Higher prevalence of obstructive airway disease in patients with thoracic or abdominal aortic aneurysm

BACKGROUND AND AIM: The risk factors of aortic aneurysm (AA) are comparable with those described for chronic obstructive pulmonary disease. This study was performed to determine whether patients with AA have a higher than average prevalence of obstructive airway disease. METHODS: We performed pulmonary function tests in 240 consecutive patients (182 men and 58 women; age, 70 +/- 10 years) with thoracic or abdominal AA. The results were compared with those in individuals without obvious cardiovascular disease (control) and in patients with coronary artery disease who were matched for age, gender, smoking status, and other atherosclerotic risk factors. RESULTS: Patients in the AA group had a lower forced expiratory volume in 1 second/forced vital capacity (%) and carbon monoxide diffusing capacity (%/predicted value) than did the control group (P <.01). The proportion of patients with airway obstruction, defined as forced expiratory volume in 1 second/forced vital capacity of 70% or less, was higher in the AA group (100/240; 42%) than in the control (51/223; 23%) and coronary artery disease (43/238; 18%) groups. Multiple logistic regression analysis results revealed that the presence of an AA and male gender were associated with a higher risk of airway obstruction (odds ratio, 2.928; 95% CI, 1.722 to 4.979; and odds ratio, 1.622; 95% CI, 1.055 to 2.493, respectively). CONCLUSION: These data suggest that AA may be a risk factor indicative of the presence of chronic obstructive pulmonary disease. A higher prevalence of depressed pulmonary function should be suspected as a preoperative risk in presence of thoracic or abdominal AA as compared with other types of cardiovascular disorders.     

腹主动脉瘤合并需外科手术的消化系统疾病六例的临床分析

目的：探讨腹主动脉瘤（AAA）合并需外科手术之消化系统疾病（DSD）的治疗方法。方法：总结自1999年3月至2001年10月6例AAA合并需手术治疗之DSD的处理经验。AAA直径为4.8-11cm，平均7.1cm。AAA和DSD同期手术治疗3例（胆囊切除2例，乙状结肠癌根治1例），AAA腔内隔绝术后行结肠肝曲癌和食道下端癌根治术2例。先行胃癌根治术后行AAA修复1例。结果：食管胃吻合口瘘术后第2天死亡1例，胃瘫1例经治疗30d后胃功能恢复，未发生移植人工血管感染。5例存活，随访6-42个月，平均19个月，无吻合口动脉瘤及支架内漏发生。结论：只要患者全身及局部情况许可，AAA和DSD可同期手术，反之分期进行，AAA腔内隔绝术可作为该类患者首先进行治疗之有效措施。     

Surgical strategy of concomitant abdominal aortic aneurysm and gastric cancer

Purpose: Selecting the most appropriate surgical approach for patients with abdominal aortic aneurysm (AAA) and concurrent gastric cancer remains controversial. In an attempt to develop guidelines for the management of two concurrent lesions, a retrospective review of patients with concomitant AAA and gastric cancer was undertaken.Methods: During the period from January 1985 to December 1992, a total of 222 patients with AAA were admitted to our hospital. Among these, seven patients (3.2%) had gastric cancer and concurrent AAA. Six of the seven patients were treated surgically for both lesions with either a one- or two-stage operation. One patient underwent only an exploratory laparotomy because of the peritoneal dissemination of the gastric cancer. Four of the six patients underwent a two-stage operation. In three cases, the resection of the malignancy was performed first because the gastric cancer was diagnosed as advanced before operation. In one case, the aneurysmectomy was performed first because the aneurysm was more than 6 cm in diameter and the gastric cancer was in an early stage of development. Two of the six patients underwent a one-stage operation and a simultaneous resection was carried out by way of segregated approaches, such as the retroperitoneal approach for AAA and the transperitoneal approach for the malignant lesion.Results: Five of the seven patients (71.4%) are still alive. The length of follow-up for these patients ranged from 4 months to 4 years.Conclusions: The principles of our surgical approaches for concomitant AAA and gastric cancer are as follows. (1) The lesion that absolutely indicates urgent operation should be operated on first. (2) If the malignant lesion is advanced, it is resected first. (3) If the malignancy is not advanced, the AAA should be resected first by the retroperitoneal approach. (4) Simultaneous resection by way of segregated approaches is useful in some patients with early gastric cancer. (5) Both lesions must be resected eventually for improvement of the long-term survival chances. (J VASC SURG 1994;19:573-6.)     

