Treatment Of Aneurysms In Patients Research Articles

Early Complications and Outcome After Treatment of Ruptured Aneurysms in Patients with Subarachnoid Hemorrhage–A Post Hoc Analysis of the EARLYDRAIN Trial

Aneurysmal subarachnoid hemorrhage (aSAH) from a ruptured intracranial aneurysm is a severe, life-threatening condition, with high morbidity and mortality. The current treatment often involves surgical clipping or endovascular treatment within the first 24-48 hours. Although there is ample evidence of complications in treating unruptured aneurysms, similar data in patients with acutely ruptured aneurysms are limited. The recently completed EARLYDRAIN trial showed improved neurologic results from lumbar drainage after aneurysm treatment in patients with aSAH. Using this data set, we aim to study the frequency and effects of complications and identify associated risk factors. A substudy was carried out of the prospective multicenter randomized controlled EARLYDRAIN trial. We analyzed treatment-associated complications (bleeding and/or infarctions) detected on computed tomography on day 1 after aneurysm occlusion. Outcomes were the occurrence of postprocedural complications, secondary infarctions in the acute phase, and the modified Rankin Scale score after 6 months. The EARLYDRAIN trial recruited 287 patients in 19 centers. Of these patients, 56 (19.5%) experienced a treatment complication. Twenty-five patients (8.7%) experienced postprocedural intracranial hemorrhage and 34 patients (11.8%) experienced a treatment-associated infarction. Patients with a complication showed more secondary infarctions (P= 0.049) and worse neurologic outcomes after 180 days (P= 0.025) compared with patients with no complication. Aneurysm location, rebleeding before the treatment, number of patients recruited per center, and the day of the treatment were independent risk factors for the occurrence of complications. The present study shows that patients with aSAH frequently experience intervention-associated complications associated with aneurysm occlusion required to prevent recurrent hemorrhage. Consequently, patients with aSAH with treatment-related complications more often experience a worse clinical course and poor outcome.

To Close, Observe, or Reconstruct: The Third Way of Managing Dialysis Fistula Aneurysms in Kidney Transplant Recipients.

Background: The management of patent dialysis fistulas in patients after kidney transplantation (KTx) is controversial—the options that are usually considered are the fistula’s closure or observation. Many complications of dialysis fistulas occur in patients after KTx, and immunosuppression increases the risk of fistula aneurysms and hyperkinetic flow. This study aimed to evaluate the results of dialysis fistula aneurysm treatment in patients after KTx and to compare them to procedures performed in an end-stage renal disease (ESRD) dialyzed population. Methods: We enrolled 83 renal transplant recipients and 123 ESRD patients with dialysis fistula aneurysms qualified for surgical revision to this single-center, prospective study. The results of the surgical treatment of dialysis fistula aneurysms were analyzed, and the primary, assisted primary and secondary patency rate, percentage and type of complications were also assessed. Results: For the treatment of dialysis fistula aneurysms in transplant patients, we performed dialysis fistula excisions with fistula closure in 50 patients (60.2%), excision with primary fistula reconstruction (n = 10, 12.0%) or excision with PTFE bypasses (n = 23, 27.7%). Postoperative complications occurred in 11 patients (13.3%) during a follow-up (median follow-up, 36 months), mostly in distant periods (median time after correction procedure, 11.7 months). The most common complication was outflow stenosis, followed by hematoma, dialysis fistula thrombosis and the formation of a new aneurysm and postoperative bleeding, infection and lymphocele. The 12-month primary, primary assisted and secondary patency rates of fistulas corrected by aneurysm excision and primary reconstruction in the KTx group were all 100%; in the control ESRD group, the 12-month primary rate was 70%, and the primary assisted and secondary patency rates were 100%. The 12-month primary, primarily assisted and secondary patency rates after dialysis fistula aneurysm excision combined with PTFE bypass were better in the KTx group than in the control ESRD group (85% vs. 71.8%, 90% vs. 84.5% and 95% vs. 91.7%, respectively). Kaplan–Meier analysis showed a significant difference in primary patency (p = 0.018) and assisted primary (p = 0.018) rates and a strong tendency in secondary patency rates (p = 0.053) between the KTx and ESRD groups after dialysis fistula excisions combined with PTFE bypass. No statistically significant differences in patency rates between fistulas treated by primary reconstruction and reconstructed with PTFE bypass were observed in KTx patients. Conclusions: Reconstructions of dialysis fistula aneurysms give good long-term results, with a low risk of complications. The reconstruction of dialysis fistulas can be an effective treatment method. Thus, this is an attractive option in addition to fistula ligation or observation in patients after KTx. Reconstructions of dialysis fistula aneurysms enable the preservation of the dialysis fistula while reducing various complications.

