Aortic Aneurysm Replacement Research Articles

Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative?

Aortic aneurysm thrombosis with extra-anatomic bypass has been proposed for persons with infrarenal aortic aneurysms who are “too debilitated” to undergo standard aortic reconstruction. Thirteen patients (mean age, 75 years) were selected between January 1980 and June 1984 for axillobifemoral bypass with bilateral iliac artery occlusion to manage their infrarenal aortic aneurysms (mean size, 6.3 cm; range, 4.9 to 7.5 cm). Preoperative risk factors were cardiac (angina, compensated congestive heart failure, and significant preoperative arrhythmias), 100% of patients; pulmonary (symptomatic chronic obstructive pulmonary disease with a 1-second forced expiratory volume less than 50% of the predicted value), 46% of patients; renal (creatinine value greater than or equal to 2.0 mg/dl or creatinine clearance less than 20 ml/min), 46% of patients; or nutritional (albumin less than or equal to 3.5 gm/dl or body weight less than 90% of ideal), 46%. Ninety-two percent of the patients had two risk factors whereas 46% had three or more risk factors. The operative mortality rate was 31%; three patients died of multisystem organ failure and another died of thrombin-induced consumptive coagulopathy and hemorrhage. (Our operative mortality rate for conventional graft replacement of abdominal aortic aneurysms is less than 3%.) Morbidity in persons surviving at least 1 month included thrombosis of the extra-anatomic bypass graft requiring thrombectomy (three patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and bilateral above-knee amputations (one patient). Thrombosis of the aneurysm was not achieved in two patients despite use of fluoroscopically controlled embolization of runoff vessels. Sixty-nine percent of patients survived 1 month, 54% survived for 2 months, and 31% were alive at 6 months after operation. One woman died 6 months postoperatively when her infrarenal aneurysm ruptured. Another person survived the emergent repair of her ruptured aneurysm 3 months after the “thrombosis” and is alive and well 1 year after the operation. One patient died 15 months after operation of an unknown cause. Each person whose aneurysm ruptured had radiographic confirmation of thrombosis of the aneurysm. When compared with the morbidity and mortality associated with untreated abdominal aortic aneurysms, the excessive morbidity and mortality that occurred in these high-risk patients indicated that aneurysm thrombosis with bypass was not an acceptable technique of management.

Is thrombosis of the infrarenal abdominal aortic aneurysm an acceptable alternative?

Aortic aneurysm thrombosis with extra-anatomic bypass has been proposed for persons with infrarenal aortic aneurysms who are "too debilitated" to undergo standard aortic reconstruction. Thirteen patients (mean age, 75 years) were selected between January 1980 and June 1984 for axillobifemoral bypass with bilateral iliac artery occlusion to manage their infrarenal aortic aneurysms (mean size, 6.3 cm; range, 4.9 to 7.5 cm). Preoperative risk factors were cardiac (angina, compensated congestive heart failure, and significant preoperative arrhythmias), 100% of patients; pulmonary (symptomatic chronic obstructive pulmonary disease with a 1-second forced expiratory volume less than 50% of the predicted value), 46% of patients; renal (creatinine value greater than or equal to 2.0 mg/dl or creatinine clearance less than 20 ml/min), 46% of patients; or nutritional (albumin less than or equal to 3.5 gm/dl or body weight less than 90% of ideal), 46%. Ninety-two percent of the patients had two risk factors whereas 46% had three or more risk factors. The operative mortality rate was 31%; three patients died of multisystem organ failure and another died of thrombin-induced consumptive coagulopathy and hemorrhage. (Our operative mortality rate for conventional graft replacement of abdominal aortic aneurysms is less than 3%.) Morbidity in persons surviving at least 1 month included thrombosis of the extra-anatomic bypass graft requiring thrombectomy (three patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and patients), ischemic colitis (two patients), ischemic neuropathy (one patient), and bilateral above-knee amputations (one patient). Thrombosis of the aneurysm was not achieved in two patients despite use of fluoroscopically controlled embolization of runoff vessels.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of the Balloon Catheter for Distal Occlusion of the Aorta in Prosthetic Replacement of Aortic Arch Aneurysms

