Elective Aneurysmectomy Research Articles

Idiopathıc Pulmonary Artery Aneurysm

Pulmonary artery aneurysms are rare pathologic conditions of the thoracic cavity. The ıdiopathic form of the disease is reported very rarely. We report the case of a 16-year-old girl with idiopathic pulmonary artery aneurysm with surface rendered 3-dimensional images of 64-slice computed tomography. A right-sided aortic arch with normal aortic branching was seen. The main pulmonary artery was moderately dilated, and there was aneurysmal dilatation of the right pulmonary artery from its origin to the level of the right descending pulmonary artery. The maximal diameter of the main pulmonary artery was 38 mm; that of the right pulmonary artery was 31 to 34 mm. The left pulmonary artery was of normal diameter (18.5 mm). There was no other accompanying abnormality. Because the patient had no severe symptoms and there were no signs of aneurysmic compression or a shunt, she was scheduled for elective aneurysmectomy.

The internal iliac arteries do not supply the inferior mesenteric artery

Ischemic colitis can be prevented after surgical treatment for abdominal aortic aneurysm by routine or elective reconstruction of the inferior mesenteric artery (IMA) when this vessel is patent. Revascularization of at least one internal iliac artery (IIA) has been recommended when the IMA is occluded, although the validity of such reconstruction has never been substantiated. This study investigated the role of the IIAs in IMA hemodynamics: Do IIAs contribute significant collateral blood supply to the IMA bed in the treatment of abdominal aortic aneurysms? Between July 1990 and June 1992, 100 patients underwent elective aneurysmectomy. At least one IIA was routinely reconstructed whenever possible; 24 patients had 27 IIA revascularizations. When the IMA was patent (49 cases), the residual pressure in the inferior mesenteric artery (IMA stump pressure) and the pressure in the radial artery were measured before and during temporary occlusion of the IIAs. The inferior mesenteric indices (P) defined by the ratio of the IMA stump pressure (PIMA) to the pressure in the radial artery (PRAD) were calculated before (P1) and during (P2) clamping of the IIAs. The mean value of P1 was 0.64±0.03 versus 0.63±0.03 for P2 (P=NS). Adjustment of variations in P1 as a function of P2 by linear regression gave a straight line with a slope of less than 1. The IMA stump pressure is independent of whether vascular continuity of the IIAs is restored or whether these vessels are excluded. The IIAs do not contribute significant collateral blood supply to the IMA bed in treatment of abdominal aortic aneurysms.

Survival Benefit of Endovascular Descending Thoracic Aortic Repair for the High-Risk Patient

Despite acceptable results reported with endovascular thoracic aortic repair (TEVAR), recent studies have questioned the merit of repair in asymptomatic patients considered high risk for open surgery. In this group, advanced age or comorbid conditions may reduce life expectancy, thus limiting the benefit of elective aneurysmectomy. This study was conducted to determine whether elective TEVAR improves survival for this cohort. Forty-six asymptomatic patients with descending thoracic aortic disease were considered high risk for open surgery for reasons of age of 80 years or older (47.8%) or comorbid conditions (84.8%), and were subsequently evaluated for elective TEVAR. Of these, 21 underwent TEVAR, while another 25 patients were excluded from TEVAR on the basis of unfavorable anatomy or refused intervention. The mean age of the cohort was 77.0 +/- 7.0 years (p = 0.9 between groups). Prevalent comorbid conditions were similar between groups, and included coronary artery disease (p = 1.0), chronic obstructive pulmonary disease (p = 1.0), and peripheral vascular disease (p = 0.23). Mean maximum aortic diameter was 6.0 +/- 1.4 cm (p = 0.54 between groups). Indications for intervention included fusiform aneurysm (65.2%) and pseudoaneurysm or penetrating ulcer (32.6%). No 30-day mortality was observed after TEVAR. All-cause mortality in the entire cohort was 50%. Median actual time to mortality was different between groups (control, 9.2 months versus TEVAR, 24.9 months; p = 0.01). Life-table analysis demonstrated improved survival for TEVAR at 24 months (p = 0.05). Although the overall prognosis for the asymptomatic patient with descending thoracic aortic disease at high risk for open surgery is poor, elective endovascular repair improves survival and should be considered a therapeutic option in this setting.

