (67%) endovascular repairs. In 38 cases (24%) suprarenal cross-clamping was performed (47% transperitoneal and 53% retroperitoneal incisions) for a hostile infrarenal neck. A hostile aortic neck was defined as severe angulation (>60 degrees ), short neck (<15 mm), extensive calcification, or circumferential thrombus. The median age was 70 years; 47% were men; 16% had diabetes mellitus, 29% pulmonary disease, 53% coronary artery disease, and 11% renal insufficiency. The median aneurysm size was 6.0 cm. A retrospective analysis was performed to compare 30-day postoperative outcomes between the trans- and retroperitoneal patient cohorts. The results were determined for two time periods to assess whether open repair with suprarenal cross- clamping was being performed more frequently as a result of increased utilization of EVAR in the contemporary period. After 2002, EVAR increased from 60% to 71% (p = 0.04) while open repair declined from 40% to 29% (p = 0.01). The retroperitoneal approach doubled from 19% to 39%, while the transperitoneal approach decreased from 81% to 61% (p = 0.02). Suprarenal cross-clamping increased by 11% after 2002. There was no significant difference in age, sex, aneurysm size, or comorbidities between the trans- and retroperitoneal groups with suprarenal cross-clamping. The 30-day mortality was 2/38 (5%) and occurred only in the transperitoneal group. The transperitoneal approach was associated with significantly greater blood loss and longer suprarenal cross-clamp times (2,400 vs. 1,800 mL and 38.0 vs. 29.5 min; p = 0.03), but there were no significant differences in 30-day postoperative complications. In our 7 years' experience, there has been a gradual increase in the utilization of EVAR for infrarenal AAAs. At the same time, more infrarenal AAAs with hostile aortic necks requiring suprarenal aortic cross-clamping were encountered. In such instances, the retroperitoneal approach is safer, with less perioperative blood loss and shorter suprarenal cross-clamp time. This is likely attributed to better exposure of the suprarenal abdominal aorta, allowing a more secure proximal anastomosis.     

Optimal timing of abdominal aortic aneurysm repair after coronary artery revascularization.

OBJECTIVE: The authors ascertained the optimal timing of repair of an abdominal aortic aneurysm (AAA) after coronary artery revascularization. SUMMARY BACKGROUND DATA: Cardiac events are the most common cause of death after elective repair of AAA. Preoperative coronary revascularization has significantly reduced postoperative cardiac complications after elective AAA repair. Currently, most patients undergo repair of asymptomatic AAA within 6 months after the coronary revascularization. METHODS: The authors performed a retrospective review of patients who underwent repair or scheduled repair of an asymptomatic AAA within 6 months after coronary artery bypass graft (CABG) between March 1988 and October 1993. RESULTS: There was no mortality in the group of patients (n = 14) who underwent repair of AAA simultaneously or within 14 days of coronary revascularization. In contrast, there was a significantly increased mortality rate of 3 of 9 (33%) in patients scheduled to undergo repair of the AAA more than 2 weeks after coronary revascularization (p < 0.05). All nonsurvivors died between 16 and 29 days after CABG, and died as a result of ruptured AAA. CONCLUSION: Elective AAA repair should be undertaken simultaneously or within 2 weeks of coronary artery revascularization because of an increased risk of postoperative AAA rupture seen after this time period. In addition, simultaneous or early postoperative AAA repair does not increase the overall operative risk.     

Combined aortic and renal artery surgery. A contemporary experience.

