Abdominal Aortic Aneurysm Resection Research Articles

Routine Coronary Angiography and Functional Cardiac Tests before Resection of Abdominal Aortic Aneurysm in Patients without Symptoms of Myocardial Infarction

INTRODUCTION: Cardiac complications are leaders in the structure of mortality of patients after resection of abdominal aortic aneurysms (AAA). In recent years more data have been obtained on the possibility of performing invasive coronary angiography (CAG) as a method of preoperative assessment of the condition of the coronary arteries. AIM: To assess the tactics of routine CAG and preventive revascularization of the myocardium in comparison with non-invasive functional tests in patients without clinical manifestations of coronary heart disease (CHD) from positions of the hospital outcomes of AAA resections. MATERIALS AND METHODS: A retrospective study included 205 patients without clinical and instrumental signs of CHD who underwent AAA resection at National Medical Research Center of Surgery named after A. Vishnevsky in 2001–2021. Patients of the first group (n = 55) underwent CAG before AAA resection and, if significant stenosis of coronary arteries was detected, revascularization of the myocardium was performed. In patients of the second group (n = 71), only functional cardiac tests were conducted before the operation. Patients of the third group were operated on without additional evaluation of cardiac status. RESULTS: In 30.9% of patients of the first group, significant coronary lesions were detected, in 29.5% of them with the involvement of the left main coronary artery. This required 10 percutaneous coronary interventions and 5 coronary artery bypass surgeries, which made 27.0% of patients in this group. No cases of myocardial infarction were recorded in this group. In the second and third groups, one case of myocardial infarction in each group was recorded (p = 0.688). There was no significant difference in the postoperative mortality in all the groups (1.8%; 4.2%; 2.5%, respectively; p = 0.704). To this end, maximally invasive diagnostic tactics increased the average waiting time for AAA resection: 52.2 ± 6.0 days in groups without coronary angiography and myocardial revascularization versus 99.2 ± 13.0 days in the first group. CONCLUSION: In a cohort of patients without anamnestic and clinical manifestations of coronary artery disease, the tactics of routine coronary angiography followed by prophylactic myocardial revascularization did not improve the short-term results of AAA resection, while the waiting period for intervention on the abdominal aorta increased. Preoperative tactics with functional cardiac tests also did not affect the treatment results.

Lessons Learned with Enhanced Recovery for Open Abdominal Aortic Aneurysm Surgery: A Long Term Regional Network Experience

This enhanced recovery programme (ERP) aimed to achieve early recovery for patients undergoing major surgery. Results of a standardised ERP protocol for open infrarenal abdominal aortic aneurysm (AAA) repair within a hub and spoke regional network are presented. In this monocentric prospective study (January 2004 - December 2021), consecutive AAAs (≥ 55 mm) were included in the ERP (patient discharge on post-operative day [POD] 4). The four phases of the ERP were pre-admission, pre-operative, intra-operative, and post-operative. Exclusion criteria were BMI > 35 kg/m2, functional capacity < 4 MET, previous aortic or abdominal surgery, and life expectancy < 5 years. Transperitoneal surgery was undertaken with routine AAA resection, graft interposition, and closure. Consecutive patients (n = 778) were enrolled into the study (mean age 72.3 ± 3.2 years; n = 712 men); 160 (20.5%) were treated in spoke hospitals. Median follow up was 78 (IQR 28, 128) months; median length of stay, procedure time, and blood loss were 4 days (IQR 3, 5), 190 min (IQR 170, 225), and 564 mL (IQR 300, 600). Infrarenal clamping and tube graft configuration were used in 96.5% (n = 751) and 72.5% (n = 564) of patients; 30 day mortality and complication rates were 0.4% (n = 3) and 9.2% (n = 72). Discharge after POD 4 occurred in 15.0%, and most significant predictors for discharge after POD 4 were haemotransfusion, re-intervention, and ileus over 3 days. Overall survival was: 98.2% at 1 year, 85.0% at 5 years, and 59.9% at 10 years. Freedom from re-intervention was 97.9% at 1 year, 94.1% at 5 years, and 86.8% at 10 years. Short and long term outcomes were comparable between hub and spoke hospitals. The ERP protocol was associated with low short and long term mortality and complication rates. Future studies should apply the ERP protocol to other vascular centres.