Synthetic Human α-Atrial Natriuretic Peptide Improves the Management of Postoperative Hypertension and Renal Dysfunction after the Repair of Abdominal Aortic Aneurysm

Delayed hypertension (HT) and renal dysfunction (RD) are observed after aortic operations accompanied by infra-renal aortic cross-clamping (AXC). Atrial natriuretic peptide (ANP) has effects on vasodilation and renal protection, and we examined the hypothesis that synthetic human alpha-ANP (hANP) improves the postoperative management for abdominal aortic aneurysm (AAA). Fifty patients undergoing elective aneurysmectomy for infrarenal-AAA between 1998 and 2001 (M:F = 43:7, mean age 70.5 +/- 7.7 years) were randomly allocated to one of 2 groups; Group H (n = 24) received hANP immediately after operation (initial dose: 0.025 microg/kg/min), and Group C (n = 26) served as a control group. All patients in Group C required nicardipine hydrochloride (4.41 +/- 1.68 mg/h) for prevention of postoperative HT, whereas only 6 patients in Group H required the increase in hANP dose due to HT (P < 0.0001). Maximum hANP dose was 0.035 +/- 0.019 microg/kg/min. Group H showed significantly smaller furosemide dosage in the initial 3 days (H vs. C; 9.2 +/- 11.0 vs. 58.8 +/- 41.5 mg, P < 0.0001), significantly lower peak-Crn (H vs. C; 1.16 +/- 0.53 vs. 2.58 +/- 1.42 mg/dL, P < 0.0001), and significantly lower plasma renin-activity (7.09 +/- 2.38 vs. 11.52 +/- 4.89 ng/mL/h, P = 0.0002) and aldosterone (51.6 +/- 12.7 vs. 81.2 +/- 34.2 pg/mL, P = 0.0002) on the first postoperative day than Group C did. These results imply that renin-angiotensin system may play a role in the incidence of postoperative HT and RD, and suggest that hANP infusion is a simple, reliable, and effective method for management during the immediate period after AAA operations.

Prognostic factors in the surgical treatment of ruptured abdominal aortic aneurysms.

Although the operative mortality following elective aneurysmectomy has achieved satisfactory results, that following surgery for ruptured abdominal aortic aneurysms (AAAs) remains high. The purpose of this study was to identify the factors affecting the mortality rate associated with the treatment of ruptured AAAs. Between 1978 and 1999, 33 patients underwent emergency surgery for a ruptured AAA. The operative mortality was 33.3% and in-hospital mortality was 6.0%. Hypotension, defined as a systolic blood pressure <80 mmHg, was seen in 19 patients at the time of presentation, 9 of whom underwent surgery in this state. In the remaining 10 patients, it was possible to increase the systolic blood pressure to > or =80 mmHg preoperatively. Of the 11 patients who died within 30 days of surgery, 9 had hypotension at the time of induction of anesthesia and only 2 had a systolic blood pressure of > or =80 mmHg. A satisfactory outcome was achieved in patients whose condition met the following criteria: a systolic blood pressure > or =80 mmHg at the time of operation, minimal aortic cross-clamping time, less blood loss and blood transfusions, and a shorter operation time to repair the ruptured AAA. Concomitant heart disease was also found to be an important prognostic factor.

25-Year Trends in Resection of Abdominal Aortic Aneurysms

An attempt was made to document trends that have occured over a 25-year period in clinical presentation, preoperative evaluation, operative management, and patient outcome in patients with an abdominal aortic aneurysm. The experience (574 aneurysmectomies) of one cardiovascular surgical group was analyzed by retrospective review of hospital and office records. Changes over time of patients' ages, aneurysm sizes and statuses, prior myocardial revascularization, operative mortality, and certain other parameters were evaluated. During the period of study, there was a significant decrease in aneurysm size, increase in patients' ages, and an increased incidence of previous coronary artery bypass. No ruptured aneurysm was < 5 cm in diameter. The incidence of rupture and the operative mortality in patients with a ruptured aneurysm did not change significantly. There was a significantly (p = 0.03) lower operative mortality of 0.4% in the latter half of the series for elective aneurysmectomy. Increased utilization of preoperative cardiologic evaluation, and myocardial revascularization, has been associated with a decreased operative mortality in patients undergoing elective aneurysmectomy even though the patients are now older and have more age-related comorbidities. Elective aneurysmectomy should be offered to most patients when an abdominal aortic aneurysm is > or =5 cm in diameter.