PURPOSE: This retrospective study examines results with simultaneous aortic and renal artery repair in 133 consecutive hypertensive patients. These results are compared with consecutive patient groups undergoing aortic reconstruction alone (269 patients) or renal artery reconstruction alone (182 patients). METHODS: From January 1987 through July 1995, 61 women and 72 men (mean age, 62.5 years) underwent combined repair of renal artery and aortic disease (abdominal aortic aneurysm [AAA]: 47 patients; occlusive disease: 86 patients; both: 12 patients). All patients were hypertensive (mean blood pressure: 194/103 mmHg; mean medications: 2.4). Evidenced by serum creatinine levels > or = 2.0 mg/dL, 46 patients (35%) had significant renal dysfunction (mean serum creatinine level: 3.78 mg/dL; range 2.0-10.6 mg/dL, including 7 dialysis-dependent patients). Aortic replacements (29% tube grafts; 71% bifurcated grafts) were combined with unilateral renal artery repair in 47% of patients; 53% had bilateral repair. Preoperative clinical features and perioperative mortality were compared with those groups having isolated aortic and renal repairs. RESULTS: There were seven perioperative deaths (5.3%) after combined repair, which differed significantly from isolated aortic repair (mortality: 0.74%; p = 0.005), but did not reach statistical significance when compared with the isolated renal artery group (mortality: 1.65%; p = 0.145). Risk analysis did not reveal a significant association between preoperative clinical features and mortality in either the combined repair group or the groups undergoing renal repair alone or aortic repair alone. Among survivors in the combined group, a favorable hypertension response was observed in 63%. This differed significantly from the group receiving renal repair alone (90% cured/improved; p < 0.001). Based on a 20% decrease in serum creatinine levels, excretory renal function was improved in 33% of patients with combined repair, including four of the seven patients removed from hemodialysis. There were eight late deaths in the combined group. CONCLUSIONS: Our experience suggest that contemporary perioperative mortality for combined aortic and renal repair has improved compared with earlier reports; however, perioperative mortality for simultaneous reconstruction remains greater than repair of aortic disease alone. Moreover, a lower rate of favorable hypertension response was observed after combined correction compared with renal artery repair alone. These differences suggest that aortic and renal artery repair should only be combined for clinical indications rather than for prophylactic repair of clinically silent disease.     

The role of preoperative radionuclide ejection fraction in direct abdominal aortic aneurysm repair

Preoperative radionuclide ventriculography was performed in 60 patients to assess whether such testing could define those at increased risk after direct abdominal aortic aneurysm (AAA) repair. None of the patients had prophylactic coronary artery reconstruction to reduce the risk of AAA repair despite angina in 27% and previous myocardial infarction (MI) in 42%. The mean ejection fraction (EF) was 52% +/- 15% (range 14% to 78%). Low EF (normal greater than 50%) was present in 40%, whereas ventricular wall motion abnormalities were present in 39% of patients. The overall perioperative (30-day) mortality rate was 5%. MI occurred in 7% within 30 postoperative days; none was fatal. Life-table analysis revealed that overall survival after AAA repair was significantly lower in patients with an EF of 50% or less (p less than 0.025, Mantel-Cox) during a follow-up of 20.1 +/- 11.9 months. Overall survival differences were even more striking for those with an EF of 35% or less (p = 0.003, Mantel-Cox). There was a marked difference in the cumulative mortality rate during follow-up, being 50% in those patients with an EF of 35% or less (n = 10) compared with 14% in those with an EF greater than 35% (n = 50, p = 0.036, Fisher exact test). There was no statistical difference in the incidence of perioperative MI or perioperative death for those with an EF of 35% or less vs EF greater than 35%.(ABSTRACT TRUNCATED AT 250 WORDS)     

Radial artery 2000--risk analysis of mortality for coronary bypass surgery with radial artery.

BACKGROUND: The aim of this study is to review our experience with using more than 2,000 RAs over the last seven years, and to assess the medium-term outcome in terms of morbidity and mortality. METHODS: Between June 1994 and June 2001, a total of 2,024 RAs have been used in 1,613 patients. The mean duration of follow-up was 40.1 months and ranged from one to 88 months. We assessed the results of postoperative mortality and morbidity, RA graft patency, coronary event free rate, and actuarial survival rate. Specifically, the independent predictors of early and late mortalities were examined. RESULTS: Perioperative myocardial infarction was indicated in 0.8%, stroke in 1.6%, respectively. Overall hospital mortality was 35 patients (2.4%). RA patency rate was 98.1%. Coronary event free rate and actuarial survival rates at seven years were 99.6% and 95.1%, respectively. Multivariate logistic regression analysis detected an ejection fraction of less than 30% (p=0.0009), re-exploration (p=0.02), and stroke (p=0.03) as significant independent predictors of operative mortality. The use of saphenous vein graft (p=0.0417) and renal impairment (p=0.0045) were significant independent predictors of late mortality. CONCLUSIONS: Our seven-year experience of CABG with RA suggested that the use of RA was safe and had excellent results in postoperative graft patency and low incidence of complications. This study suggested that the use of RA instead of the saphenous vein graft made a better outcome for late survival in the patients undergoing CABG.     

