Symptomatic Abdominal Aortic Aneurysm Research Articles

Con: endovascular stent repair for aortic aneurysm surgery is not associated with lower perioperative risk

CONVENTIONAL OPEN operative repair (OR) of abdominal aortic aneurysms (AAAs) has been the gold standard beginning with the initial report in 1951 by Dubost and collaborators.1 The endoluminal approach to the management of AAA repair was reported by Parodi et al2 and Volodos et al3 in 1991 and development of endoluminal grafts has increased exponentially since then. Endoluminal or endovascular AAA repair (ER) has gained astonishing popularity. The early results of ER were extremely promising, showing a reduction in hospital stay, decrease in blood loss, and lower complication rates compared with results of standard OR.4,5 However, mortality rates of ER were not uniformly superior, and sometimes inferior to, OR.6 The opportunity for a less invasive technique to treat a potentially life-threatening disorder, permit more rapid recovery, reduce morbidity, and potentially achieve cost savings by shortened hospitalizations and decreased use of hospital resources is attractive to patients, physicians, hospital administrators, and insurers. The initial enthusiasm for ER was understandably high, although estimates of the number of patients with AAA anatomy suitable for ER varied widely. A recently designed national multicenter ER trial in Great Britain has estimated that 60% of all infrarenal AAAs are amenable to ER treatment.7 Whereas many authorities have suggested that ER could substantially lower the excessive mortality and morbidity associated with ruptured and symptomatic AAAs, Lee and colleagues8 have shown that only about 40% of such patients are eligible for ER treatment because of unfavorable anatomic features. As experience using endoluminal repair of AAAs increased, reports of adverse outcomes became progressively more frequent. For example, the EUROSTAR Project (EUROpean Collaborators on Stent/graft Techniques for Aortic Aneurysm Repair) is essentially a voluntary registry established in 1996.9 To date, nearly 100 European centers of vascular surgery have contributed data on more than 3,000 patients treated with a variety of commercially available endografts. Initially, the perioperative mortality for ER was 3.4%, and the endoleak (persistent flow within the AAA sac) rate was 15.7% after 430 patients had been entered into the database during the first year. However, at 2 years, after 895 patients had been voluntarily registered, the early endoleak rate remained essentially unchanged, but another 18% of patients had developed new endoleaks; moreover, additional problems associated with ER such as late limb occlusions were noted with increasing frequency, and reports began to appear with alarming perioperative mortality rates, as high as 11.3%.9,10 Thus, early unrealistic optimism about ER repair of AAAs has been replaced with a more pragmatic understanding of its benefits and limitations. Randomized, controlled, prospective trials (RCTs) are necessary to establish the most appropriate application of the ER technique compared with established conventional open repair, and, to date, there has been no large-scale randomized controlled trial of OR versus ER for AAAs. Predictably, as shown by many innovations in surgical approaches, there is a pendulum effect. Even the lay press has become involved. The initial media onslaught publicizing unrealistic benefits and successes of ER was closely followed by numerous backlash publications urging caution in the widespread application of ER for AAAs. A front-page story by Julie Appleby12 that appeared in the September 24, 2001 issue of the USA Today newspaper was entitled Debate Follows Development of Medical Device: Smaller Incision Cuts Recovery Time, but Durability Questioned. ER has also been assailed in the medical literature, as reflected in an editorial by Collin and Murie13 entitled Endovascular Treatment of Abdominal Aortic Aneurysms: A Failed Experiment, in which the authors opined that “the gestation period of experimental endovascular aneurysm repair has already been ten years. . .When eventually delivered, it will probably be stillborn. We believe it is dead already.”