The place of regional anesthesia in vascular surgery: literature review and personal experience

Background. Vascular surgery is a high-risk procedure, and most interventions carry a greater than 5% risk of an acute cardiac event. Direct reconstruction of aorto-iliac-femoral segment is associated with a 2.8% perioperative mortality, whereas extra-anatomic bypass has an 8.8% mortality. Arteriosclerosis obliterans is a growing public health concern affecting 8.5 million people in the United States and 200 million people worldwide. Main goals of preoperative assessment of vascular patients are risk stratification and its potential reduction by safe methods of anesthesia. Aim: to compare regional anesthesia during carotid endarterectomy, abdominal aortic aneurysm resection and repair, repair of the lower limb vessels and lower extremity amputation based on the data of the world literature and the choice of safe methods of anesthesia. Materials and methods. The materials are modern world literature, Scopus, Web of Science, MedLine, the Cochrane databases and the latest scientific research. Using the comparative method of analysis, the world literature data were compared with the experience of using regional methods of analgesia at the Kyiv Regional Clinical Hospital. Conclusions. Given the data presented in the article, it can be considered that regional anesthesia is the optimal method for use as monoanesthesia or in combination with general anesthesia in vascular surgery. The use of these methods of anesthesia by an experienced anesthesiologist can decrease length of stay in the hospital and improve the disease course in this rather complex patient population. The decision to use regional techniques should be made by the patient, surgeon, and anesthesiologist after an individualized discussion of the risk-benefit profile for each patient and type of surgery.

Chronic contained ruptured abdominal aortic aneurysm with a rare presentation of lower limb neuropathic claudication: a report of two cases.

We present the two cases of 62-year-old and 65-year-old males. Preoperative radiology for each patient showed an infrarenal aortic aneurysm with a retroperitoneal hematoma in contact with the lumbar vertebral bodies and psoas muscle. The draped aorta sign was evident in both cases. A curative surgical intervention was accomplished for both patients, respectively. This was achieved through the removal of the existing hematomas that were compressing the vertebrae in addition to the complete isolation and resection of the respective abdominal aortic aneurysms along with thorough reconstruction of the aortoiliac spindles with patent synthetic grafts to ensure the patency of the preexisting vascular axis. A contained rupture of an abdominal aortic aneurysm is a rare occurring vascular pathology that manifests with nonspecific symptoms, such as femoral neuropathy and lower back pain proportionate to the degree of the level of erosion of the affected lumbar vertebrae. This will increase the possibility of misdiagnosis and delays in treatment. Such a life-threatening vascular emergency should be timely detected and treated to avoid its complications and patient mortality.

Digestive hemorrhage and fever as a result of a double secondary aortoenteric fistula following the repair of a juxtarenal abdominal aortic aneurysm and an infection of the aortobifemoral bypass graft: a case report.

During aortoc reconstructive surgery, the patient may present with a variety of unusual complaints, including fever and GI bleeding. These symptoms are indicative of problems, including the development of an aortoentric fistula, particularly when there is a double secondary fistula. The patient was admitted to the hospital due to hematemesis, melena, and high-grade fever after undergoing synthetic grafting aortobifemoral bypass (anatomical reconstruction) and partial resection of the juxtarenal abdominal aortic aneurysm. Pus discharge and a double aortoenteric fistula in unusual sites such as the second-third portion of the duodenum and caecum are visible in upper GI endoscopy and computed tomography angiography. The patient underwent a two-stage open surgery, the first stage involving aortic limb graft exclusion and extra anatomical reconstruction, and the second stage involving graft removal, fistula management, and bowel repair. Then the patient spent a few days in the surgical intensive care unit before being discharged. Primary and secondary AEF are the two categories of AEF. In patients who underwent aortic reconstruction surgery, the frequency of secondary AEF ranges from 0.36 to 1.6%. Due to the 8:1 injury ratio in the secondery AEF, men suffer more injuries than women.There are two types of fistula depending on whether or not the suture line is involved. The first form is graft enteric erosion, which excludes the suture line, while the second type is entric graft fistula, where the suture line is included. Most common site fistula is third and fourth part of duodenum and least common site is fistula formation in large bowel. An uncommon complication is double secondary AEF following aortic reconstruction surgery. Since one of the most significant presentations an AEF patient can present with is major GI bleeding and sepsis, A delay in seeking immediate medical treatment could result in the patient's death. It should be emphasized that one of the mechanisms for AEF formation and a frequent cause of sepsis in patients is recurrent aortic graft infection following aortic reconstruction surgery.