Open heart surgery in patients with end-stage renal failure: fifteen-year experience

Abstract   Objective: Risk factors and results of cardiac surgery with cardiopulmonary bypass (CPB) in hemodialysis-dependent renal failure patients at our center were evaluated. Methods: Out of 16,425 patients undergoing open heart surgery with CPB at our center between January 1991 and April 2006, 91 (0.6%) experienced hemodialysis-dependent end-stage renal failure. Preoperative, operative, and postoperative findings of two groups of patients were evaluated: those with normal renal function (control group) and those with chronic renal failure undergoing regular hemodialysis (HDRF group). Survival analyses of the hemodialysis group of patients were performed. Results: In the hemodialysis group, 54 (59.3%) patients underwent coronary artery surgery, 31 (34.1%) patients had valve surgery, four (4.4%) patients had aortic surgery, and two others (2.2%) experienced concomitant coronary and peripheral artery surgery. CPB and aortic cross-clamping (ACC) times were longer in the HDRF group (p = 0.000 and 0.002, respectively). There was no significant difference between the two groups with regard to either reoperations, infections, pulmonary and gastrointestinal system complications, or cerebrovascular event parameters (p = 0.167, 0.341, 1.000, 1.000, and 1.000, respectively). There was no difference between groups in the postoperative development of low cardiac output (p = 0.398). The early mortality rate was 7.7% (seven patients) in the HDRF group and 4.8% (780 patients) in the controls (p = 0.211). The actuarial survival rates in HDRF survivors at one, two, three, four, five, and ten years were overall 86%, 80%, 68.1%, 45.4%, 20%, and 6.8%, respectively. Conclusions: Open heart surgery in hemodialysis patients is associated with a higher incidence of risks, but can be performed with acceptable operative complications and mortality with an effective hemodialysis program.     

Aortic valve replacement with coronary bypass grafting. Significant determinants of ten-year survival

Concomitant aortic valve replacement (AVR) and myocardial revascularization were performed on 197 patients between 1969 and 1981. Operative mortality during the period 1969 to 1975 was 15.6% compared to 5.0% for the years 1976 to 1981 (p less than 0.02). The incidence of perioperative myocardial infarction (PMI) declined over the same period from 14.2% to 2.0% (p less than .01). Functional class and left ventricular end-diastolic pressure significantly influenced mortality, whereas age, sex, duration of symptoms, cardiac index, wall motion abnormality, type of valve lesion, and completeness of revascularization did not. Type of myocardial preservation did not significantly affect operative mortality, although a trend favoring either cardioplegia or continuous perfusion of both coronary ostia and grafts was observed. Life-table analysis shows a survival rate during the 10 year follow-up period equal to that of patients undergoing isolated AVR. Cornary bypass grafting (CABG) returns patients with combined aortic valve (AVD) and coronary artery disease (CAD) to a prognostic curve determined by their valvular disease alone.     

Elective and emergency hepatic resection. Determinants of operative mortality and morbidity.