High thoracic epidural with general anesthesia for combined off-pump coronary artery and aortic aneurysm surgery

ATIENTS WHO PRESENT for repair of abdominal aortic aneurysm (AAA) often have coronary artery disease and vice versa. Elective surgery for AAA is associated with a 2% to 4% mortality, whereas elective coronary artery bypass grafting (CABG) is associated with a mortality of 0.5% to 4%. Indeed, the perioperative morbidity and mortality caused by myocardial infarction during any operation may be as high as 50%. Patients requiring both AAA repair and CABG may have these performed as a 2-staged process or as a single combined procedure. These may be done with or without cardiopulmonary bypass (off-pump coronary artery bypass [OPCAB]). The latter procedure is relatively new but may help to avoid some of the problems associated with bypass, such as neurologic and hematologic sequelae. The mortality for a combined procedure may be perceived to be high, but the procedure may be indicated in those with severe coronary artery disease and symptomatic AAA when benefits of a combined procedure outweigh the risks. The following cases are of 2 combined procedures, using the off-pump technique, describing the anesthetic and, in particular, the management of high thoracic epidural anesthesia for these cases.

Combined Off-pump Coronary Artery Bypass and Abdominal Aortic Surgery Is Associated with Low Morbidity and Mortality

Patients with abdominal aortic aneurysms (AAAs) often have concomitant coronary artery disease. In patients with large or symptomatic AAAs and symptomatic coronary artery disease, it may be necessary to address both problems simultaneously. We report a case series of five patients undergoing simultaneous off-pump coronary artery bypass and abdominal aortic reconstruction. Our series and a literature review indicate that simultaneous coronary artery bypass grafting on the beating heart and abdominal aortic surgery is safe and effective and has a low perioperative morbidity rate.

A 21-year experience of abdominal aortic aneurysm operations in Edinburgh.

This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996). A prospectively gathered database was analysed. Infrarenal AAA repair was performed in 1515 patients: 492 (32.5 per cent) had elective repair of an asymptomatic AAA; 194 (12.8 per cent) had elective repair of a symptomatic AAA; 156 (10.3 per cent) had emergency repair of a symptomatic non-ruptured AAA; and 673 (44.4 per cent) had surgery for a ruptured AAA. The 30-day and/or same admission mortality rates were 6.1, 5.8, 14.1 and 37 per cent respectively. Operative mortality increased in all four groups over the study interval, although this only attained statistical significance in patients having elective repair of a symptomatic, non-ruptured AAA. There was a significant increase in the age of patients undergoing elective repair of an asymptomatic AAA, but not in the other three groups. There was also a significant increase in the proportion of straight 'tube' grafts inserted in all four groups. It remains the minority of patients who have elective operation before the onset of symptoms and/or rupture. Despite anaesthetic and surgical specialization, the results of AAA repair have not improved over the past two decades. Operative mortality may be increasing, possibly because of the increasing age and associated comorbidity of the patients presenting to this unit.

Emergency treatment of symptomatic or ruptured abdominal aortic aneurysms: the role of endovascular repair.

To report the initial experience with endovascular aortic repair (EVAR) in patients with ruptured or symptomatic abdominal aortic aneurysms (AAA) and to compare the results with conventional open surgery. Between May 1999 and December 2001, 24 patients (21 men; mean age 75 years, range 56-89) with ruptured or symptomatic AAA underwent EVAR using a specially designed aortomonoiliac endograft. Six patients were selected based on device and operator availability; the subsequent 18 patients were treated under a modified management protocol that offered stent-graft repair to all symptomatic AAA patients. The results of this new treatment protocol were analyzed on an intention-to-treat basis for the last 8 months of the study. The 30-day outcomes in all patients treated with emergency EVAR were compared with 40 consecutive, contemporaneous patients undergoing open surgery for symptomatic or ruptured AAA. No early conversions to open surgery were performed. Significantly decreased operative blood loss and intensive care stay (p<0.05 for both) were observed in EVAR patients. The mortality rate for EVAR patients was 17% compared to 32% in conventionally treated patients (NS). Among patients with ruptured AAA, the 30-day mortality rates were 24% (4/17) and 41% (12/29) for EVAR and open surgery, respectively (NS). Of 26 unselected patients who were treated prospectively under the modified protocol, the majority (81%, 21/26) had anatomy suitable for endovascular repair; however, only 18 (69%) underwent EVAR owing to a short infrarenal neck (n=2) or device/operator unavailability (n=6). EVAR is a feasible treatment in the majority of patients with ruptured or symptomatic AAA. The 30-day mortality appears to be similar between conventionally treated patients and those undergoing endovascular repair.