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease

Objective: Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated. Methods: Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts. Results: There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events. Conclusion: Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.     

Surgical treatment of thoracic aortic aneurysm in patients with concomitant coronary artery disease.

OBJECTIVE: Surgical treatment of thoracic aortic surgery in patients with coronary artery disease was investigated. METHODS: Between 1990 and April 2003, 330 patients underwent elective thoracic aortic surgery. Fifty-six patients who underwent aortic root reconstruction were excluded and 274 patients were examined. Fifty-four (20%) patients showed concomitant coronary artery disease. Ten had undergone coronary revascularization previously; and 3 underwent coronary revascularization [2 coronary artery bypass grafting (CABG), 1 percutaneous transluminal coronary angioplasty (PTCA)] before aortic surgery. Twenty-three patients underwent elective CABG simultaneously and 2 patients had additional coronary artery bypass because of cardiac ischemia during operation. The number of patients who underwent thoracic aortic surgery including Asc Ao+AVR was 2, hemi arch 1, total arch 15, distal arch 5, distal arch+LV aneurysmectomy 1, and thoracoabdominal Ao 1. Two patients underwent coronary revascularization with arterial grafts and the others with SVG grafts. RESULTS: There was one hospital death (4%). In patients without coronary bypass, 2 patients suffered cardiac ischemic events. CONCLUSION: Our thoracic aortic operations with concomitant CABG using SVG were overall successful. Our current strategies for thoracic aortic surgery in patients with concomitant coronary artery disease include conducting a dipyridamole myocardial perfusion-imaging test first in patients not at risk of coronary artery disease, and if the test is positive, coronary angiography is performed and aggressive coronary revascularization is conducted where possible.     

Management of patients with concomitant lung cancer and abdominal aortic aneurysm

BACKGROUND: Management of patients with an abdominal aortic aneurysm (AAA) and malignancy is challenging. We aimed to define the coincidence of AAA and lung cancer and to determine a treatment strategy. METHODS: The outcomes for patients diagnosed with AAA and lung cancer between 1991 and 2004 at our institution were reviewed retrospectively. RESULTS: We identified 75 patients with both lesions among 1,096 AAA and 1,875 lung cancer patients. Survival correlated with cancer stage; only 3 deaths were directly attributable to the patient's AAA. Of 59 patients who did not have AAA repair at the time of cancer diagnosis, 12 were repaired. Twenty-seven of those 59 patients had a 5.0-cm or larger AAA; only 1 patient with a 7.5-cm AAA had a rupture 5 months after thoracotomy and died. CONCLUSIONS: The co-existence of AAA and lung cancer is not rare; prognosis is poor and largely determined by the lung cancer stage. Open or endovascular repair of AAA rarely is justified in patients with advanced disease unless the AAA is symptomatic or large (>7 cm). Treatment for AAAs greater than 5.5 cm should be based on stage, histology, and patient comorbidities.     

Operative strategy for thoracoabdominal aortic aneurysm with concomitant reconstruction of four main abdominal branches]

A thoracoabdominal aortic aneurysm (TAAA) involving major abdominal branches remains still difficult to be managed. From 1983 to 1990, we successfully operated five such cases. Our operative strategy for TAAA which necessitates concomitant reconstruction of four major abdominal branches is i) to utilize temporary bypass to maintain distal perfusion during aortic cross-clamping, ii) to reconstruct bilateral renal arteries prior to aortic clamping in order to shorten renal ischemic time as much as possible, iii) to reconstruct celiac and superior mesenteric arteries by Crawford's method, iv) to reconstruct two pairs of intercostal arteries by using diagonal anastomosis in the proximal site, and v) to divide the left renal vein temporarily for easy manipulation of renal arteries. All five cases were recovered uneventfully. This procedure, in which the renal ischemic time is saved as short as possible, is considered a safe and reasonable one for thoracoabdominal aortic aneurysms.     