Reconstruction of caval veins

To study the possibilities and results of reconstruction of caval veins. We analyzed the results of reconstruction of caval veins in 31 patients (19 men and 12 women) including superior vena cava (SVC) in 5 cases and inferior vena cava (IVC) in 26 cases. Penetrating wounds with vascular damage were found in 8 patients. Iatrogenic damage to IVC was observed in 19 patients (nephrectomy for kidney cancer - 2, nephrectomy for secondary kidney wrinkling - 1, echinococcectomy from retroperitoneal space - 1, adrenalectomy for adrenal tumors - 5, right-sided lumbar sympathectomy - 1, resection of abdominal aortic aneurysm - 1, resection of a large retroperitoneal tumor - 6). Iatrogenic damage to SVC occurred in 2 patients during resection of mediastinal tumor. In other 4 cases, elective surgery for mediastinal tumor (1), pancreatic head cancer (2) and liver alveococcosis (1) was accompanied by resection and replacement of caval veins. All interventions for caval vein injury were performed under adequate infusion therapy. Seven (22.6%) patients died. One patient with blunt chest trauma and damage to SVC died during thoracotomy. In another patient, infrarenal IVC was intersected during mobilization of retroperitoneal hydatid cyst that required ligation for vital indications. High venous hypertension below the ligature led to eruption of sutures on the venous stump. The patient died from hypovolemia after additional IVC ligation. Other 5 patients died in early postoperative period without leaving the state of shock. These patients had damage to retrohepatic segment of IVC (1), vascular-organ (1) and iatrogenic (3) injuries. One patient died from pulmonary embolism, two patients - from venous bleeding between the 2nd and the 5th postoperative days. Patients died before reoperations. Two patients with postoperative bleeding underwent redo surgery with favorable outcomes. One patient underwent redo surgery for peritonitis with a favorable result. Thus, 7 (22.6%) patients with caval vein injury died in intraoperative and early postoperative period. Non-specific complications occurred in 4 (12.9%) patients. These events were corrected by conservative measures. Other 24 (77.4%) patients with traumatic and iatrogenic injuries of caval veins were discharged. Caval vein injury is less common event compared to other vascular damages. Nevertheless, this complication is accompanied by severe blood loss, shock and hypovolemia. We can only assume damage to a great vessel in patients with penetrating wounds before surgery and appropriate symptoms of internal bleeding. However, final diagnosis is made during surgery. Hemostasis is a responsible and difficult surgical stage in these patients. There is usually no alternative to reconstructive surgery in these cases. However, ligation is permissible in extremely ill patients and only in infrarenal segment of IVC. Vascular suture is a more acceptable and effective option for reconstruction. However, patch repair is advisable for large defects. In our opinion, this approach is better regarding long-term patency compared to total replacement with synthetic prostheses.

A case of successful surgical treatment of a ruptured giant aneurysm of the infrarenal aorta in an elderly patient

Today, abdominal aortic aneurysm surgery is a fairly well-studied area of medicine. Nevertheless, some questions remain rather debatable. No clear criteria for giant aneurysms have been developed so far. The available foreign and domestic literature reports about 40 cases of surgical treatment of giant abdominal aortic aneurysms, 16 of which are cases of aneurysm rupture. Open surgery remains the method of choice in the treatment of giant aneurysms due to the pronounced technical difficulties of endovascular intervention. The authors present a case of successful surgical treatment of a giant aneurysm rupture in an elderly patient. The peculiarity of this patient's condition is the occurrence of aneurysm rupture after hospital admission. The patient refused surgical treatment for two years after aneurysm detection. On examination after admission, multispiral computed tomography revealed an aneurysm size of 101 mm. On the eve of surgery, pain syndrome in the left abdomen and tachycardia appeared. Aneurysm rupture was suspected and the patient was urgently admitted to the operating room. The surgery was performed under the conditions of machine reinfusion of autoblood. The patient underwent abdominal aortic aneurysm resection with linear prosthesis and retroperitoneal hematoma removal. The postoperative period had no peculiarities. On the 10th day after the operation the patient was discharged in satisfactory condition to the outpatient treatment. This clinical case demonstrates the possibility of successful surgical treatment of giant aneurysm rupture in elderly patients.

