Successful Abdominal Aortic Aneurysm Repair Research Articles

A multi-institutional experience in the aortic and arterial pathology in individuals with genetically confirmed vascular Ehlers-Danlos syndrome

ObjectiveVascular Ehlers-Danlos syndrome (vEDS) is a rare connective tissue disorder owing to pathogenic variants in COL3A1 that lead to impaired type III collagen production. We aim to describe the contemporary multi-institutional experience of aortic and arterial pathology in individuals with vEDS, to evaluate disease patterns and refine management recommendations. MethodsThis cross-sectional, retrospective study of individuals with genetically confirmed vEDS was conducted between 2000 and 2015 at multiple institutions participating in the Vascular Low Frequency Disease Consortium. Aortic and arterial events including aneurysms, pseudoaneurysms, dissections, fistulae, or ruptures were studied. Demographics, COL3A1 variants, management, and outcomes data were collected and analyzed. Individuals with and without arterial events were compared. ResultsEleven institutions identified 86 individuals with pathogenic variants in COL3A1 (47.7% male, 86% Caucasian; median age, 41 years; interquartile range [IQR], 31.0-49.5 years; 65.1% missense COL3A1 variants). The median follow-up from the time of vEDS diagnosis was 7.5 years (IQR, 3.5-12.0 years). A total of 139 aortic/arterial pathologies were diagnosed in 53 individuals (61.6%; 50.9% male; 88.5% Caucasian; median age, 33 years; IQR, 25.0-42.3 years). The aortic/arterial events presented as an emergency in 52 cases (37.4%). The most commonly affected arteries were the mesenteric arteries (31.7%), followed by cerebrovascular (16.5%), iliac (16.5%), and renal arteries (12.2%). The most common management was medical management. When undertaken, the predominant endovascular interventions were arterial embolization of medium sized arteries (13.4%), followed by stenting (2.5%). Aortic pathology was noted in 17 individuals (32%; 58.8% male; 94.1% Caucasian; median age, 38.5 years; IQR, 30.8-44.7 years). Most notably, four individuals underwent successful abdominal aortic aneurysm repair with excellent results on follow-up. Individuals with missense mutations, in which glycine was substituted with a large amino acid, had an earlier onset of aortic/arterial pathology (median age, 30 years; IQR, 23.5-37 years) compared with the other pathogenic COL3A1 variants (median age, 36 years; IQR, 29.5-44.8 years; P = .065). There were 12 deaths (22.6%) at a median age of 36 years (IQR, 28-51 years). ConclusionsMost of the vEDS arterial manifestations were managed medically in this cohort. When intervention is required for an enlarging aneurysm or rupture, embolization, and less frequently stenting, seem to be well-tolerated. Open repair of abdominal aortic aneurysm seems to be as well-tolerated as in those without vEDS; vEDS should not be a deterrent to offering an operation. Future work to elucidate the role of surgical interventions and refine management recommendations in the context of patient centered outcomes is warranted.

Abdominal Aortic Aneurysm Associated with Horseshoe Kidney

The optimal approach to abdominal aortic aneurysm with horseshoe kidney is still debated. We describe a successful abdominal aortic aneurysm repair through a left retroperitoneal approach in a 77-year-old woman with a horseshoe kidney.

Successful Abdominal Aortic Aneurysm Repair in Kidney Transplant Recipient−Staged Repair for Type B Chronic Aortic Dissection−

Successful Abdominal Aortic Aneurysm Repair in Kidney Transplant Recipient−Staged Repair for Type B Chronic Aortic Dissection−

Mid-term Survival After Abdominal Aortic Aneurysm Surgery Predicted by Cardiopulmonary Exercise Testing

Background: Cardiopulmonary exercise (CPX) testing measures how efficiently subjects meet increased metabolic demand. This study aimed to determine whether preoperative CPX testing predicted postoperative survival following elective abdominal aortic aneurysm (AAA) repair. Methods: Some 130 patients had CPX testing before elective open AAA repair. Additional preoperative, operative and postoperative variables were recorded prospectively. Median follow-up was 35 months. The correlation of variables with survival was assessed by single and multiple regression analyses. Results: CPX testing identified 30 of 130 patients who had been unfit before surgery. Two years after surgery the Kaplan–Meier survival estimate was 55 per cent for the 30 unfit patients, compared with 97 per cent for the 100 fit patients. The absolute difference in survival between these two groups at 2 years was 42 (95 per cent confidence interval 18 to 65) per cent (P < 0·001). Conclusion: Preoperative CPX testing, combined with simple co-morbidity scoring, identified patients unlikely to survive in the mid-term, even after successful AAA repair. Copyright © 2007 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd.