To determine the reasons for improved mortality and morbidity rates after major hepatic resection, five variables were analyzed retrospectively in 300 patients operated on over a 27-year period: (1) the indication for surgery, (2) the surgical approach, (3) the urgency with which surgery was performed, (4) the nature of the surgical procedure, and (5) the experience of the surgeon. The operative mortality rate decreased from 19% between 1962 and 1979 to 9.7% between 1980 and 1988 (p less than 0.05). The operative mortality rates for patients undergoing resection for benign hepatic neoplasms was 3.4%; for metastatic tumors, 6.3%; for primary hepatic malignancies, 19%; and for trauma, 33%. Fifty-seven percent of operations before 1980 were performed through a thoracoabdominal exposure as compared with 19% after 1980. Overall a thoracoabdominal exposure of the liver was associated with a 20% mortality rate as compared with 8.6% for operations with abdominal exposure of the liver (p less than 0.02). Elective operations accounted for 65% of hepatic resections before 1980, as compared with 90% after 1980, and were associated with an 8.8% mortality rate as compared with 30.7% for urgent and emergency operations (p less than 0.001). Segmental and wedge resections were associated with a 5.3% mortality rate as compared with 14.7% for major hepatic resections (p less than 0.05), but this difference did not affect overall operative mortality rates because there was no change in the proportion of major hepatic resections after 1980. Surgical experience was not a determinant of operative mortality or morbidity rates in elective operations. Although there was no reduction in the complication rate after 1980, there was a reduction in postoperative stay from 26 days before 1980 to 16 days after 1980 (p less than 0.001). A reduction in the incidence of postoperative sepsis and a change in its management was associated with improved operative mortality rates.     

Midterm outcomes of off-pump and on-pump coronary artery revascularization in renal transplant recipients

Abstract Objectives: Renal transplant recipients have high mortality from cardiac causes and are frequently in need of coronary interventions. Surgical coronary revascularization is associated with significant morbidity and mortality in this patient population. This study was undertaken to evaluate outcomes of on‐pump versus off‐pump revascularization in renal transplant recipients. Methods: We retrospectively reviewed 43 renal transplant recipients who underwent surgical coronary revascularization with functioning allografts. Revascularization was performed on‐pump [coronary artery bypass grafting (CABG)] in 21 patients and off‐pump [off‐pump coronary artery bypass (OPCAB)] in 22 patients. Results: Preoperative characteristics did not differ between the two groups except for age and incidence of prior sternotomy. Total operative time and transfusion requirements were similar. The on‐pump group received a higher number of bypass grafts (p = 0.03). Overall 30‐day, one‐year, five‐year, and eight‐year survival was 90%, 76%, 61%, and 32% for CABG group, and 95%, 86%, 62%, and 48% for OPCAB group (p = 0.53). The postoperative peak creatinine was higher in the CABG patients than in OPCAB patients (p = 0.04). At discharge, there was no difference in mean creatinine between the two groups. The rate of return to permanent dialysis after revascularization was similar (28% for CABG and 22% for OPCAB, p = 0.73). There was no difference in dialysis‐free survival up to eight‐years postrevascularization (p = 0.63). Conclusions: Despite higher mortality risk, surgical coronary revascularization can be performed safely in renal transplant recipients. OPCAB resulted in no improvement in patient survival or renal allograft function compared to on‐pump revascularization. (J Card Surg 2011;26:591‐595)     

Coronary artery disease in patients requiring abdominal aortic aneurysm repair. Selective use of a combined operation.