A case of suspected propofol infusion syndrome after abdominal aortic aneurysm surgery

BackgroundPropofol infusion syndrome (PRIS) is a rare but potentially lethal side effect during propofol administration.Case presentationThe patient was scheduled for abdominal aortic aneurysm resection and reconstruction. Propofol used during sedation for ventilation after the surgery-induced rhabdomyolysis, heart failure, and renal failure. Discontinuation of propofol administration led to a dramatic improvement in the fatal symptoms, resulting in a diagnosis of PRIS.ConclusionsWe herein report a rare case of a PRIS during sedation in the intensive care unit after abdominal aortic aneurysm surgery. Physicians using propofol should therefore be aware of the potential risk of PRIS.

腹部大動脈瘤術後10年目に手術した人工血管周囲血腫拡大の1例

腹部大動脈瘤術後，腰動脈からの出血のために人工血管を被覆した瘤壁が拡大し，術後10年目に再手術を施行した稀な1例を経験したので報告する．症例は78歳の男性，68歳時に90mmの腎動脈下腹部大動脈瘤に対し人工血管置換術が施行された．術後1カ月目のCTで少量の血腫が人工血管周囲に認められていたが，6年目の腹部CTでも血腫は消失せず，術後10年目には62mmに拡大したため再手術を施行した．被覆した瘤壁を切開すると，壁内に多量の赤色血栓が認められた．出血源は前回手術で処置されていたと思われる腰動脈であった．今回の原因として，一旦止血されていた腰動脈から術後比較的早期に再出血し，被覆瘤壁が拡大したと思われた．また，腹部大動脈瘤術後に7年後に頸動脈血栓内膜摘除を施行され，その後，抗血小板剤を投与されたことは瘤壁拡大に拍車をかけたと思われた．

Mycotic Aneurysm of the Aortic Arch Presenting With Left Vocal Cord Palsy

We report a case of a 71-year-old man with a mycotic aneurysm of the aortic arch who presented with progressive hoarseness. Three weeks prior to this event the patient was admitted to an outside hospital in septic condition and was diagnosed with a mycotic abdominal aortic aneurysm. Resection of the infected abdominal aortic aneurysm with right axillofemoral and femoral-femoral bypass grafts was performed and the patient was discharged home on intravenous antibiotics. At our institution, the aortic arch aneurysm was treated with extensive debridement and replaced with a Dacron prosthesis under circulatory arrest with antegrade cerebral perfusion through the axillofemoral bypass.

A Most Unusual Passage Per Rectum

Question: A 60-year-old man with acute myelogenous leukemia (AML) in remission relapsed and was admitted for salvage chemotherapy. He received induction with methotrexate, epirubicin and cisplatin. During the course of treatment, he became hypotensive and tachycardic, prompting transfer to the intensive care unit. Septic shock was empirically treated with broad-spectrum antibiotics. His course was further complicated by persistent pancytopenia, atrial fibrillation with rapid ventricular response, disseminated intravascular coagulation and respiratory failure requiring mechanical ventilation. He developed abdominal distension, proximal small bowel dilation, and mesenteric edema by computed tomography without pneumoperitoneum. Subsequent radiographic studies over several days revealed no interval changes; conservative therapy with nasogastric tube suction and methylnaltrexone was given. Five days later, he had an episode of melena accompanied by passage rectally of a 15-cm tubular structure (Figure A). Within hours of this event, he developed multisystem organ failure and hypotension followed by asystolic cardiac arrest. The tubular structure was sent for pathologic review (Figure B). What is your diagnosis? See the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. Pathologic review revealed necrotic mucosa with cross-section containing luminal debris (black arrow), necrotic epithelium (red arrow), bacterial colonies and calcifications (blue arrow), and underlying superficial muscularis (green arrow). The superficial muscularis was thought to represent either thickened muscularis mucosa or a superficial layer of muscularis propria (Figure B). The final pathologic diagnosis was consistent with a partial thickness colonic cast. Passage of a partial or full thickness colonic cast is an extremely rare event. It was first described by Speakman and Turnbull in 1984 after an abdominal aortic aneurysm resection.1Speakman M.J. Turnbull A.R. Passage of a colon ‘cast’ following resection of an abdominal aortic aneurysm.Br J Surg. 1984; 71: 935Crossref PubMed Scopus (22) Google Scholar Since then, approximately one dozen additional case reports have been published.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar The common theme among most reported cases has been intestinal ischemia after abdominal surgery—usually repair or resection of an abdominal aortic aneurysm.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar Other surgeries that have led to this serious complication include rectal resection, J-pouch formation, and Hartmann pouch reversal.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar Nonsurgical conditions associated with passage of a colonic cast include graft-versus-host-disease,3Al Ashgar H. Peedikayil M. Chaudhri N. et al.Defecation of a “colon cast” as a rare presentation of acute graft-versus-host disease.Ann Saudi Med. 2009; 29: 231-233Crossref PubMed Scopus (35) Google Scholar acute pancreatitis, and now salvage chemotherapy for AML. Appropriate suspicion should arise in critically ill patients who have undergone colorectal or abdominal aneurysm surgery or those with significant intestinal ischemia and critical illness; such settings may rarely herald passage of a colonic cast. Although passage is often a near-terminal event, resection of the ischemic segment in the appropriate clinical setting may be a life-saving measure.2Erguney S. Yavuz N. Ersoy Y.E. et al.Passage of “colonic cast” after colorectal surgery: report of four cases and review of the literature.J Gastrointest Surg. 2007; 11: 1045-1051Crossref PubMed Scopus (15) Google Scholar