The internal iliac arteries do not supply the inferior mesenteric artery

Ischemic colitis can be prevented after surgical treatment for abdominal aortic aneurysm by routine or elective reconstruction of the inferior mesenteric artery (IMA) when this vessel is patent. Revascularization of at least one internal iliac artery (IIA) has been recommended when the IMA is occluded, although the validity of such reconstruction has never been substantiated. This study investigated the role of the IIAs in IMA hemodynamics: Do IIAs contribute significant collateral blood supply to the IMA bed in the treatment of abdominal aortic aneurysms? Between July 1990 and June 1992, 100 patients underwent elective aneurysmectomy. At least one IIA was routinely reconstructed whenever possible; 24 patients had 27 IIA revascularizations. When the IMA was patent (49 cases), the residual pressure in the inferior mesenteric artery (IMA stump pressure) and the pressure in the radial artery were measured before and during temporary occlusion of the IIAs. The inferior mesenteric indices (P) defined by the ratio of the IMA stump pressure (PIMA) to the pressure in the radial artery (PRAD) were calculated before (P1) and during (P2) clamping of the IIAs. The mean value of P1 was 0.64 ± 0.03 versus 0.63 ± 0.03 for P2 (P=NS). Adjustment of variations in P1 as a function of P2 by linear regression gave a straight line with a slope of less than 1. The IMA stump pressure is independent of whether vascular continuity of the IIAs is restored or whether these vessels are excluded. The IIAs do not contribute significant collateral blood supply to the IMA bed in treatment of abdominal aortic aneurysms.

The Internal Iliac Arteries Do Not Supply the Inferior Mesenteric Artery

Ischemic colitis can be prevented after surgical treatment for abdominal aortic aneurysm by routine or elective reconstruction of the inferior mesenteric artery (IMA) when this vessel is patent. Revascularization of at least one internal iliac artery (IIA) has been recommended when the IMA is occluded, although the validity of such reconstruction has never been substantiated. This study investigated the role of the IIAs in IMA hemodynamics: Do IIAs contribute significant collateral blood supply to the IMA bed in the treatment of abdominal aortic aneurysms? Between July 1990 and June 1992, 100 patients underwent elective aneurysmectomy. At least one IIA was routinely reconstructed whenever possible; 24 patients had 27 IIA revascularizations. When the IMA was patent (49 cases), the residual pressure in the inferior mesenteric artery (IMA stump pressure) and the pressure in the radial artery were measured before and during temporary occlusion of the IIAs. The inferior mesenteric indices (P) defined by the ratio of the IMA stump pressure (PIMA) to the pressure in the radial artery (PRAD) were calculated before (P1) and during (P2) clamping of the IIAs. The mean value of P1 was 0.64 ± 0.03 versus 0.63 ± 0.03 for P2 (P=NS). Adjustment of variations in P1 as a function of P2 by linear regression gave a straight line with a slope of less than 1. The IMA stump pressure is independent of whether vascular continuity of the IIAs is restored or whether these vessels are excluded. The IIAs do not contribute significant collateral blood supply to the IMA bed in treatment of abdominal aortic aneurysms.