Hybrid Surgery to Manage Aortic Arch Pathology.

Background and Objectives: Aortic arch disease is still a high-risk surgical challenge despite major advances both in surgical and anesthesiological management. A combined surgical and endovascular approach has been proposed for aortic arch disease treatment to avoid hypothermia and circulatory arrest in high-risk patients. Materials and Methods: Between June 2004 and June 2021, 112 patients were referred to our department for aortic arch surgery; 38 (33.9%) patients underwent supra-aortic debranching and endovascular treatment. Of these, 21 (55%) patients underwent type I aortic arch hybrid debranching procedure and in 17 (45%) patients a type II aortic arch hybrid debranching procedure was performed. None of the patients were emergent. Results: No intra-operative deaths were recorded. In the type I aortic arch hybrid debranching patients’ group, one patient died at home waiting the endovascular step, one developed ascending aortic dissection and another one developed a pseudoaneurysm at the site of the debranching at follow-up. In the type II aortic arch hybrid debranching patients’ group, left carotid artery branch closure was detected at follow-up in one patient. Thirty day/in-hospital rates of adverse neurological events for both the surgical and endovascular procedures were 3% for minor stroke, with no permanent neurological deficit and 0% for permanent paraplegia/paraparesis. In 100% of the cases, the endovascular step succeeded and the type Ia endoleak rate was 0%. Conclusions: Hybrid arch surgery is a valuable option for aortic arch aneurysm treatment in patients with high surgical risk. The choice of aortic arch debranching between type I or type II is crucial and depends on anatomic and clinical patient characteristics. Further larger scale studies are needed to better define the advantages of these techniques.

External Ventricular Drainage in Patients With Acute Aneurysmal Subarachnoid Hemorrhage After Microsurgical Clipping: Our 2006-2018 Experience and a Literature Review.