The chief cause of operative mortality after abdominal aortic aneurysm (AAA) repair is myocardial infarction. For this reason, routine coronary angiography followed by prophylactic coronary artery bypass grafting (CABG) prior to AAA repair has been recommended by some surgeons. We report here the results of the selective use of a combined operation. Two hundred twenty-seven patients had elective or emergency repair of nonruptured AAA on our service from 1972 to 1983. Prior to surgery, all patients underwent careful clinical evaluation for the presence of coronary artery disease (CAD) and were classified into the following: group I (n = 121), no clinical evidence of CAD, 53%; group II (n = 96), clinical evidence of stable CAD, symptomatic or asymptomatic, 42%; group III (n = 10), unstable CAD, five per cent; Group IIIa (n = 4), asymptomatic AAA; and group IIIb (n = 6), symptomatic AAA. Seven patients ultimately assigned to group II underwent stress electrocardiogram (ECG) and eight group II patients had coronary angiography before surgery. All patients in groups I and II underwent elective or urgent repair of their AAA without CABG. Prior to surgery, these patients were managed with placement of a pulmonary artery catheter and incremental volume loading to construct a left ventricular performance curve as a guide to surgical fluid replacement. All were carefully monitored for at least 48 hours after surgery in an intensive care unit. Four patients (group IIIa) with unstable CAD and asymptomatic AAA underwent CABG followed by elective AAA repair within six months. Six patients (group IIIb) with unstable CAD and symptomatic AAA underwent combined open heart surgery (CABG and, in one patient, valve replacement) and AAA repair as a single operation. There was no operative mortality in group III patients. Thirty-day operative mortality for the entire group of 227 patients was 1.3% (three deaths), with only one death from a myocardial infarction (0.4%). While there is clearly a high incidence of CAD in patients with AAA, the present results indicate that these individuals can be managed with low risk by a selective approach based upon clinical assessment of their CAD. Our experience further demonstrates that patients with unstable CAD and symptomatic AAA may have both lesions safely repaired as a single operative procedure.     

Surgical experience in descending thoracic aneurysmectomy with and without adjuncts to avoid ischemia

Over the past twelve years, surgical treatment of descending thoracic aneurysms has been performed in 360 patients. Three different operative strategies were employed during resection to provide distal aortic perfusion by temporary bypass (Group 1, 75 patients) or shunt (Group 2, 22 patients) or to simplify the operative procedure with aortic cross-clamping alone (Group 3, 263 patients). The surgical results were determined primarily by patient-related and disease-related variables. Advanced age (older than 70 years), atherosclerotic cause, and emergency operation significantly increased the risks of early mortality and morbidity. The incidence of death (11.7%), paraplegia (6.5%), or renal failure (6%) was not reduced by the use of adjunctive perfusion, and bleeding complications increased significantly in Groups 1 and 2. Spinal cord injury was increased significantly by emergency operations, cross-clamp times exceeding 30 minutes, and extensive aneurysms (p less than 0.05). The risk of renal failure was increased by advanced age and atherosclerotic cause (p less than 0.05). With an experienced surgical team, the primary risks of descending thoracic aneurysmectomy are not influenced by the method of adjunctive perfusion, but are determined by patient factors such as the nature and extent of the aneurysm.     

Surgical repair of ruptured abdominal aortic aneurysms in the state of Maryland: Factors influencing outcome among 527 recent cases

Purpose: Abdominal aortic aneurysm (AAA) rupture has been historically associated with high operative mortality rates. In this community-based, cross-sectional study, we examined factors influencing outcome after operations performed for ruptured AAA (rAAA). Methods: An analysis of a state database identified 3820 patients who underwent AAA repair between 1990 and 1995, including 527 (13.8%) who had an operation for an rAAA. Demographic variables examined included patient age, gender, race, associated comorbidity rates, operative surgeon experience with rAAA, and annual hospital rAAA and total AAA operative volumes. Outcomes measured included operative mortality rates, hospital length of stay, and charges. Results: Operative mortality rates increased significantly with advancing age (P < 0.0001) but were not related to gender (P = 0.474) or race (p = 0.598) and were significantly lower among patients with hypertension (P = 0.006) or pulmonary disease (P = 0.045). There was no relationship between hospital rAAA or total AAA volume and rAAA repair mortality rate, although high-volume surgeons (i.e., performing more than 10 rAAA repairs) had decreased mortality rates and hospital charges compared with other surgeons. Hospital lengths of stay and charges increased with age among survivors, but not nonsurvivors, of rAAA repair. Despite a stable incidence of rAAA repairs during the study interval and no significant change in the mean age of patients undergoing operation or the percentage of operations performed by high-volume surgeons, the statewide mortality rate declined from 59.3% to 43.2% (P = 0.039). Conclusion: The incidence of rAAA does not appear to be declining. Although operative rAAA repair continues to be associated with substantial risk and remains an especially lethal condition among the elderly, the operative mortality rate has declined in recent years in Maryland. Lower operative mortality rates and hospital charges are associated with operations performed by high-volume surgeons. (J Vasc Surg 1998;28:413-21.)     