A CASE REPORT OF ISOLATED INTERNAL ILIAC ARTERY ANEURYSM WITH URETERAL OBSTRUCTION

It seldome occurs that an isolated internal iliac artery aneurysm causes ureteral obstruction. This paper reports an operated case of isolated internal iliac artery aneurysm compressed and stretched the ureter causing hydronephrosis. A 67-year-old woman was uregently referred to the hospital because of colicky pain of the right lower abdomen. Right ureteral obstruction and hydronephrosis caused by the compression of the isolated right internal iliac artery aneurysm were revealed. Immediate percutaneous nephrostomy was followed by elective aneurysmectomy. Right ureter was adhered to the surface of the right internal iliac artery aneurysm (4cm in diamter) and was compressed and stretched. Ureterolysis and resection of the aneurysm were performed. She took an uneventful course with restored right ureteral flow. Although the aneurysm was atherosclerotic in origin, there supposed to be an inflammatory process between the ureter and the aneurysm. this is the fourth reported case in Japan about the internal iliac artery aneurysm associated with ureteral obstruction.

Rapid progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta

Objectives. This study was undertaken to evaluate the progression of aortic aneurysms after patch aortoplasty repair of coarctation of the aorta.Background. Previous studies demonstrated a 5% to 25% incidence rate of repair site aneurysm 3 to 18 years after patch aortoplasty repair of coarctation. The natural history of aneurysmal progression in this disease entity has not previously been examined.Methods. Twenty-nine patients were identified 5.6 ± 1 years (mean ± SE) postoperatively and classified into two groups: Group A, aneurysm (n = 7); Group B, no aneurysm (n = 22). The presence of an aneurysm was defined angiographically as a ratio of the repair site diameter to diaphragmatic aortic diameter (aortic ratio) ≥1.5. A 23% prevalence (7 of 29) of aortic aneurysm was identified. One patient in Group A underwent semiemergency aneurysmectomy and two patients in Group B were lost to follow-up. The remaining 26 patients were reevaluated 3 to 5 years later by clinical examination and chest radiography. Aortograms were performed in all patients with suspected aneurysm formation or progression.Results. Five of six patients in Group A demonstrated progressive aneurysmal dilation documented by an increase in aortic ratio from 1.64 ± 0.06 to 2.04 ± 0.2 (p = 0.03) and an increase in absolute aneurysm diameter from 2.5 ± 0.3 to 3.6 ± 0.5 cm (p = 0.006). Only 1 of 20 patients in Group B had evidence of new aneurysmal dilation (p < 0.05 vs. Group A). Four patients in Group A have undergone elective aneurysmectomy, with equal distribution of true and pseudoaneurysms by pathologic examination.Conclusions. Aortic aneurysm formation is common after patch aortoplasty repair of coarctation of the aorta. The majority of patients with an aortic ratio ≥1.5 will show significant progressive aneurysmal dilation within 3 to 5 years.

Influence of coronary artery disease on morbidity and mortality after abdominal aortic aneurysmectomy: A population-based study, 1971–1987

The prognostic importance of coronary artery disease at the time of elective abdominal aortic aneurysmectomy was evaluated among 131 residents of Olmsted County, Minnesota who underwent elective aneurysmectomy from 1971 to 1987 and were followed up to 1988 for death and cardiac events (cardiac death, myocardial infarction, coronary bypass surgery and angioplasty). Before aneurysmectomy, 75 patients (Group 1) had no clinically recognized coronary disease, 47 patients (Group 2) had suspected or overt uncorrected coronary artery disease (history of prior myocardial infarction, angina or a positive stress test) and 9 patients (Group 3) had undergone coronary artery bypass grafting or coronary angioplasty.The 30 day operative mortality rate was 3% (2 of 75) in Group 1 and 9% (4 of 47) in Group 2 (p = 0.15). According to Kaplan-Meier analysis, estimated survival 8 years after aneurysmectomy was 59% (expected rate 68%, p = 0.29) in Group 1 versus 34% (expected rate 61%, p = 0.01) in Group 2. The cumulative incidence rate of cardiac events at 8 years was 15% and 61%, respectively, for patients without and with suspected/overt coronary artery disease (p < 0.01). Using multivariable proportional hazards analysis, uncorrected coronary artery disease was associated with a nearly twofold increased risk of death (hazard ratio 1.79, 95% confidence interval 1.06 to 3.00) and a fourfold increased risk of cardiac events (hazard ratio 3.71, 95% confidence interval 1.79 to 7.69).These population-based data support an aggressive lifelong approach to the management of coronary artery disease in patients undergoing abdominal aortic aneurysmectomy.