IntroductionThe placement of an external ventricular drain (EVD) is widely practiced in neurosurgery for various diseases and conditions accompanied by impaired cerebrospinal fluid (CSF) circulation, intracranial hypertension (ICHyp), intraventricular hemorrhage (IVH), and hydrocephalus. Specialists have been using this method in patients with acute aneurysmal subarachnoid hemorrhage (aSAH) for more than 50 years. Extensive experience gained at the Burdenko Neurosurgical Center (BNC) in Moscow, the Russian Federation, in the surgical treatment of patients with acute aSAH enabled us to describe the results of using an EVD in patients after microsurgery. The objective of the research was to assess the effectiveness and safety of the EVD and clarify the indications for the microsurgical treatment of aneurysms in patients with acute SAH.Materials and methodsFrom 2006 until the end of 2018, 645 patients registered in the BNC database underwent microsurgery for acute (0-21 days) aSAH. During the case study, we assessed the severity of hemorrhage according to the Fisher scale, the condition of patients on the Hunt-Hess (H-H) scale during surgery, the time of placement of EVD (before, during, and after surgery), and the duration of EVD. The number of patients with parenchymal intracranial pressure (ICP) transducers was assessed by the degree of correlation of ICP data through the EVD and parenchymal ICP transducer. One of the aims of the research was to compare the frequency of using EVD and decompressive craniectomy (DCH). The incidence of EVD-associated meningitis was analyzed. The need for a ventriculoperitoneal shunt (VPS) in patients after using EVD was also assessed. Overall outcomes were assessed using a modified Rankin scale (mRS) at the time of patient discharge. Exclusion criteria were as follows: patients aged less than 18 years and the lack of assessed data. Patients undergoing endovascular and conservative treatments also were excluded.ResultsAmong the patients enrolled in the study, 22% (n=142) had EVD. Among these, 99 cases (69.7%) had EVD installed in the operating room just before the start of the surgical intervention. In some cases, ventriculostomy was performed on a delayed basis (16.3%). A satisfactory outcome (mRS scores of 1 and 2) was observed in 24.7% (n=35). Moderate and profound disability at the time of discharge was noted in 55.7% (n=79). Vegetative outcome at discharge was noted in 8.4% (n=12), and mortality occurred in 12.3% (n=15).ConclusionEVD ensures effective monitoring and reduction of ICP. EVD is associated with a relatively low risk of infectious, liquorodynamic, and hemorrhagic complications and does not worsen outcomes when used in patients with aSAH. We propose that all patients in the acute stage of SAH with H-H severity of III-V should receive EVD immediately before surgery.

Temporal Muscle as an Indicator of Sarcopenia is Independently Associated with Hunt and Kosnik Grade on Admission and the Modified Rankin Scale Score at 6 Months of Patients with Subarachnoid Hemorrhage Treated by Endovascular Coiling

Sarcopenia is defined as the loss of skeletal muscle mass and is considered an important factor for clinical outcomes in various diseases. Recent studies have shown that temporal muscle thickness (TMT) and area (TMA) can be novel indicators of sarcopenia. We examined clinical characteristics, including TMT and TMA, of patients with subarachnoid hemorrhage (SAH) treated by endovascular coiling. A retrospective analysis of 298 patients with SAH who were treated with endovascular coiling from 2009 to 2019 was conducted. Their premorbid modified Rankin Scale (mRS) score was 0-2. The association between the factors and Hunt and Kosnik (H-K) grades on admission and that between the clinical variables and mRS scores 6 months after the operation were analyzed. In all 298 patients with SAH, Fisher group 4 and TMA <200 mm2 were independently associated with H-K grade III-V on admission in the multivariate analysis. In 254 patients with H-K grades I-III on admission, age, H-K grade III, presence of ventriculoperitoneal shunt, presence of postoperative complications, and TMA <200 mm2 were independent factors related to poor outcomes in the multivariate analysis. The H-K grade on admission was independently associated with TMA. The mRS score 6 months after aneurysm treatment in patients with H-K grades I-III was also independently associated with TMA. Sarcopenia could be one of a few modifiable factors that prevent severe symptoms of SAH and improve outcomes after coiling by strengthened nutrition and physical activity.

Endovascular Management of a Saccular Aneurysm in the Supra-Sma Region of Aorta Occluding the Celiac Trunk, in a Patient with Behcets Disease

