Management Of Aortic Aneurysms Research Articles

Management of aortic aneurysm infected with Salmonella.

This study reviewed the clinical outcomes of patients with an aortic aneurysm infected with Salmonella treated by a single centre over 6 years. Data were collected by a retrospective case-note review. Between September 1995 and December 2001, 121 patients with non-typhoid Salmonella bacteraemia were treated, of whom 24 patients had an aortic aneurysm infected with Salmonella. Ten had a suprarenal and 14 an infrarenal aortic infection. The most common responsible pathogen was group C Salmonella (12 patients). All of the 20 patients who had combined medical and surgical therapy survived, whereas two of four who had medical therapy alone died. There were two late deaths during a mean follow-up of 23 (range 3-63) months. The incidence of aortic infection in patients with non-typhoid Salmonella bacteraemia was high in Taiwan. Timely surgical intervention and prolonged intravenous antibiotic therapy resulted in excellent outcomes.

Detection and Management of Small Aortic Aneurysms

Abdominal aortic aneurysms arise through a chronic degenerative process that produces localized weakening of the aortic wall. They have a natural history characterized by progressive expansion and eventual rupture.1 Population-based screening studies reveal that up to 9 percent of persons over 65 years of age have an unsuspected and asymptomatic abdominal aortic aneurysm, and it is estimated that ruptured abdominal aortic aneurysms cause at least 15,000 deaths each year in the United States.2 The principal goal of treatment for these aneurysms is to extend life by preventing the rupture of the aneurysm. There is long-standing evidence that elective surgical repair . . .

Endovascular exclusion of abdominal aortic pathology in patients with concomitant malignancy.

The advent of endoluminal aortic repair has gained increasing popularity as an alternative to traditional open surgery in the setting of multiple comorbid disease states. This study analyzes a single center experience of excluding aortic disease in patients with concomitant malignancy. As part of a Federal Drug Administration FDA-approved trial, 318 patients underwent aortic stent-graft repair between June 1996 and February 2001. During that period five patients with advanced-stage neoplasia were treated. Endovascular management of symptomatic abdominal aortic aneurysms (AAA) with a mean diameter of 7.8 cm (range, 6-10 cm), was performed in four patients. In the fifth patient, a custom-made aortic prosthesis was utilized to exclude a paraanastamotic abdominal aneurysm (PAAA) from a previous open AAA repair. Malignancies included esophageal, lung, renal, prostate, and urinary bladder cancers. A mean follow-up of 10.1 months was available. Successful endoluminal repair was accomplished in all five patients with minimal in-hospital morbidity. Mean length of stay was 3.4 days. There were no device-related mortalities and no persistent endoleaks detected for the duration of follow-up. Aneurysm sac enlargement was not seen in any of the patients and complete resolution of the PAAA was noted at one year. Exclusion of AAA and other aortic pathology in patients with an associated malignancy can be performed with a relatively low procedure-related morbidity and mortality. In this population, stent-graft repair remains an individualized option with a multidisciplinary team necessary to explore this therapeutic approach.

Management of right-sided aortic arch aneurysms

Specific technical problems are associated with the management of patients who have either of the two types of right-sided arches and aneurysms of the aortic arch and descending aorta. Two different approaches to addressing these problems, depending on the predominant congenital vascular anatomy, are presented.

Aortic and arterial aneurysms in behçet disease: management with stent-grafts--initial experience.

To assess the application of stent-grafts in the management of aortic and arterial aneurysms in patients with Behçet disease. Nine aneurysms in seven patients were managed with various types of stent-grafts. Diagnoses were based on clinical findings. The aortic aneurysms (n = 3) were thoracic (n = 1), suprarenal (n = 1), or infrarenal (n = 1). The arterial aneurysms (n = 6) were in the right and left subclavian (n = 2), right common carotid (n = 2), right brachiocephalic (n = 1), or left common iliac arteries (n = 1). A tandem connection of Gianturco stent covered with polytetrafluorethylene was placed in three aneurysms, and a balloon-expandable stent was placed in six. The stent-graft was successfully placed in all patients. Immediate follow-up angiography revealed complete exclusion of the aneurysm in all cases. Follow-up computed tomography performed 3 days to 2 weeks later revealed complete exclusion and thrombosis of the aneurysm and patency of the stent-graft in six patients. In one patient, total occlusion of the artery with a stent occurred due to flow disturbance caused by double lesions. During follow-up (range, 6-59 months; mean, 28 months), the aneurysm resolved and completely regressed in four patients. A recurrent aneurysm at the distal margin of previously inserted stent-graft was successfully managed with an additional stent-graft. The findings in this initial experience suggest that stent-graft insertion may be a safe and effective alternative to surgical treatment of aortic and arterial aneurysms in patients with Behçet disease.