Selective Screening for Abdominal Aortic Aneurysms With Physical Examination and Ultrasound

To the Editor. —4In their assessment of the utility of selective screening for abdominal aortic aneurysms (AAA), Lederle et al 1 have presented a case for selective AAA screening by drawing tenuous support from referral center—based studies of AAA prognosis. First, the authors cite a referral center study arguing that successful surgery, the survival rate approaches that of the general It seems unlikely that patients with an arteriosclerotic process such as AAA, which is linked to other processes associated with impaired survival such as hypertension and coronary artery disease, will have a survival following aneurysmectomy similar to that of the general population. In this regard, of the 131 Olmsted County, Minnesota, residents who underwent elective aneurysmectomy in the 1971-1987 time period, 5-year survival was only 61% (expected survival for 1980 Minnesota whites of the same age and gender distribution was 79%) and 10-year survival was 24% (expected,

Abdominal aortic aneurysm in elderly patients: Selective management based on clinical status and aneurysmal expansion rate

The records of 125 patients 75 years of age or older with a diagnosis of unruptured abdominal aortic aneurysm were reviewed. Operative mortality was 4.3 percent in 69 patients considered at low risk and 39.8 percent in 13 patients at high risk who underwent aneurysmectomy shortly after diagnosis. Forty-three patients with an asymptomatic abdominal aortic aneurysm initially measuring 3.5 to 6 cm did not undergo aneurysmal resection and were followed for 6 to 72 months (mean 24 months) with serial echography. The mean enlargement rate was 0.48 cm/year. In the 43 patients, resection of the abdominal aortic aneurysm was performed for aneurysmal expansion to greater than 6 cm, development of symptoms, or a sudden change in aneurysmal diameter. Two patients were lost to follow-up, 21 underwent elective resection, aneurysms ruptured in 2, 9 died from other causes, and 9 were alive and asymptomatic at last follow-up. An aggressive surgical approach seems appropriate, even in the asymptomatic elderly patient with a small aneurysm of 4.5 to 6 cm. Serial echographic measurement appears useful in determining which patients with a very small aneurysm of less than 4.5 cm or who are considered to be high risk surgical candidates require elective aneurysmectomy.

Left ventricular function after elective aneurysmectomy.

Employing rest and exercise first-pass radionuclide angiography before and 3 months after surgery, we studied patients with hemodynamically stable left ventricular aneurysm (LVA) undergoing both coronary artery bypass surgery to relieve angina pectoris and elective aneurysmectomy. There were 15 patients, 14 men and 1 woman with a mean age of 54 +/- 7 years. All patients had anterior and/or apical LVA. After surgery the postexercise mean left ventricular ejection fraction (LVEF) for the whole group improved significantly (p less than 0.004) compared with the preoperative value, but the resting LVEF did not change. The duration of exercise improved (p less than 0.01) after surgery, but not the double product. However, based upon the preoperative LVEF response to exercise, two groups were seen: Group A (n = 5) had greater than or equal to 5% increase in their LVEF with exercise versus Group B (n = 10), who had less than 5% increase or a decrease in their LVEF. Postoperatively, Group A decreased their LVEF with exercise and failed to improve exercise capacity or double product. Postoperatively, Group B increased the LVEF by greater than or equal to 5% as well as increasing exercise capacity (p less than 0.01), and double product (p less than 0.03). Group A had lower preoperative LVEF than Group B (p less than 0.01) and larger LVA. Patients with hemodynamically stable LVA who require coronary artery bypass surgery for angina should not have aneurysmectomy. The presence of hemodynamically stable LVA is not a contraindication to deriving benefit from myocardial revascularization.

Determinants of failure in the treatment of ruptured abdominal aortic aneurysm.