Introduction - Behcets disease is a multisystem disorder which can present with various vascular manifestations in 12% of the patients(1). Being classified under variable vessel vasculitis, it may involve both the arteries and the veins of all sizes(2). The spectrum of presentation includes venous thrombosis, systemic or pulmonary arterial anuerysms, stenosis or occlusions. The most common vascular presentation is venous thrombosis(3). The incidence of arterial manifestations in Behcets disease is comparably less(4). The aorta is the mostly commonly involved artery reported in literature followed by the femoral artery and the pulmonary artery. Aneurysm is the most common presentation in the aorta and rupture of a large artery aneurysm is the most common cause of death(1). The pathogenesis involved is the inflammation of the vasa vasorum leading to medial destruction and fibrosis(5). Management options include open surgical repair or endovascular approach, both done under a cover of immunosuppressive regimen. In the present era, open vascular repair can be avoided as it involves a high risk of perioperative complications in view of the inflammatory pathology leading to fragile vessel walls and also due the high risk of post operative psuedoaneurysm formation(6). Endovascular treatment options for an aortic aneurysm include stent grafts or coil embolisation, with the former being the most commonly reported modality in literature(7) . Coil embolisation has been used for both saccular aneurysms of the aorta and intracranial vessels(8). Methods - We report a case of saccular aneurysm in the celiac region of the abdominal aorta of size 2.8cm anteroposterior X 2.2cm transverse X 2.1cm superioinferior, occluding the celiac trunk in an 18 year old young male with Behcets disease. On initial evaluation his systemic inflammatory markers (ESR and CRP) were raised and the SMA origin was partially occluded by acute thrombus. In view of the same he was started on steroids, immunosuppressive medications and anticoagulation. His symptoms improved well on conservative management. On one month follow up the saccular aneurysm showed significant increase in size of 3.7cm anteroposterior X 2.9cm transverse X 3.6cm superioinferior necessitating urgent intervention to prevent life threatening complications like rupture. He underwent supra-SMA aortic stenting with bare metal stent and coil embolisation of the aneurysm sac. Post operatively he was discharged on steroids and immunosupression. Results - Immediate post operative and 1st month follow up duplex showed no flow in the aneurysm sac. Conclusion - This case report exemplifies that an endovascular approach can be used to treat a saccular aneurysm of the aorta with bare metal stent and coils without the risk of distal embolisation of coils. References1)Park JH, Han MC, Bettmann MA. Arterial manifestations of Behcet’s disease. AJR Am J Roentgenol 1984; 143:821–825.2)Lie.JT, Vascular involvement in Bechets disease: arterial and venous and vessels of all sizes, J Rheumatol 1992; 19:402-10 .3)Koc Y, Gullu I, Akpek G, et al. Vascular involvement in Behcet’s disease. J Rheumatol 1992; 19:402–410.4)N. Y. Jung, S. K. Kim, E. C. Chung, H. Park, and Y. K. Cho, Endovascular treatment for rupture of intrahepatic artery aneurysm in a patient with Behcet’s syndrome,” American Journal of Roentgenology, vol. 188, no. 5, pp.W400–W402, 2007.5)A. Freyrie, O. Paragona, G. Cenacchi, G. Pasquinelli, G. Guiducci, and G. L. Faggioli, True and false aneurysms in Behcet’s disease: case report with ultrastructural observations, Journal of Vascular Surgery, vol. 17, no. 4, pp. 762–767, 1993.6)Sasaki S, Yasuda K, Takigami K, Shiiya N, Matsui Y, Sakuma M. Surgical experiences with peripheral arterial aneurysms due to vasculo-Behcet’s disease. J Cardiovasc Surg (Torino) 1998; 39:147–150.7)J. H. Park, J. W. Chung, J. H. Joh, et al., Aortic and arterial aneurysms in Behcet disease: management with stent-grafts- Initial experience, Radiology, vol. 220, no. 3, pp. 745–750, 2001.8)W. H. Kim, D. Choi, J.-S. Kim, Y.-G. Ko, Y. Jang, and W. H. Shim, “Effectiveness and safety of endovascular aneurysm treatment in patients with vasculo-Behc¸et disease,” Journal of EndovascularTherapy, vol. 16, no. 5, pp. 631–636, 2009.

Surpass Flow Diverter for Treatment of Posterior Circulation Aneurysms.