The surgical treatment of infrarenal abdominal aortic aneurysm and its complications based on own experience

The purpose of the study — to research the own results of surgical treatment of infrarenal abdominal aortic aneurysms and to identify measures to prevent possible complications. A retrospective analysis of 46 cases was done. The main cause of deaths in the early postoperative period was a myocardial infarction — in 6 ((13.1 ± 1.4)%) patients and acute ischemia of the left half of the colon — in 2 ((4.3 ± 0.8)%) cases. In the distant period the survival depended on the state of blood flow in the basin of the coronary and brachiocephalic arteries, the development of local complications and cancer. Chronic ischemia of the left half of colon was diagnosed in 8 ((20.5 ± 2.0)%) patients and was the most frequent complication in the later stages after resection of abdominal aortic aneurysms.

Three trocars laparoscopic abdominal aortic aneurysm repair

Total laparoscopic abdominal aortic aneurysm resection with tube graft interposition was performed in a 53-year-old woman diagnosed with an infrarenal abdominal aortic aneurysm. The operation was accomplished by a method using three trocars. The operation took 240 minutes. Blood loss was 600 mL. No complications occurred in 13 months of postoperative follow-up. These results show that total laparoscopic abdominal aortic aneurysm repair with three trocars is feasible and worthwhile.

Amplatzer Device Deployment for Saccular Aortic Arch Aneurysm

Amplatzer septal occluder devices (AGA Medical Corporation, Plymouth, MN) have been used in the treatment of saccular and aortic false aneurysms.1,2 We have reservations about the long-term reliability of this approach. A 62-year-old man, who was a heavy smoker and had arteriopathy, was under regular surveillance for chronic obstructive airways disease and bullous emphysema. He had previously undergone abdominal aortic aneurysm resection (1997) with prolonged postoperative respiratory support. Subsequently, a huge circumflex coronary aneurysm (5.9×5.0 cm, Figure 1A) caused lateral myocardial infarction (2005) and an enlarging saccular arch aneurysm (3.5 cm, Figures 1B and 1C, 2 and 3) compressed the pulmonary arterial bifurcation with worsening dyspnea (New York Heart Association class 4). In addition, the coronary angiogram showed severe midvessel left anterior descending stenosis and moderate disease of right coronary artery. Figure 1. A , CT scan in transverse section showing a large circumflex coronary aneurysm (arrow) following covered stent closure of the entry. Diffuse coronary disease is apparent in the LAD branch. B , CT reconstruction demonstrating the nonthrombosed …

Long-term incidence of myocardial infarct, stroke, and mortality in patients operated on for abdominal aortic aneurysms