EVT endovascular graft for abdominal aortic aneurysm.

A variety of prostheses are now available for the endovascular treatment of abdominal aortic aneurysm (AAA). Significant advantages of the EVT device are its unibody design, secure hook attachment system and graft fabric approximating that used in conventional surgery. Implantation of the EVT device was attempted in 60 patients who were studied prospectively with an analysis of subsequent problems encountered. Conversion to open repair was required in four cases (6.7%). There were nine tube grafts inserted, 13 aorto-unilateral iliac with crossover grafts and 34 aorto-bi-iliac grafts. There was one death (mortality 1.7%). Endoleaks were identified in eight patients (14%), none of which were proximal; three sealed spontaneously, two were treated with coil embolization, two are being observed and one patient had an iliac attachment converted to an open anastomosis. Access vessel problems were seen in 21 patients (35%); two-thirds were corrected at the time of initial surgery. Seven patients (12%) had primary graft limb problems identified and treated before leaving the operating room. Nine patients (16%) developed secondary graft limb problems, which were diagnosed and treated after the initial surgery. Endovascular treatment was used in eight and was successful in six with surgical revision required in two. On review of these cases to assess if the problem could have been predicted at the time of initial surgery, it was felt that more aggressive treatment of intraoperatively diagnosed graft limb stenoses, even though considered mild, may have prevented 50% of subsequent secondary graft limb occlusions. Although the EVT device has significant advantages in the endovascular management of aortic aneurysm, potential graft limb problems need to be actively identified with the majority able to be successfully managed by supplementary endovascular techniques.

Management of aortic aneurysm in the presence of a horseshoe kidney.

The coexistence of an aortic aneurysm and a horseshoe kidney poses a technical challenge to the vascular surgeon at the time of aneurysm repair. The aim of this review is to develop a guideline for the treatment of patients with this dual pathology. A literature review combined with local experience provided a total of 176 cases. These were divided into two groups: asymptomatic aneurysms (134) and ruptured aneurysms (42), both in combination with a horseshoe kidney. Six types of operative approach were described: transperitoneal approach with or without separation of the renal isthmus, retroperitoneal approach, placement of a stent-graft, aneurysmal wrap and exploration without exclusion of the aneurysm. Diagnosis of the horseshoe kidney was made before operation in 81 per cent of patients in the asymptomatic group, and in 55 per cent (23 of 42) in the ruptured group. Computed tomography proved to be the most reliable diagnostic procedure. Occlusion of renal arteries originating from the aneurysm was reported in 51 per cent in the asymptomatic group, and in 74 per cent (23 of 31) in the ruptured group. The preferred surgical options for asymptomatic patients with an aortic aneurysm and a horseshoe kidney are the placement of a stent-graft or a retroperitoneal approach; both avoid many of the technical difficulties related to the presence of the horseshoe kidney. The approach of choice for a ruptured aneurysm is transperitoneal. Separation of the renal isthmus should be avoided.

Challenges in Stent Grafting: Dealing with Difficult Neck and Iliac Artery Anatomy

Development of stent-graft endovascular exclusion has forever changed the management of aortic aneurysms. This new modality is most advantageous for AAA patients who are at high risk for standard open repair. They, in turn, are more likely to present with challenging neck and iliac artery anatomy that may increase the likelihood of failure, and even preclude endoluminal therapy altogether. A complete understanding of critical anatomical issues and available troubleshooting adjunctive techniques is paramount if we are to expand applicability of stent-graft technology to increasing numbers of difficult patients with large aneurysms.

Population screening reduces mortality rate from aortic aneurysm in men.

Rupture of an unsuspected abdominal aortic aneurysm is a major cause of death in men over the age of 65 years. A significant reduction in deaths is likely to result only from higher rates of detection and increased numbers of elective aneurysm repairs. Screening of men reaching the age of 65 years has been taking place in the county of Gloucestershire, UK since 1990 and the aim of this study was to investigate any change in the mortality rate from aortic aneurysm in the screened portion of the population. Total number of deaths from all aortic aneurysm-related causes in the county's population was calculated from hospital and post-mortem records, together with computerized death certificate records, for the years 1994-1998. The overall number of aneurysm-related deaths in men aged 65-73 years, who have been progressively influenced by the screening programme, was compared with that for men of all other ages. The total number of aneurysm-related deaths in men aged 65-73 years decreased progressively year by year between 1994 and 1998; this reduction is highly statistically significant (P < 0. 001). No such change was observed in the unscreened part of the population. Screening for asymptomatic abdominal aortic aneurysm results in a significant reduction in numbers of deaths from all aneurysm-related causes in the screened portion of the male population.