Flow diverters for the treatment of posterior circulation aneurysms remain controversial. We aimed to identify factors contributing to outcome measures in patients treated with the Surpass flow diverter for aneurysms in this location. We conducted an observational study of 53 patients who underwent flow-diverter treatment for posterior circulation aneurysms at 15 centers. Key outcome measures were mortality, complete aneurysm occlusion, and modified Rankin Scale score at follow-up. At follow-up (median, 11.3 months; interquartile range, 5.9-12.7 months), 9 patients had died, resulting in an all-cause mortality rate of 17.3% (95% CI, 7%-27.6%); 7 deaths (14%) were directly related to the procedure and none occurred in patients with a baseline mRS score of zero. After adjusting for covariates, a baseline mRS of 3-5 was more significantly (P = .003) associated with a higher hazard ratio for death than a baseline mRS of 0-2 (hazard ratio, 17.11; 95% CI, 2.69-109.02). After adjusting for follow-up duration, a 1-point increase in the baseline mRS was significantly (P < .001) associated with higher values of mRS at follow-up (odds ratio, 2.93; 95% CI, 1.79-4.79). Follow-up angiography in 44 patients (median, 11.3 months; interquartile range, 5.9-12.7 months) showed complete aneurysm occlusion in 29 (66%; 95% CI, 50.1%-79.5%). Clinical results of flow-diverter treatment of posterior circulation aneurysms depend very much on patient selection. In this study, poorer outcomes were related to the treatment of aneurysms in patients with higher baseline mRS scores. Angiographic results showed a high occlusion rate for this subset of complex aneurysms.

Platelet Testing is Associated with Worse Clinical Outcomes for Patients Treated with the Pipeline Embolization Device.

The necessity for platelet-inhibition testing before aneurysm treatment in patients premedicated with antiplatelet agents is controversial. Using the International Retrospective Study of Pipeline Embolization Device registry, we studied complication rates in groups of patients who underwent platelet testing and those who did not undergo platelet testing to determine if these test results were associated with improved outcomes. Patients in the International Retrospective Study of Pipeline Embolization Device registry with an unruptured aneurysm were categorized as those who underwent platelet testing before Pipeline embolization device treatment or those who did not. Complication rates were compared by using the Fisher exact or Pearson χ(2) test. Multivariate analysis was performed to determine if platelet function testing was independently associated with poor outcomes after adjusting for age, number of devices and aneurysms, aneurysm location and size, and practitioner and center volume. Compared with the patients who received a Pipeline embolization device without platelet testing, those who underwent platelet testing and Pipeline embolization device placement experienced higher rates of intracranial hemorrhage (0 of 187 [0.0%] vs 12 of 511 [2.3%], respectively; P = .04), neurologic morbidity (4 of 187 [2.1%] vs 42 of 511 [8.2%], respectively; P < .01), and combined neurologic morbidity and mortality (6 of 187 [3.2%] vs 45 of 511 [8.8%], respectively; P = .01). More patients in the platelet testing and Pipeline embolization device group were treated with multiple devices (227 [38.0%] vs 56 [27.8] patients, respectively; P = .01). On multivariate analysis, the group of patients who underwent platelet testing and Pipeline embolization device placement had higher odds of neurologic morbidity (OR, 3.25 [95% CI, 1.10-9.61]; P = .03). Platelet testing in patients who undergo Pipeline embolization device placement is associated with higher rates of morbidity. Additional prospective studies are needed to determine if and when platelet testing in these patients is appropriate.

Abstract W MP43: Platelet Testing is Associated With Worse Clinical Outcomes for Intracranial Aneurysm Patients Treated with the Pipeline Embolization Device