The multicenter experience with a third-generation endovascular device for abdominal aortic aneurysm repair. A report from the EUROSTAR database

AIM: The purpose of this study was to evaluate the effect of the preoperative diameter of abdominal aortic aneurysms (AAA) upon the midterm outcome obtained by endovascular AAA repair, using a third-generation endovascular device, the Excluder bifurcated endoprosthesis (W. L. Gore & Associates, Inc. Sunnyvale, CA, USA). METHODS: The data of 676 patients, who had undergone endovascular aneurysm repair (EVAR) were analysed. Patients were enrolled over a 6-year period to April 2004 in the EUROSTAR database. Outcomes were compared between 2 groups defined by the preoperative diameter of the aneurysm: group A (n=300), smaller than 5.5 cm; group B (n=376), 5.5 cm or larger. Patient characteristics, details of aorto-iliac anatomy, operative procedure and postoperative complications in the 2 patient groups were compared. Outcome events included aneurysm-related death, overall death, conversion, and late rupture of the aneurysm. Life table analyses and log rank tests were used to compare outcome in the study groups. Multivariate Cox models were used to determine whether baseline and follow-up variables were independently associated with adverse outcomes. RESULTS: Patients in group B were significantly older than patients in group A (73 years vs 71 years respectively; p=0.006), and more frequently were at higher operative risk (ASA-classification >3; 44% vs 59%; p<0.0001). Anatomic differences included a higher incidence of aorto-iliac angulation, a wider and shorter infrarenal neck in group B. Risk factors that were more frequently observed in group B included hypertension, carotid disease and pulmonary disorders. Additional operative events including device migration occurred more frequently in group B (0% vs 2%; p=0.03). Device-related (type I and III combined) endoleaks were more frequently observed at completion arteriography in group B compared to group A (2% vs 4%; p=n.s.). Thirty-day mortality was comparable between the 2 study groups. However, the overall death rate after 3 years of follow-up was significantly higher in patients with larger aneurysms, group B (4% vs 14%; p=0.0025). Similarly, aneurysm-related death was significantly higher in group B (after 3 years 0.3% vs 3%; p=0.02). Aneurysm growth after EVAR was modest low in both study groups (after 2 years 6% vs 8%; non-significant). There was no correlation between growth of the sac and aneurysm-related death. CONCLUSIONS: The midterm outcome after endovascular repair by Excluder devices was satisfactory in patients with small and large AAAs. A higher rate in all-cause deaths and aneurysm-related deaths in patients with larger aneurysms was observed. Post-EVAR aneurysm growth was observed in a small percentage of patients but this did not contribute to aneurysm-related death.     

腹主动脉瘤96例的诊断与手术治疗

摘要：目的 探讨腹主动脉瘤(AAA)的诊断、手术方式的选择及并发症的防治。方法 回顾性分析14年余收治的96例AAA的诊断和手术治疗的临床资料。对82例肾动脉水平以下型AAA行动脉瘤切除人工血管置换术，12例肾下型行涤纶片动脉瘤体包裹术，2例肾动脉上型腹主动脉假性动脉瘤行側壁瘤体切除修补术。结果 主动脉造影、MRA或EBT可确定动脉瘤上界与肾动脉间的距离。93例获得临床治愈。手术死亡3例，手术病死率3.1%(3/96)；其中急诊手术病死率50.0%(2/4)，限期手术病死率1.1%(1/92)，两者差异显著（P<0.05）。6例术后出现乙状结肠缺血症状，2例肢体远端有缺血症状，2例急性肾功能不全，均经非手术治疗痊愈。手术并发症发生率21.3％。82例获随访，随访时间6个月至15年。术后5年生存率为81.7%。 结论 AAA切除人工血管置换术是治疗AAA的基本方法。