Abdominal Aortic Aneurysm with Coexistent Horseshoe Kidney

Surgical repair of an abdominal aortic aneurysm (AAA) concomitant with a horseshoe kidney (HSK) may be technically demanding because of the complex anomalies of the kidney and of its collecting system and arteries, the greater risk of HSK-related complications, and the often unexpected intraoperative finding of HSK itself. We reviewed a database of more than 500 patients with AAA observed in our surgical department from 1994 to the time of writing. Five patients had AAA concomitant with HSK. Two of these patients did not undergo surgery because of the small dimension of the aneurysm or because of their poor health. The other three underwent successful repair of AAA with different techniques; namely, an aortobifemoral bypass via a thoracoabdominal retroperitoneal incision in one, a straight graft via an emergency median laparotomy in one, and an endovascular repair followed by open surgery 4 years later for endotension in one. Abnormal minor renal arteries were deliberately occluded and only one of these caused a minor renal infarct, but without functional impairment. These data and a review of the literature indicate that HSK should not preclude repair of coexistent AAA, as imaging procedures provide the information necessary to plan the best approach for each patient. Up-to-date surgical procedures, a posteriori retroperitoneal approach or endovascular repair, and deliberate occlusion of the minor renal arteries appear feasible and safe as they avoid most of the anatomical problems and provide results equivalent to those of uncomplicated aortic surgery.

Mid-term survival after abdominal aortic aneurysm surgery predicted by cardiopulmonary exercise testing

Cardiopulmonary exercise (CPX) testing measures how efficiently subjects meet increased metabolic demand. This study aimed to determine whether preoperative CPX testing predicted postoperative survival following elective abdominal aortic aneurysm (AAA) repair. Some 130 patients had CPX testing before elective open AAA repair. Additional preoperative, operative and postoperative variables were recorded prospectively. Median follow-up was 35 months. The correlation of variables with survival was assessed by single and multiple regression analyses. CPX testing identified 30 of 130 patients who had been unfit before surgery. Two years after surgery the Kaplan-Meier survival estimate was 55 per cent for the 30 unfit patients, compared with 97 per cent for the 100 fit patients. The absolute difference in survival between these two groups at 2 years was 42 (95 per cent confidence interval 18 to 65) per cent (P < 0.001). Preoperative CPX testing, combined with simple co-morbidity scoring, identified patients unlikely to survive in the mid-term, even after successful AAA repair.

Exercise equilibrium radionuclide angiography predicts long-term cardiac prognosis in patients with abdominal aortic aneurysm being considered for surgery.

Patients with an abdominal aortic aneurysm (AAA) have a high prevalence of coronary disease and are at risk for cardiac events. This may offset the prognostic benefit of surgical repair. We investigated whether preoperative exercise equilibrium radionuclide angiography (ERNA) could be used to identify patients at high risk for cardiac events after successful AAA repair. Between 1990 and 1995, 173 patients with an AAA were referred for supine bicycle exercise ERNA preoperatively. Follow-up information was obtained from a questionnaire sent to each patient's family physician. Cardiac events were defined as cardiac death or nonfatal myocardial infarction. A total of 139 patients were able to exercise and did not die or suffer myocardial infarction perioperatively. The median follow-up period was 3.8 years. Diabetes mellitus, an exercise ejection fraction (EF) below 0.50, and a fall in EF with exercise were univariable predictors of cardiac risk during the follow-up period (P < .05). On multivariable analysis, diabetes mellitus (risk ratio [RR], 6.9; 95% CI 1.5 to 32.0) and an EF fall (RR, 4.1; 95% CI 1.5 to 11.4) emerged as the most important predictors. Exercise ERNA predicts long-term cardiac events in patients being considered for elective AAA repair. Such predictive information may influence the decision to operate, for example, on small unthreatening aneurysms, or lead to invasive cardiological management to minimize risk.