Objective: Controversy exists as to whether platelet inhibition testing is necessary prior to aneurysm treatment in patients premedicated with antiplatelet agents. Using the IntrePED ( Int ernational Re trospective Study of P ipeline E mbolization D evice) registry, we studied complication rates in platelet-testing and non-platelet testing groups to determine if platelet testing is associated with improved outcomes. Materials and Methods: Patients with unruptured intracranial aneurysms from the INTREPED registry were divided into those who received platelet testing (testing group) and those who did not (nontesting group). Morbidity, mortality and thrombotic and hemorrhagic complication rates were studied. Comparisons between groups for continuous variables were evaluated using t -tests and Fisher’s exact test or Pearson’s chi-square for binary categorical variables. Multivariate logistic regression analysis was performed to determine if platelet function testing was independently associated with poor outcomes adjusting for age, number of devices, aneurysm location, size, and use of multiple exchange wires. Results: When compared to the non-testing group, the platelet testing group suffered higher rates of ipsilateral intracranial hemorrhage (12/511, 2.3% versus 0/187, 0.0%, P=0.04), neurological morbidity (42/511, 8.2% versus 4/187, 2.1%, P=0.01), and combined neurological morbidity and mortality (45/511, 8.8% versus 6/187, 3.2%, P=0.01). More patients in the testing group were treated with multiple PEDs (228 patients, 38.1% versus 57 patients, 28.4%, P=0.01). On multivariate analysis, the platelet testing group had a higher odds of total major morbidity (OR=3.80, 95%CI=1.30=11.08, P=0.01) and total major morbidity and neurological mortality (OR=2.74, 95%CI=1.11-6.79). Conclusion: Our findings caution against blind acceptance of platelet testing in Pipeline patients. Further prospective studies are needed to determine if and when platelet testing in Pipeline patients is appropriate.

Ruptured Iliac Artery Stump Aneurysm Combined with Aortic Pseudoaneurysm in a Patient with Behçet's Disease

Operative treatment of aneurysm in patients with Behçet's disease frequently results in recurrent aneurysm at the anastomosis site or in the remaining artery. Herein, in a Behçet's patient with aortic and iliac pseudoaneurysms, a ruptured iliac artery stump aneurysm after ligation of the right external iliac artery 1 year prior to this admission is reported. This case suggests that the ligation or interposition of aneurysms associated with Behçet's disease should be done at the intact artery, remote to the diseased segment. In addition, a small pseudoaneurysm of the aorta could be monitored with close follow-up with immunosuppressive medication and surveillance at regular intervals if the aneurysm is not symptomatic and is not rapidly growing to a certain critical size.

Commentary: Endovascular Aneurysm Treatment in Patients With Vasculo-Behçet Disease

Commentary: Endovascular Aneurysm Treatment in Patients With Vasculo-Behçet Disease

Effectiveness and Safety of Endovascular Aneurysm Treatment in Patients With Vasculo-Behçet Disease

To compare long-term outcomes of endovascular and surgical treatment of arterial aneurysms in patients with vasculo-Behçet disease (VBD). The medical records of 912 patients with Behçet disease who were seen between May 1995 and January 2007 were reviewed. Among them, 34 (3.7%) patients with 39 non-cerebral aneurysmal lesions were diagnosed with VBD. Between February 1998 and November 2006, 16 VBD patients (14 men; mean age 39.2+/-9.2 years, range 25-63) were treated for 20 arterial aneurysms with an endovascular technique (stent-graft and/or coil embolization). All patients received immunosuppressive therapy (prednisolone 60 mg/d) before endovascular therapy to induce remission. From February 1993 to January 2007, 8 arterial aneurysms in 7 patients (all men; mean age 33.0+/-7.9 years, range 25-51) were treated with surgical graft interposition over 31.5+/-23.2 months. The endovascular procedure was successful in all lesions. The mean follow-up was 47.6+/-41.8 months, during which 4 complications in 3 patients (3/16, 18.8%) occurred (2 occluded stent-grafts and 2 access site pseudoaneurysm). There were no deaths. The cumulative primary patency rate in the endovascular group was 89% at 24 months. In the 7 patients undergoing graft interposition for 8 arterial aneurysms, 3 (42.9%) events occurred in follow-up: 2 recurrent pseudoaneurysms and 1 aneurysm-related death. In Behçet disease, aneurysm treatment is performed whenever possible because of the high risk of rupture. Endovascular treatment of arterial aneurysms was effective and safe, with an acceptable vascular complication rate and excellent patency of the treated site.