Surgical management of atherosclerotic aortic arch aneurysms using selective cerebral perfusion: 7-year experience in 52 patients.

Patients with atherosclerotic aortic arch aneurysms are at greater risk for brain complication. We report our techniques and results of operation using selective cerebral perfusion. We retrospectively analyzed 52 consecutive patients with atherosclerotic aortic arch aneurysms (mean age, 70 years, range, 53-86 years), who underwent operation between April 1992 and March 1999. The operation was non-elective in 11 patients (21.1%). Concomitant operations included eight coronary artery bypass grafting and one aortic valve replacement. Simultaneous distal aortic reconstruction was performed in three patients. The operation was performed through median sternotomy. To avoid brain embolism, total arch replacement with a branched prosthesis was performed in 48 patients, in an attempt to exclude affected segments of aorta. In addition, retrograde femoral artery perfusion was avoided and cerebral circulation was isolated before aortic manipulation. To achieve even blood flow distribution, we employed perfusion and continuous pressure monitoring of all the three arch vessels. The perfusion rate was 12+/-2 ml/kg per min and the pressure was kept around 50 mmHg. Deep hypothermic arrest of the lower torso (bladder temperature, 22 degrees C) was used during open distal aortic anastomosis. The hospital mortality rate was 11.5% (six of 52), and 7.3% (three of 41) for elective cases. Only one patient (1. 9%) developed permanent focal neurological deficit. Six other patients showed temporary brain complications, which was global (delirium) in three and focal in three others. Selective cerebral perfusion is a safe brain protection method, and our strategy seems effective for embolic stroke prevention.

Mortality and paraplegia after thoracoabdominal aortic aneurysm repair: a risk factor analysis

Background. Recent recommendations regarding thoracoabdominal aortic aneurysm (TAAA) management have emphasized individualized treatment based on balancing a patient’s calculated risk of rupture with their anticipated risk of postoperative death or paraplegia. The purpose of this study was to enhance this risk-benefit decision by providing contemporary results and determining which preoperative risk factors currently predict mortality and paraplegia after TAAA surgery.Methods. Risk factor analyses based on data regarding 1,220 consecutive patients undergoing TAAA repair from 1986 through 1998 were performed using multiple logistic regression with step-wise model selection.Results. The 30-day mortality rate was 4.8% (58 of 1,220) and the incidence of paraplegia was 4.6% (56 of 1,206). For elective cases, predictors of operative mortality included renal insufficiency (p = 0.0001), increasing age (p = 0.0005), symptomatic aneurysms (p = 0.0059), and extent II aneurysms (p = 0.0054). Extent II aneurysms (p = 0.0023) and diabetes (p = 0.0402) were predictors of paraplegia.Conclusions. These risk models may assist in decisions regarding elective TAAA operations. For patients who are acceptable candidates, contemporary surgical management provides favorable results.

Advances in the Management of Aortic Aneurysms

When is elective surgery warranted for patients with asymptomatic abdominal aortic aneurysms (AAAs)? The U.K. Small Aneurysm Trial was the first large

Thoracoabdominal Aortic Aneurysm Repair: How I do it

There remains no consensus on the operative management of Thoracoabdominal aortic aneurysm (TAA). Our approach emphasizes operative expediency and simplicity (without circulatory assist techniques), avoiding anticoagulation and systemic hypothermia. The technique involves a fundamental clamp/sew method with specific adjuncts directed against the principle complications: epidural cooling (introduced in 1993) for spinal cord protection, regional renal hypothermia, and in-line mesenteric shunting to minimize visceral ischemia. In a cohort of over 200 TAA patients (50% Types 1 &amp; 11) treated during the past decade perioperative mortality has been 8% and paraparesis/paraplegia occured in 7%. These figures are halved for patients treated in elective circumstances.

Prevalence of aortic aneurysm in men with a history of inguinal hernia repair.

Population-based screening for abdominal aortic aneurysm (AAA) is still a subject of debate. This study examined whether subjects with a history of inguinal hernia were at increased risk sufficient to justify screening. The prevalence of AAA was documented in 156 men aged 55 years and older, discharged after inguinal hernia surgery, and compared with the prevalence in 1771 men without a history of inguinal hernia who were participating in a screening survey for AAA. The influence of age and smoking status was assessed. The prevalence of AAA in men with a history of inguinal hernia was 12.2 (95 per cent confidence interval (c.i.) 7.0-17.4) per cent and 3.7 (95 per cent c.i. 2.8-4.6) per cent in those without such a history; prevalence ratio 3.3 (95 per cent c.i. 2.0-5.3). In current smokers the prevalence of abdominal aneurysm was 4.2 (95 per cent c.i. 2.1-8.2) times higher in those with compared with those without a history of inguinal hernia. In non-smokers the prevalence ratio was 1.9 (95 per cent c.i. 0.5-7.0). Men with a history of inguinal hernia are at increased risk of AAA, most notably if they are cigarette smokers. Ultrasonographic screening could be considered before operation for inguinal hernia.