Incision and abdominal wall hernias in patients with aneurysm or occlusive aortic disease

INTRODUCTION: Patients undergoing midline incision for abdominal aortic reconstruction appear to be at greater risk for postoperative incision hernia compared with patients undergoing celiotomy for general surgical procedures. Controversy exists as to whether incidence of abdominal wall hernia and increased risk for incision hernia is higher in patients with abdominal aortic aneurysm (AAA) than in patients operated on because of aortoiliac occlusive disease (AOD). We conducted a prospective multi-institutional study to assess frequency of incision hernia after aortic surgery through a midline laparotomy and of previous abdominal wall hernia. METHODS: Patients with AAA (n = 177) or AOD (n = 82) from three major institutions were prospectively enrolled in the study and examined. Data collected included demographic data, cardiopulmonary risk factors, smoking status, history of previous or current abdominal wall hernia (incision, inguinal, umbilical, femoral), previous midline incision, suture type, and postoperative complications. At a minimum of 6 months after laparotomy, patients were evaluated clinically for a new incision hernia. Differences were tested with the unpaired t test, X(2) test, or Fisher exact test, and multiple logistic regression was used to control for confounding variables. RESULTS: Mean follow-up of the cohort was 32.8 +/- 2.3 months. Rate of abdominal wall hernia and inguinal hernia in patients with AAA versus AOD was 38.4% versus 11% (P =.001) and 23.7% versus 6.1% (P =.003), respectively. Rate of postoperative incision hernia in patients with AAA was 28.2%, and in patients with AOD was 11.0% (P =.002). Adjusting for age, smoking, chronic obstructive pulmonary disease, body mass index, diabetes, bowel obstruction, and suture type, patients with AAA had almost a ninefold risk for postoperative incision hernia formation (odds ratio [OR], 8.8; P =.0049). CONCLUSION: Compared with patients with AOD, patients with AAA have a higher frequency of abdominal wall hernia and inguinal hernia, and are at significant increased risk for development of incision hernia postoperatively. The higher frequency of hernia formation in patients with AAA suggests the presence of a structural defect within the fascia. Further studies are needed to delineate the molecular changes of the aorta and its relation to the abdominal wall fascia.     

腹主动脉瘤腔内修复术中髂动脉瘤的处理策略

目的:探讨腹主动脉瘤合并髂动脉瘤的腔内修复术(EVAR)方法。方法:回顾性分析2007年8月—2014年3月35例腹主动脉瘤合并髂动脉瘤行EVAR术患者资料,其中9例合并单侧髂内动脉瘤,1例合并双侧髂内动脉瘤,14例合并单侧髂总动脉瘤(直径18 mm),11例合并双侧髂总动脉瘤,所用腔内技术包括栓塞髂内动脉瘤后覆盖,髂内动脉瘤单纯覆盖,"喇叭口"支架,以及"三明治"技术重建一侧髂内动脉等。结果:所有腔内技术均获得成功,手术时间(125±40)min,出血量(173±65)m L。术中发现内漏8例(22.9%),其中I型内漏4例(近端2例,远端2例)均经球囊扩张后内漏消失,III型内漏1例,经扩张及部分加弹簧圈栓塞后内漏消失,II型内漏2例及IV型内漏1例,均未予处理。35例术后随访6~60个月,无动脉瘤破裂,2例术后6个月发现腹主动脉瘤体增大,造影确诊远端I型内漏,经弹簧圈栓塞后内漏消失,其余33例瘤体直径无增大。结论:对于合并髂动脉瘤的腹主动脉瘤患者,有效处理髂内动脉,然后根据髂总动脉直径选择合适的治疗方法可以达到理想的近期效果。     

Coronary artery disease in patients with abdominal aortic aneurysm

Selective coronary angiography to determine the prevalence of coronary artery disease (CAD) has been performed in patients with abdominal aortic aneurysm (AAA). Thirty patients in this series consisted of 26 men and 4 women with an age range of 48-87 years (mean +/- SD: 67.5 +/- 8.2 years). As the atherosclerotic risk factors, cigarette smoking was present in 19 patients (63.3%), hypertension was in 18 (60%), hypercholesteremia was in 10 (33.3%), and diabetes mellitus was in 2 (6.7%). Cerebral vascular disease was present in 11 patients (36.7%). Regarding CAD, angina pectoris or old myocardial infarction was found in 9 patients (30%), and abnormal electrocardiography (ECG) was in 16 patients (53.3%). Coronary angiography prior to operation of AAA was performed to 22 patients (73.3%), and 15 patients (68.2%) among them had significant coronary artery stenosis, and 9 patients underwent myocardial revascularization (4 CABG, 5 PTCA). CAD was frequently complicated both in patients without symptoms or ECG abnormalities and in less than 65-year patients. In order to prevent fatal myocardial infarction, we recommend routine coronary angiography to patients with AAA. And if necessary, myocardial revascularization must be indicated prior to aneurysmectomy.     