Follow-up of Large Aneurysms Treated with Coil Embolization at an Acute Stage in Patients with Poor-Grade Subarachnoid Hemorrhage

This study evaluated the clinical and angiographic outcome of large aneurysms treated with coil embolization at an acute stage in patients with poor-grade subarachnoid hemorrhage (SAH). Between July 1, 2001 and June 30, 2004, eight consecutive WFNS grade 5 patients with large aneurysms (15~23 mm) were treated with endovascular coil embolization within two days and followed for at least 30 months. There were three middle cerebral and five internal carotid artery aneurysms. No patients were treated by craniotomy and none survived without treatment. Two patients died of primary brain damage or cerebral vasospasm within one month. One patient died of pneumonia at 24 months. Four patients were alive with good recovery or moderate disability at the time of final follow-up (30~66 months). Angiography immediately after the procedure showed complete occlusion in three, neck remnant in four, and body filling in one patient. No complication was seen related to the procedure. Three aneurysms that were initially neck remnant developed body filling due to coil compaction. Two were re-treated with coils at six and 12 months and resulted in neck remnant. One patient refused re-treatment and died of re-bleeding. Endovascular coil embolization can be selected at an acute stage for the treatment of aneurysms in patients with poor-grade SAH without intraparenchymal hematoma even if the aneur-ysm is large. Serial follow up by MRA/angiography is necessary for at least 12 months.

Left Ventricular Aneurysm in Patients with Previous Cardiac Surgery

Left ventricular aneurysm in patients who have undergone previous cardiac surgery is infrequently reported. We reviewed the results in all patients treated for left ventricular aneurysm between 1983 and 1995 at St. Vincent Hospital and Medical Center. Of 109 patients undergoing left ventricular aneurysm surgery, 10 had open heart surgery an average of 8.9 years previously. There was no mortality or significant morbidity in those who had previous operations. Functional status improved significantly after surgery. We concluded that surgical treatment of left ventricular aneurysm in patients who had previous open heart surgery can be performed with acceptable risks and leads to functional improvement.

Epidural Anaesthesia and Mini-Laparotomy for the Treatment of Abdominal Aortic Aneurysms in Patients with Severe Chronic Obstructive Pulmonary Disease

Purpose: The purpose of this study is to compare the use of epidural and general anaesthesia techniques in the treatment of abdominal aortic aneurysms (AAA) through mini-laparotomy in patients with severe chronic obstructive pulmonary disease (COPD).Methods: Between March 2002 and October 2005, 23 patients with severe COPD underwent elective infrarenal abdominal aortic aneurysm repair. Endovascular therapy could not be established due to financial reasons and health insurance policies. All the operations were performed through mini-laparotomy, using epidural anaesthesia on 10 patients (Group I) and general anaesthesia on the remaining patients (Group II). Pulmonary disease was diagnosed by clinical history and pulmonary function tests. The diagnosis of severe COPD was made with the presence of one or more of the following criteria: Room air PaO2 < 60 mmHg, PaCO2 > 45 mmHg in arterial blood gas samples, FEV1 < 50% of predicted value and FVC < 75% of predicted value in respiratory function tests.Results: There was no significant difference between the ages, sex, pre-operative morbidity status, operation time and total blood loss of the patients in the two groups. Postoperative intensive care unit requirement, postoperative pulmonary complications and hospital stay were significantly higher in group II. All patients tolerated surgery safely. There was one in-hospital mortality from group II on the 35th postoperative day due to prolonged entubation and sepsis related to pulmonary infections. There was no late morbidity or mortality related to the technique in the postoperative follow-up period of the discharged patients.Conclusion: Epidural anaesthesia for abdominal aortic aneurysm repair through mini-laparotomy is feasible and should be especially considered in patients with severe COPD where endovascular treatment could not be performed.