A balloon catheter was utilized to occlude the distal aorta during prosthetic replacement of an aortic arch aneurysm in 4 consecutive patients under conditions of separate cerebral and peripheral perfusion and deep hypothermia. All patients survived the procedure, and 3 were doing well 1 to 1.5 years following operation. One patient sustained a cerebral infarction and recovered with some sequent disability. The use of a balloon occlusion catheter allowed us to perform the operation through a median sternotomy only, and eliminated the procedure of pulmonary dissection for distal clamping and the risk of emboli. In addition, its use provided a relatively bloodless field and sufficient protection for organs in the lower body through adequate perfusion, even when their function was poor or when the distal anastomosis was prolonged. We realized improved surgical results in the treatment of aneurysms of the aortic arch.

Early and late risk of aortic valve replacement: A 12 year concomitant comparison of the porcine bioprosthetic and tilting disc prosthetic aortic valves

Aortic valve replacement was performed in 912 consecutive patients from January, 1972, to January, 1983. The 616 male and 296 female patients, whose ages ranged from 16 to 95 years (mean 60.6 years and median 63 years), received 663 bioprosthetic valves and 249 tilting disc valves. A higher incidence of Functional Class IV heart disease and ascending aortic aneurysms was noted in the group receiving the tilting disc valve. Six hundred fifty-seven patients had primarily aortic stenosis and 255 had primarily aortic regurgitation. Associated procedures were done in 308 patients (33%): 233 had coronary bypass grafting, 46 had replacement of ascending aortic aneurysms, and 29 had miscellaneous procedures. The overall operative mortality was 6.4% (59/912). The operative mortality was 4.5% (29/640) for isolated aortic valve replacement, 4.2% (21/233) for valve replacement plus coronary bypass, and 17% (8/46) for valve replacement plus replacement of an ascending aortic aneurysm. The mortality was 4.2% (20/663) for the group receiving bioprostheses and 12.4% (31/249) for those receiving tilting disc valves. The operative mortality for 1983 for all aortic valve replacement procedures was 2.1%; for isolated valve replacement, 1%; for valve replacement plus coronary bypass, 4.4%; and for valve replacement plus aortic aneurysm replacement, 0%. The long-term follow-up was analyzed as of Jan. 1, 1984, so that there was a minimum follow-up of 12 months (mean 55 months and median 51 months). The actuarial survival rate at 108 months for all patients was 67% +/- 2%; for valve replacement alone, 71% +/- 3%; for valve replacement plus coronary bypass, 58% +/- 7%; for valve replacement plus ascending aortic aneurysm replacement, 45% +/- 10%; for aortic stenosis, 70% +/- 3%; for aortic regurgitation, 61% +/- 4%; for Functional Classes I to III, 77% +/- 3%; for Class IV, 53% +/- 4%; for age less than 63 years, 75% +/- 3%; and for age greater than 63 years, 57% +/- 4%. At 108 months, the probability of freedom from thromboembolism was 85% +/- 3% after bioprosthetic valve replacement and 83% +/- 3% after replacement with a tilting disc valve (p = NS). The probability of freedom from hemorrhage at 108 months was 98.6% +/- 7% for the bioprosthetic valve group and 89% +/- 2% for the tilting disc valve group (p less than 0.001). The valve thrombosis rate was 0.34% per patient-year for the tilting disc valves and 0.07% per patient-year for the bioprostheses.(ABSTRACT TRUNCATED AT 400 WORDS)

Rigid intraluminal prosthesis for replacement of thoracic and abdominal aorta

From December 1976 to April 1983, 55 patients underwent operations in which intraluminal ring grafts were used for replacement of thoracic and abdominal aortic aneurysms. Twenty-eight patients had dissections, and 11 had ascending aneurysms. There were 10 descending aneurysms; three of these were traumatic. There were two arch aneurysms, three abdominal aneurysms, and one thoracoabdominal aneurysm. The follow-up period was 78 months with a mean follow-up period of 24 months. There were six postoperative deaths and six late deaths. No evidence of complications of thrombosis, migration, erosion, or pseudoaneurysm resulting from the ring within the 78-month follow-up period was seen, and we conclude that this is a safe, reliable, quick method for replacement of the aorta in certain well-defined situations.