Endovascular thoracic aortic aneurysm repair with concomitant myocardial and carotid revascularization

A 73-year-old woman presented with a large saccular aneurysm involving the distal aortic arch. Preoperative aortography and cardiac catheterization revealed left main coronary artery and left common carotid artery stenoses. Concomitant coronary artery bypass grafting to the left anterior descending and first diagonal arteries, ascending aorta-to-left common carotid artery bypass grafting, and endovascular thoracic aortic aneurysm repair with antegrade stent-graft deployment and intentional left subclavian artery coverage were performed.     

The prognostic value of dobutamine stress echocardiography in patients with abdominal aortic aneurysm and concomitant coronary artery disease

Patients undergoing abdominal aortic aneurysm (AAA) are at increased risk for cardiovascular complications such as cardiac death and nonfatal myocardial infarction. Dobutamine stress echocardiography is an established, cost-effective technique for the detection of coronary artery disease (CAD). This review will focus on the additional prognostic value of dobutamine stress echocardiography for perioperative and late prognosis in patients with AAA and CAD.     

Rupture of an abdominal aortic aneurysm with concomitant aorto-caval fistula

Aorto-caval fistulas are one of the most uncommon complications of infrarenal aortic aneurysms and have a high pre and perioperative mortality rates. Its prompt diagnosis and early treatment may be helpful in lowering the surgical morbidity and mortality. One successfully treated case of a ruptured aortic aneurysm with concomitant aorto-caval fistula is reported, discussing the clinical presentation, the diagnosis and the details of the surgical techniques employed.     

Combined thoracic aortic dissection and abdominal aortic fusiform aneurysm.

Certain clinical and autopsy findings are described in 13 patients who had both aortic dissection (AD) and fusiform abdominal aortic aneurysm (AAA). All 13 patients had severe and extensive aortic atherosclerosis. The AAA was diagnosed clinically in 9 patients, and 5 had the AAA resected. The AD was diagnosed clinically in 5 patients, and 2 underwent attempted operative repair. Two patients who had the AAA resected because of suspected rupture were found later to have ruptured a more proximal AD. Thus, AD occurs occasionally in patients who have AAA. In older persons with suspected rupture of an AAA, a more proximal rupture of an AD should be ruled out. When both AAA and AD are present in the same patient, the AD is more likely the cause of cardiovascular collapse than is rupture of the AAA.     

A single-stage operation for abdominal aortic aneurysm with concomitant colorectal carcinoma.

The coexistence of abdominal aortic aneurysm (AAA) and colorectal carcinoma needs special operative consideration. A single-stage operation for concomitant AAA and colorectal carcinoma has been thought to increase the risk of vascular prosthetic graft infection. We report two patients who received a single-stage operation for AAA and colorectal carcinoma. The first patient had a fusiform aneurysm of the infrarenal aorta. The second patient had a saccular aneurysm of the infrarenal aorta and a fusiform aneurysm of the left internal iliac artery. Both patients had left-sided colorectal carcinoma classified as Dukes' stage B. The two patients underwent a single-stage operation with Hartmann's procedure to avoid graft infection caused by anastomotic leakage. They tolerated the operation and had no postoperative complications including graft infection. A single-stage operation for concomitant AAA and left-sided colorectal carcinoma could be safely performed with Hartmann's procedure in two cases.     

Simultaneous endovascular exclusion of thoracic aortic aneurysm with open abdominal aortic aneurysm repair.

BACKGROUND: The treatment of aneurysms at multiple sites within the aorta is problematic. METHODS: Between March 2002 and June 2003 in the Department of General, Vascular and Transplant Surgery, Medical University of Warsaw six patients with coexisting abdominal and descending thoracic aortic aneurysms underwent simultaneous open abdominal aortic aneurysm (AAA) repair and endoluminal thoracic aortic aneurysm (TAA) repair. The indication for a combined procedure was a diagnosed descending TAA and AAA with no significant risk factors for open aortic surgery or technical contraindications for endovascular treatment of TAA. RESULTS: One patient died in the peri-operative period while the other five patients all recovered well after surgery and were discharged with both aneurysms excluded. CONCLUSION: Endovascular treatment of TAA combined with a simultaneous open AAA repair is an efficient and relatively safe treatment modality in patients with TAA and AAA disqualified from endovascular repair. The fact that thoracotomy is not a necessity significantly lowers the complication rate in these patients.     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.