Thoracoabdominal aortic aneurysm repair: how I do it

There remains no consensus on the operative management of Thoracoabdominal aortic aneurysm (TAA). Our approach emphasizes operative expediency and simplicity (without circulatory assist techniques), avoiding anticoagulation and systemic hypothermia. The technique involves a fundamental clamp/sew method with specific adjuncts directed against the principle complications: epidural cooling (introduced in 1993) for spinal cord protection, regional renal hypothermia, and in-line mesenteric shunting to minimize visceral ischemia. In a cohort of over 200 TAA patients (50% Types I & II) treated during the past decade perioperative mortality has been 8% and paraparesis/paraplegia occured in 7%. These figures are halved for patients treated in elective circumstances.

Surgical Treatment of Siblings with Marfan Syndrome

Rupture of an ascending aortic aneurysm is the most common cause of death in patients with Marfan syndrome, while type-A aortic dissection is the second most common fatal lesion. The aortic root dimension and the rate at which it increases are the best indications for surgical treatment. We regard aortic enlargement to 5.5 cm as the upper limit of safety and we are inclined to advocate surgery at an earlier stage in high-risk families. We report our results of the surgical management of aortic aneurysm in the two siblings; a third sibling is currently being followed medically.

Retrograde Cerebral Perfusion for Aortic Arch Surgery in Octogenarians

We reviewed our surgical management of aortic arch aneurysms in 11 octogenarians. Seven operations (63.6%) were performed on an emergency basis for ruptured atherosclerotic aneurysm in 5 cases and for acute dissection in 2. Deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis were employed routinely for brain protection during aortic arch replacement. There was one intraoperative death due to hemorrhage. One survivor died of bowel necrosis 47 days postoperatively and another suffered sudden death 5 months postoperatively. Both of these patients had been treated for a ruptured aneurysm and had suffered from postoperative neurological deficit. There were 2 late deaths due to unrelated events: subarachnoid hemorrhage and hepatic failure. The surgical outcomes were considered satisfactory, except in emergency cases of ruptured aneurysm where there was a high mortality and neurological morbidity. It is recommended that arch aneurysms at risk of rupture should be repaired electively before rupture, even in octogenarians, using deep-hypothermic circulatory arrest, continuous retrograde cerebral perfusion, and open aortic anastomosis.

Facts, at last, on management of small infrarenal aortic aneurysms

Facts, at last, on management of small infrarenal aortic aneurysms

Acute traumatic rupture of the thoracic aorta: Delayed treatment with endoluminal covered stent. A report of two cases

Acute traumatic rupture of the thoracic aorta: Delayed treatment with endoluminal covered stent. A report of two cases

Effect of panel composition on physician ratings of appropriateness of abdominal aortic aneurysm surgery: elucidating differences between multispecialty panel results and specialty society recommendations

Objective: to investigate how the composition of multispecialty physician panels is associated with both the summary ratings assigned by such panels and the agreement of such panels with the recommendations of specialty societies. Data sources/study setting: we examined the final ratings assigned by a nine-member multispecialty RAND Corporation physician panel regarding indications for abdominal aortic aneurysm surgery and the recommendations of a specialty society representing vascular surgeons who perform the same surgery. Study design: the panel was retrospectively divided into two sub-panels, one composed of the three vascular surgeons on the panel and the other composed of the six remaining physicians. We analyzed the two sub-panels' rating patterns with respect to each other and with respect to concurrent guidelines generated by the Joint Council of the Society of Vascular Surgery and the North American Chapter of the International Society for Cardiovascular Surgery. Principal findings: of the 782 indications considered by the panel for appropriateness, the vascular surgeons had an average of mean ratings for appropriateness of 5.1, significantly higher than the 4.5 average of the other physicians. Across the 221 indications considered by the panel for necessity, the vascular surgeons had an average of mean necessity ratings of 6.8, significantly higher than the 5.8 average of the other physicians. The vascular surgeons' rankings of agreement with the guidelines of the Joint Council were significantly higher than those of the physician panelists from other specialties. Conclusions: statements of clinical appropriateness and necessity produced by summarizing ratings assigned to indications by expert panel members may disguise marked underlying disagreements among well-defined groups of practitioners within these panels. In the case of abdominal aortic aneurysm management, these disagreements within the RAND panel explain the marked discrepancy between the RAND multidisciplinary panel ratings and the recommendations issued by vascular surgeon professional societies.