Embolotherapy of Persistent Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysm with the Ancure-Endovascular Technologies Endograft System

Endoleak is a potential complication after endovascular repair of abdominal aortic aneurysm (AAA). It may result in continued growth of the aneurysm and potentially result in aneurysm rupture. The authors present their experience with embolotherapy in patients with persistent perigraft flow treated with the Ancure-Endovascular Technologies endograft system. Between February 1996 and August 1998, 54 patients underwent successful repair of AAA with use of the Ancure system. All underwent operative angiography and discharge computed tomography (CT). Follow-up included CT at 6, 12, and 24 months, and CT was also performed at 3 months if an endoleak was present on the discharge CT. Persistent endoleak was defined as perigraft flow still present on the 6-month CT. Seven of 21 initial endoleaks persisted at 6 months. Six patients returned for embolization of the perigraft space and outflow vessels including lumbar arteries and the inferior mesenteric artery (IMA). Five of the six patients had leaks from the proximal (n = 1) or distal attachment sites (n = 4) of the Ancure system with outflow into lumbar arteries and/or the IMA; one leak was caused by retrograde IMA flow. The six patients underwent nine embolization procedures with only one minor complication. Follow-up CT showed complete resolution of endoleak and decrease in size of the aneurysm sac in all patients. Although endoleak is commonly seen initially with the Ancure system, persistent leak occurred in 13% of the patients in the study. Persistent flow in most patients arises from a graft attachment site combined with patent outflow vessels such as the IMA or lumbar arteries. Persistent endoleaks can be effectively and safely embolized with use of a combination of coil embolization of the perigraft space and embolization of outflow vessels. Such intervention resulted in a decrease in size of the aneurysm sac.

Late Survival After Abdominal Aortic Aneurysm Repair

Objectivesthis study was undertaken to determine the late survival of patients operated successfully for abdominal aortic aneurysm (AAA) repair, to compare survival data with that of the age- and sex-matched general population, to identify the causes of late death, and to determine the factors influencing late survival.Materials and methodsa total of 187 consecutive patients underwent elective surgical AAA repair between January 1987 and December 1991. There were 11 postoperative deaths (early mortality rate 5.9%). The remaining 176 patients formed the basis of this cohort-based retrospective study. Six patients (3.4%) were lost to follow-up. Mean follow-up was 71 months.Resultsa total of 70 patients (39.8%) died during the study period. Coronary artery disease (CAD) and cancer were the two main causes. The survival rate at five years (71.6%) was lower than that of the sex- and age-matched general population (90.6%). Neither arterial hypertension nor CAD had any influence on late survival. In contrast, age and chronic renal failure were predictive variables of late survival.Conclusionsthe life expectancy of patients who undergo successful AAA repair is not as good as that of the age- and sex-matched general population. Late survival depends on the patients» age at the time of surgery and the existence of preoperative chronic renal failure.

Long-Term Survival after Elective Repair of Infrarenal Abdominal Aortic Aneurysm: Results of a Prospective Multicentric Study

During 1989, 28 centers of the Association for Academic Research in Vascular Surgery (AURC) reported all cases involving patients with infrarenal abdominal aortic aneurysm (AAA) who reached the operating room alive. In a total series of 1107 procedures, 834 were performed electively. During 1993 and 1994, an effort was made to contact and, if possible re-examine the 794 (95.2%) patients who survived these elective procedures in order to establish survival curves, determine the causes of late death, and ascertain the predictive value for long-term survival of 628 perioperative variables recorded in 1989. Survival curves were calculated using the actuarial and Kaplan-Meier methods and compared with those obtained from national statistical records in a control population matched for age and sex. Variables with potential predictive value for late death were selected by univariate statistical analysis using either the chi2 or student t-test. In the group of 794 (92.5%) patients who survived elective AAA repair in 1989, survival rates were 93.9 +/- 1.8% at 1 year, 89.5 +/- 3.2% at 2 years, 83.5 +/- 3.2% at 3 years, 77.6 +/- 3.9% at 4 years, and 66.9 +/- 10.6% at 5 years. These rates were significantly lower than those observed in the control population. The mean annual death rate from cardiovascular disease was 1.8%, which was higher than in the control population matched for age and sex. Analysis using the Cox proportional risk model showed that the following variables were significant, independent predictors of late death: diameter of aneurysm (p < 0.02), choice of surgical approach in function of general status (p < 0.02), left ventricular insufficiency (p < 0.02), age (p < 0.02), carotid artery occlusion (p < 0.03), use of a surgical approach other than lobotomy (p < 0.04), cardiac arrhythmia (p < 0.04), duration of aortic clamping (p < 0.05), ECG evidence of myocardial ischemia (p < 0.05), abnormality at the upper limit of the aneurysm (p < 0.05), and advanced renal insufficiency (p < 0.05). Life expectancy in patients that undergo successful AAA repair is lower than in the general population. Although death is often unrelated to AAA or the repair procedure, the incidence of morbidity due to cardiovascular disease is higher than in a control population matched for age and sex. These findings suggest that better management of concurrent cardiovascular disease during the perioperative period and long-term follow-up holds the key to improving life expectancy in patients undergoing AAA repair.