Patients Underwent Emergency Repair Research Articles

Emergency thoracoabdominal aortic aneurysm repair: Clinical outcome

Objective: Emergency repair of thoracoabdominal aortic aneurysm remains a formidable operation with high morbidity and mortality. Although advanced surgical and perioperative care techniques have reduced the risks in elective repair of these aneurysms, the mortality rate has remained high when emergency surgery is performed. We have evaluated the outcome of patients undergoing emergency repair of thoracoabdominal aortic aneurysm. Methods: Of 47 consecutive patients with thoracoabdominal aortic aneurysm observed from January 1993 to September 1998, 19 required an emergency operation. Twelve had a ruptured aneurysm and 7 an acute dissection. Twelve type I, 3 type II, 1 type III, and 3 type IV thoracoabdominal aortic aneurysms (Crawford’s classification) were diagnosed. All patients were operated on via a thoracolaparotomy with partial femoral-femoral extracorporeal circulation. The cerebrospinal fluid pressure was monitored, and the aorta was replaced with a vascular graft. Patent intercostal arteries were reimplanted when feasible. Results: The early (30-day) mortality was 42.1%; there were 2 late deaths. Complications in the 11 surviving patients are summarized as follows: paraplegia/paraparesis, 3 cases; renal, 4 cases; pulmonary, 4 cases; cardiac, 1 case; cerebrovascular, 1 case; and reexploration for bleeding, 1 case. Hemodialysis and aortic dissection were predictive factors of hospital mortality. Conclusions: Our surgical experience in emergency repair of thoracoabdominal aortic aneurysm must be considered encouraging in terms of late outcome despite the in-hospital mortality of 42.1% and serious postoperative complications in the surviving patients. Moreover, our results show that acute aortic dissection and the need for hemodialysis are predictive factors for mortality. (J Thorac Cardiovasc Surg 1999;118:477-82)

Posterior elbow dislocation with associated vascular injury after blunt trauma.

Injury of the brachial artery is a rare (5-13%) but serious complication after closed elbow dislocation without associated fractures. Retrospective analysis of long-term results (mean, 4.1 years) in four patients. All patients underwent emergency repair of the arterial injury within 2.5 hours. In three patients, a reversed saphenous vein graft was used; in one patient the artery was sutured. This latter patient needed another operation with interposition of a reversed saphenous graft, because the primary anastomosis occluded. The capsule and the collateral ligaments were immediately reconstructed in three patients because of instability. No patient showed claudication of the arm. In three patients, a sensory deficiency of median nerve persisted. Average range of motion was 128 degrees of flexion (120-135 degrees) and an extension deficit of 7.5 degrees (15-0 degrees). Primary repair of vascular injury after closed elbow dislocation with vein graft and immediate reconstruction of ligamentous injuries results in good long-term functional outcome.

Aortobronchial fistula as a late complication of posttraumatic chronic aortic aneurysm.

A 23-year-old man sustained blunt thoracic trauma during a hang gliding accident in 1985. Initial plain films of the chest and thoracic CT scans did not disclose evidence of a thoracic aortic aneurysm, dissection, or mediastinal hematoma. Abdominal CT showed a splenic rupture, for which splenectomy was done immediately. Three years later, a routine chest radiograph showed aneurysmal dilatation of the thoracic aorta. Contrast-enhanced CT scans of the chest confirmed the diagnosis of a marginally calcified 3.5 cm (diameter) x 4.5 cm (length) thoracic aortic aneurysm adjacentto the origin of the left subclavian artery (Fig. 1A). The patient refused to undergo surgical treatment, despite counseling regarding the increased mortality from delay oftreatrnent. Follow-up CT and MR imaging were done at 6-month intervals to monitor the progression of disease. The patient was a recreational bodybuilder, and clinical history revealed anabolic drug abuse during the past 5 years. Eight years after the initial injury, the patient had massive hemoptysis during his daily workout. The patient was admitted to the intensive care unit with hypotension, dyspnea, and ventricular tachycardia. Contrast-enhanced thoracic CT revealed a 5.5-cm (diameter) aneurysm of the thoracic descending aorta near the ligamenturn arteriosurn. The aneurysm was marginally calcified and partially thrombosed, such that the caudal portion of thrombus resulted in partial obstruction of the left main bronchus (Fig. 1 B). Soft tissue strongly suggestive of clot was identified within the bronchial lumen (Fig. 1C), and air trapping resulted in hyperinflation of the left lung. Aortobronchial fistula was diagnosed. The patient underwent emergency repair of the aneurysm with placement of a Dacron graft. At operation, a fistulous connection between the aneurysm and the left main bronchus was confirmed. lntraoperative bronchoscopy confirmed the presence of a clot and bronchomalacia, treated conservatively because of the patient’s poor condition. Despite thorough inflation and ventilation of the left lung, the postoperative course was complicated by left hemopneumothorax, hernomediastinum, and multiresistant Streptococcus faecails pneumonia, requiring tracheotomy. On the sixth postoperative day, the patient had a cardiac arrest and was successfully resuscitated. CT 6 weeks later revealed a perfused aortic lumen of 2.5 cm with marginal thrombus, persistent compression of the left main bronchus with atelectasis of the left lower lobe, and a left pleural effusion. Despite the stormy course, the patient recovered and only had damage of the left recurrent laryngeal nerve, presumably from cornpression due to the aneurysm itself preoperatively, as the patient had complained of hoarseness earlier.

Composite graft repair of Marfan aneurysm of the ascending aorta: Results in 100 patients

One hundred consecutive patients with the Marfan syndrome underwent composite graft repair of an ascending aortic aneurysm between September 1976 and June 1989. Twenty-two patients had ascending aortic dissection at the time of composite graft repair; 18 patients also had a mitral valve procedure. There were no hospital deaths among 92 patients undergoing elective repair. One of 8 patients undergoing emergency repair of a ruptured aneurysm died in the operating room. The overall hospital mortality rate was 1%. There have been ten late deaths among the 99 hospital survivors (10.1%). Five deaths occurred among the first 11 patients in this series and five occurred among the last 88 patients (5.7%). Three late deaths resulted from composite graft endocarditis; 3 other patients with endocarditis are alive after aortic root replacement with cryopreserved homografts. Late coronary dehiscence caused death in 1 patient and was successfully repaired in a second. Actuarial survival for the 100 patients was 92.6% at 5 years and 75.8% at 10 years. Currently, composite graft repair of Marfan aneurysms of the ascending aorta can be performed with low hospital and late mortality. Marfan aneurysms with a diameter of 6 cm or greater should be repaired with the Bentall composite graft procedure, even if the patient is asymptomatic.