The risks of myocardial infarction (MI) and stroke after abdominal aortic aneurysm (AAA) resection are not known. Prophylaxis with aspirin and statins is not generally recommended, although patients with AAAs have an increased prevalence of cardiovascular atherosclerosis. We report the incidences of MI, stroke, and death in an unselected national cohort of patients operated on for AAAs, with the general population as the control group. In a matched cohort study, 11,094 Danish patients who underwent acute or elective open AAA repair from January 1986 through June 2009 were compared with four randomly chosen age- and sex-matched individuals (controls) from the general population (n = 44,364). Data were collected retrospectively from the Danish Vascular Registry (Karbase), the National Population Registry, and the National Inpatient Registry. The groups were analyzed for the incidences of MI, stroke, and death, with up to 20 years of follow-up. AAA patients had an annual MI incidence of 2.5% (hazard ratio, 2.1; 95% confidence interval [CI], 1.9-2.2) compared with the general population. The annual incidence of stroke was 2.9% (hazard ratio, 1.8; 95% CI, 1.6-1.9), and there was a 2.4-fold (95% CI, 2.3-2.4) increase in the hazard of all-cause mortality compared with the general population. AAA patients of both sexes have a high risk of atherosclerotic events (MI, stroke) and death, so lifelong prophylaxis must be considered from our epidemiologic data. Randomized trials investigating the potential benefit of aspirin and statin therapy in AAA patients are needed.

Comparison of retroperitoneal and transperitoneal approach for reconstruction of abdominal aortic aneurysm in patients with previous laparotomy

Although the standard surgical approach for repair of infrarenal abdominal aortic aneurysm (AAA) has been the transperitoneal approach, several reports have suggested the usefulness of retroperitoneal aortic reconstruction. However, the superiority of the retroperitoneal compared with transperitoneal approach is still controversial. To compare the efficacy of the retroperitoneal with that of the transperitoneal approach in elective AAA resection, 19 consecutive cases with previous laparotomies were randomly reviewed. From January 1990 through December 1992, 94 consecutive patients underwent elective reconstructions of an infrarenal AAA. Among them, 75 patients had had no previous surgery of any kind. In all of them, the transperitoneal approach was used (Group I). Nineteen other patients who had various laparotomies were randomly divided into two groups. The transperitoneal approach was used in 10 patients (Group II), and the retroperitoneal approach was used in 9 patients (Group III). Thus, the patients were separated into three groups and the intra- and postoperative parameters were compared. Surgical data including operative time, intraoperative blood loss, and aortic cross-clamping time did not differ significantly between the transperitoneal approach in the patients without laparotomy (Group I) and the retroperitoneal approach (Group II). In addition, the postoperative recovery including the initiation of alimentation and postoperative hospitalization also did not differ significantly between the two groups. However, there was a significant difference in the operative time and the blood loss between the retroperitoneal approach (Group II) and transperitoneal approach (Group III) in the patients with previous laparotomy. In addition, the postoperative parameters including the initiation of oral intake was sooner and hospitalization was significantly shorter in the retroperitoneal group (Group II) than in the transperitoneal group (Group III) with previous laparotomy. There was no incidence of postoperative adhesive ileus in the patients with the retroperitoneal approach (Group II). The results demonstrated no important advantage for the retroperitoneal approach compared with routine transperitoneal approach in the patients without previous laparotomy. However, in the patients with previous laparotomies, the retroperitoneal approach is a preferable alternative to the transperitoneal route.

Secondary aortoduodenal fistula identified by ultrasonography.

A 73-year-old man underwent coronary artery bypass grafting, abdominal aortic aneurysm resection, and prosthetic implantation as a single procedure in 2002. His progress was favorable until April 2008, when he was admitted to our hospital with melena. B-mode ultrasonography revealed a 5-mm defect in the abdominal aorta at the graft anastomosis, and an umbilicated lesion was seen projecting between the posterior wall of the third part of the duodenum and the abdominal aorta. A color signal was noticed at this site on color Doppler ultrasonography, leading to the diagnosis of a secondary aortoduodenal fistula (ADF). We resected the inflammatory mass comprising the graft and the third part of the duodenum, and performed prosthetic re-implantation, omentopexy, and duodenojejunostomy. We could not find any previous reports of successful identification of secondary ADF using ultrasonography. When a patient with gastrointestinal hemorrhage following reconstructive aortic surgery is encountered in the emergency department, ultrasonography may be considered to be a useful modality in the diagnosis of secondary ADF.