Computed tomography of the postoperative abdominal aorta.

Computed tomography (CT) of the abdomen was performed on 46 patients who had undergone graft replacement of abdominal aortic aneurysms. Twelve postoperative complications were found in nine patients. They included hemorrhage, infection, anastomotic pseudoaneurysms, major vessel occlusion, postoperative pancreatitis, and others. The varied appearance of the normal postoperative graft is also presented. It is concluded that CT is a rapid, sensitive, and noninvasive method for detecting or excluding postoperative complications of abdominal aortic surgery.

Management of graft infections following abdominal aortic aneurysm replacement

AbstractGraft infection following resection of an abdominal aortic aneurysm is a rare but highly lethal complication. It is most commonly associated with aortoenteric fistula or external contamination when graft limbs extend to the groin. Other sources are bowel or urinary tract entry, latent infection in the aneurysm wall, breaks in sterile technique, or bacteremia. Diagnosis should be suspected when a patient with an aortic graft develops unexplained fever, especially with back or abdominal pain, gastrointestinal bleeding of any kind, or metastatic infection to the limbs. Diagnosis is difficult to establish. Endoscopy to demonstrate erosion into the distal duodenum or to rule out other sources of bleeding was useful in all 6 patients in which it was employed. Positive arterial cultures distal to the graft, the finding of bilateral hydronephrosis, and demonstration of periaortic inflammation on gallium scan are highly suggestive. Aortography was helpful in 2 of 6 patients but was useless when negative. Barium contrast x‐ray studies were usually negative (90%) or confusing. Management requires excision of all infected graft material, usually the entire prosthesis. Restoration of limb circulation, usually with axillo femoral bypass, should be done in all patients except those with prior amputation or previous iliac artery or graft occlusion with adequate collaterals. A 35% patient survival rate was achieved in 20 patients with graft infection and aortoenteric fistula. However, when a correct diagnosis was made without delay and appropriate principles of management were instituted, 78% (7 of 9) patients survived and no amputations were required in the 5 patients with intact limbs. Prevention of postaneurysmectomy graft infection requires meticulous aseptic technique, effective graft coverage and separation from loops of bowel with viable tissue, and the use of prophylactic systemic and local antibiotics.

Abdominal aortic aneurysm

Elective resection and prosthetic graft replacement of asymptomatic abdominal aortic aneurysms 5 cm or more in diameter are dependable measures to counter the formidable threat of rupture. Operative mortality should be less than 5% among patients without severe associated disease. Those patients who have large aneurysms but who represent marginal risks for major vascular repair may be guided through such an operation with reasonable safety by meticulous preoperative and postoperative care. Particular attention should be devoted to assessment and support of pulmonary and renal function and to detection of associated arteriosclerosis of the coronary and carotid arteries.

Late complications from plastic replacement of aortic abdominal aneurysms.

DEFINITIVE therapy of aneurysms of the abdominal aorta began to reach a satisfactory state with the development of the freeze-dried aortic homograft. Aside from the nuisance caused by the difficulties in obtaining these grafts, late complications have occurred at a high rate. These include atheroarteriosclerotic changes, thromboses, aneurysmal dilation with threat of rupture, and late infection. Complications due to the homograft appeared more frequently in the femoropopliteal system than in the aorta. Barner and DeWeese, 1 reviewing aneurysmal degeneration of arterial homografts, felt that the reason for this divergence in behavior between the aortic and femoral popliteal systems was due to the fact that the media of the aorta was 70% to 80% elastin, whereas the femoropopliteal segment had 1% to 5% elastin in the media and 10% to 30% elastin in the adventitia. They conclude that if aneurysmal degeneration develops, the graft should be resected and replaced with