The Surgical Treatment of Abdominal Aortic Aneurysms in Patients with Light to Moderate Renal Dysfunction

Objective : The incremental surgical risk caused by mild or moderate renal dysfunction in patients undergoing surgery for an abdominal aortic aneurysm is not well defined. The aim of this study is to analyze the prognostic significance of mild or moderate renal dysfunction in 79 patients who have undergone repair of an infrarenal abdominal aortic aneurysm at our institution.Methods : The postoperative results of 35 non-dialysis-dependent patients (Group I) with renal dysfunction were included and compared with a group of 44 patients (Group II) with similar characteristics of age, gender and pre-operative risk factors. All operations were performed through a standard transperitoneal median laparotomy. Results : The mean operation and aortic cross-clamp times did not differ significantly between the two groups (234 ± 15 min vs. 189 ± 17min; p = 0.25 and 57 ± 12 min. vs. 52 ±9 min.; p = 0.52). Early operative mortality was 5.71% in patients with renal dysfunction and did not differ significantly when compared with the other group of patients 4.5%; p = 0.083). Blood requirement was higher (p < 0.01) and the hospital stay was longer (p < 0.001) in group I. There were 18 patients in group I (51.4%) and three patients in group II (6.8%) in whom the pre-operative serum creatinine level increased above 2.5 mg/dl during the postoperative period. The postoperative increase of creatinine level differed significantly in patients with pre-operative renal dysfunction (p < 0.001). There were nine patients (25.7%) in group I and four patients (9.1%) in group II who required mechanical ventilation for more than 24 hours (p = 0.025). There was no significant difference between the two groups in terms of cardiac morbidity p = 0.234).Conclusion : Patients with even a mild or moderate degree of renal dysfunction require close monitoring and prolonged hospital care during the postoperative period. Although satisfactory early surgical outcomes may be expected in this particular group of patients, pulmonary and renal morbidity rates are higher than in patients with normal renal function.

Clinical outcome after surgery of intracranial unruptured aneurysms: results of a series between 1991 and 2001.

The clinical results of surgery for unruptured aneurysms in the Neurosurgical Department of Kiel were analyzed to further discuss whether an operative treatment can be advised. Between 1991 and 2001, 54 unruptured aneurysms in 45 patients were operated in our department. No complications occurred in 38 patients; transient complications (slight aphasia, hemiparesis, psychiatric disorders) in 4 patients; postoperative seizures in one, epidural haematoma with the need of re-operation in one, and infection in another patient. At the time of discharge, GOS was 5 in 33 patients, 4 in 12 patients. But the slight disabilities were due to the aneurysm operation only in two patients, in the other 10 patients they were caused by pre-existing concomitant diseases. The Rankin-Scale after at least 6 months was 1 (no disability) in 31 patients (37 patients investigated); 2 (slight disability) in 5, and 3 (moderate disability) in one patient. In only one of these patients, the slight disability was caused by the aneurysm operation. During a telephone interview performed between 6 months and 7 years after the operation, all patients except two (31 patients investigated) gave a positive answer to the question, whether, in case of diagnosis of an aneurysm, they would undergo an operation again. Regarding our results, we still advocate treatment of unruptured aneurysms in patients who are in stable clinical conditions, especially in young patients and in patients with unique aneurysm configurations and aneurysm sizes approaching 10 mm.

Surgical treatment of abdominal aortic aneurysm in patients over seventy years old.

Aneurysmectomy is generally the first choice as treatment in most patients with abdominal aortic aneurysm. However, justification of surgical procedures in the aged has been questioned, because of the risk which increases with chronologic age. In the present study, our experience with patients over 70 who underwent abdominal aortic aneurysmectomy is discussed. Forty patients with abdominal aortic aneurysm underwent surgery in our institution up to January, 1983. Ten of these patients were 70 years or older. Operation was performed electively in 6 and as an emergency in 4. The one operative death (10 per cent) was the case of a 74-year old woman with a ruptured aneurysm. The operative mortality was 17.5 per cent in patients under 70 years of age. It would appear that advanced age, per se, is not a contraindication for abdominal aneurysmectomy.