In situ versus extra-anatomic reconstruction for primary infected infrarenal abdominal aortic aneurysms

There is no standard procedure for revascularization after infected infrarenal abdominal aortic aneurysm resection. This study examines the outcomes of two contemporary methods. We retrospectively reviewed medical records for patients who underwent repair of infected infrarenal abdominal aortic aneurysms from January 1998 to December 2007 at a single institution. Patients with infected prosthetic aortic grafts were excluded. Twenty-eight patients (22 men; mean age, 65 ± 12) had in situ graft (group I, n = 13) or extra-anatomic bypass (group II, n = 15), with a mean follow-up of 22 months. Mean hospital lengths of stay were 36 ± 16 days for group I and 46 ± 17 days for group II. Overall perioperative mortality was 5 of 28 (18%), comprising 1 of 13 in group I (8%) and 4 of 15 in group II (27%; P = .333). No early or late vascular-related complications occurred in group I. In group II, three patients had early vascular-related complications, including, graft infection, graft occlusion and ischemia colitis, and five patients had late vascular-related complications, including graft infection and graft occlusion. One patient ultimately lost a limb. Group I had a 0% late complication rate vs 33% in group II (P = .044). For cumulative survival rates, Kaplan-Meier analysis and log-rank testing revealed no significant differences between groups I and II. In situ graft revascularization is viable in afebrile patients or patients who have good response to preoperative antibiotic therapy. Extra-anatomic bypass grafting for infected infrarenal abdominal aneurysm resection has a similar long-term survival rate and should be considered in patients who are unsuitable for in situ graft revascularization; however, the postoperative complication rate is higher. Further prospective study with large patient populations is needed to determine the selection criteria for using in situ revascularization as alternative methods for treatment of infected abdominal aneurysms.

Cholesterol Embolization Syndrome

Cholesterol embolization syndrome refers to embolization of the contents of an atherosclerotic plaque (primarily cholesterol crystals) from a proximal large-caliber artery to distal small to medium arteries causing end-organ damage by mechanical plugging and an inflammatory response. Synonyms used in the medical literature include atheromatous embolization, cholesterol crystal embolization, and atheroembolism. Cholesterol embolization syndrome should be distinguished from the related and much more common syndrome of arterio-arterial thromboembolism in which fragments of a thrombus that forms atop an atheromatous plaque in the aorta or a large artery travel distally and occlude medium to large arteries.1 Cholesterol embolization syndrome is generally characterized by a multitude of small emboli (showers of microemboli) occurring over time. This is in contrast to arterio-arterial thromboembolism, which is usually characterized by an abrupt release of 1 or a few large emboli, leading to severe ischemia of target organs. Cholesterol embolization syndrome has a variety of clinical presentations. Cholesterol emboli originating in the descending thoracic and abdominal aorta may lead to renal failure, gut ischemia, and emboli to the skeletal muscles and the skin. Dermatologic manifestations (most commonly livedo reticularis and blue toe syndrome) are usually confined to the lower extremities but may extend to the abdomen and the chest. Cholesterol emboli originating in the ascending aorta may in addition cause neurological damage that is typically diffuse and due to small infarcts. Cholesterol embolization syndrome is also characterized by a nonspecific acute inflammatory response leading to constitutional symptoms (such as fever and malaise) and abnormalities in laboratory tests (such as hypereosinophilia and elevated erythrocyte sedimentation rate). These manifestations will be discussed in detail later in the text. Danish physician Fenger and his colleagues appear to have provided the first description of atheroembolism in the Danish medical brochure Ugeskrift for Laeger (Doctors’ Weekly).2 In 1844, they …

A case of an infected abdominal aortic aneurysm caused by infectious spondylitis

An 82-year-old female was admitted with a diagnosis of infectious spondylitis.The culturing of vertebral body biopsy specimens yielded a non-tuberculous acid-fast bacterium (Mycobacterium intracellulare). CT disclosed a saccular mass in the abdominal aorta in contact with the collapsed vertebral bodies (L2-3), and a diagnosis of infected abdominal aortic aneurysm was made. Axillofemoral bypass, resection of the infected abdominal aortic aneurysm, vertebrectomy (L2-3) and reconstruction with a fibular graft, and packing with the greater omentum were performed. An acid fast bacterium was detected from the thrombus in the aneurysm. The clinical course suggested that this patient developed an infected abdominal aortic aneurysm due to Mycobacterium intracellulare transmitted from infectious spondylitis.