One must identify those fatal errors in the treatment of patients with ruptured abdominal aortic aneurysms (AAAs) to improve future treatment and reduce mortality. Our vascular registry identified 29 patients with ruptured AAAs who died following admission to the UCLA Hospital, Los Angeles, and the Sepulveda (Calif) Veterans Administration Hospital between 1971 and 1981. Review of the records identified four categories of error that contributed to death. These included failure to proceed with elective aneurysmectomy in 12 patients with known AAAs, error in the diagnosis of aortic rupture that led to delay in getting nine patients to the operating room, intraoperative technical error that produced venous injury in eight patients, and undue delay in anesthetic induction in four patients. Following the outline of a careful treatment approach should further reduce the mortality in the treatment of patients with ruptured AAAs.

Surgery for abdominal aortic aneurysms: With special reference to high‐risk patients

Between 1973 and 1980, 150 patients with an abdominal aneurysm underwent aneurysmectomy at St Vincent's Hospital, Sydney. Of these, 52 were high-risk patients with significant medical disease, including myocardial ischaemia, angina pectoris, obstructive airways disease, portal hypertension, and end-stage renal disease. The operative mortality for the 150 patients was 4.6%; it was 9.6% in the high-risk group. The predicted overall survival rate at seven years, with a minimum of two years' follow-up, was 55%, which compares favourably with that reported in other series, particularly in view of the advanced age of most of the patients--43% were in the eighth decade of their lives. The predicted survival rate of 26% for the high-risk group is nearly four times the survival rate predicted by Szilagyi for patients with untreated aneurysms. This increased life expectancy justifies the adoption of the widest possible selection criteria for elective aneurysmectomy.

Management of ventricular aneurysms following myocardial infarction.

AbstractAneurysmectomy is the most effective form of therapy for patients with symptomatic aneurysms of the left ventricle following myocardial infarction. Operation should not be undertaken less than 2 months following myocardial infarction unless there is severe hemodynamic derangement. Circulatory assist devices, such as the intra‐aortic balloon pump, have been of particular help in this group of severely ill patients. Results of elective aneurysmectomy performed 2 months or more following myocardial infarction are quite good, with the long‐term outlook for the patient generally depending on the function of the uninvolved myocardium and the status of the remaining coronary circulation. When ventricular irritability results in life‐threatening arrhythmia, aneurysmectomy must often be performed. The results in this group of patients have been somewhat disappointing, but newer techniques of localizing irritable foci may result in the development of more effective surgical procedures.

Ultrasound Aortic Measurement and Elective Aneurysmectomy

In a study of 53 cases, aneurysm size was measured with the use of preoperative physical examination, lateral abdominal roentgenography, and B-mode aortic ultrasonography for comparison with direct intraoperative measurement during aneurysmectomy. Mean aneurysm diameter on the basis of physical examination overestimated aortic size by 1 cm; physical examination measurement was within 0.5 cm of true aortic size in 38% of patients and within 1 cm in 58% of patients. The lateral roentgenogram also overestimated mean aortic diameter by 1 cm and was within 0.5 cm of true aortic size in 44% of patients and within 1 cm in 72% of patients. Measurement using B-mode aortic ultrasonography closely approximated intraoperative aneurysm measurement. Measurement was identical in 34% of patients and was within 0.5 cm and 1 cm in 75% and 92% of patients, respectively.

Ultrasound aortic measurement and elective aneurysmectomy

Ultrasound aortic measurement and elective aneurysmectomy

Division of the left renal vein: a safe surgical adjunct.

Ten patients have undergone surgical division of the left renal vein (LRV) during operations on the abdominal aorta. Nine were elective procedures performed during the resection of a complicated abdominal aortic aneurysm (six patients) or treatment of complete infrarenal aortic occlusion (three patients). The first patient in this series underwent emergency LRV ligation at the renal hilum for the control of hemorrhage incurred during an elective aneurysmectomy. This patient survived postoperative renal failure and myocardial infarction, but died 21 months later from another myocardial infarction. At the time of death, he had moderate renal insufficiency. None of the remaining nine patients undergoing elective LRV division experienced any apparent renal dysfunction, as measured by urine sediment, serum creatinine, blood urea nitrogen, and intravenous pyelography. Although not recommended as a routine maneuver, division of the LRV is advocated as a safe adjunct for surgical exposure in difficult aortic procedures.