Eligibility rates of ruptured and symptomatic AAA for endovascular repair.

To determine the anatomical eligibility rate for endovascular repair of ruptured and symptomatic abdominal aortic aneurysms (AAA) using commercially available endografts. In a retrospective review, 28 preoperative computed tomographic (CT) scans were examined from among 83 patients who underwent surgical repair of a ruptured or acutely symptomatic AAA at a university-based tertiary care center during the past 10 years. The proximal aortic neck, aneurysm, and iliac dimensions were compared to corresponding measurements from 100 preoperative CT scans from patients who underwent elective repair of asymptomatic AAA. Based on expanded selection criteria for the 2 FDA-approved endografts (AneuRx and Ancure), eligibility rates for endovascular repair were compared between patients with ruptured/symptomatic and asymptomatic AAAs. The proximal neck of the ruptured/symptomatic AAAs was on the average 2 mm larger in diameter (25 +/- 4 versus 23 +/- 3 mm, p=0.04) and 7 mm shorter (16 +/- 10 versus 23 +/- 14, p=0.017) than asymptomatic AAAs. The maximum AAA diameter was significantly larger in the ruptured/symptomatic group (64 +/- 16 mm) than in the asymptomatic group (58 +/- 11 mm, p=0.033). Of the 28 ruptured/symptomatic AAAs assessed morphologically, 13 (46%) were anatomically eligible for endovascular repair compared to 74 of the 100 asymptomatic AAAs (p=0.006). The main cause for exclusion was an unfavorable proximal neck, which was present in 15 (54%) of the 28 ruptured/symptomatic AAAs and in 24 (24%) of the 100 asymptomatic AAAs (p=0.003). A significantly smaller proportion of patients presenting with ruptured/symptomatic AAA are anatomically eligible for endovascular AAA repair compared to patients with asymptomatic AAA due to unfavorable proximal neck anatomy.

Hemostatic markers before operation in patients with acutely symptomatic nonruptured and ruptured infrarenal abdominal aortic aneurysm

Background: In patients with acutely symptomatic but nonruptured abdominal aortic aneurysm (AAA), emergent repair is associated with an increased mortality rate as compared with semi-elective repair. Previous results have shown that ruptured but not asymptomatic AAA repair is associated with intense thrombin generation and inhibition of systemic fibrinolysis. The purpose of this study was to determine whether circulating markers of coagulation and fibrinolysis may be used to distinguish acutely symptomatic nonruptured and ruptured AAA. Methods: A prospective study was performed of 44 patients who underwent emergency AAA repair for suspected rupture. Platelet count, fibrinogen level, prothrombin time, activated partial thromboplastin time, tissue plasminogen activator (t-PA) activity, plasminogen activator inhibitor (PAI) activity, prothrombin fragment (PF) 1+2 level, and D dimer level were measured before surgery. Results: When compared with ruptured AAAs (n = 37), acutely symptomatic nonruptured AAAs (n = 7) were associated with increased fibrinogen level (P =.033), reduced activated partial thromboplastin time (P =.043), increased t-PA activity (P =.023), reduced PAI activity (P =.005), reduced PF 1+2 level (P =.001), and reduced D dimer level (P =.005; all P values determined with Mann-Whitney test). The differences in t-PA activity (P =.01), PAI activity (P =.004), and PF 1+2 level (P =.01) persisted in patients whose conditions were normotensive. In all patients, a PF 1+2 level of greater than or equal to 2.5 nmol/L was associated with a sensitivity, specificity, and positive and negative predictive value for rupture of 89%, 86%, 97%, and 60%, respectively. In patients whose conditions were normotensive, PAI activity of greater than or equal to 16 AU/mL was associated with a sensitivity, specificity, and positive and negative predictive value of 83%, 100%, 100%, and 88%, respectively. Conclusion: These data show that acutely symptomatic nonruptured AAA is associated with increased systemic fibrinolysis (caused by reduced fibrinolytic inhibition) and reduced thrombin generation as compared with rupture. Preoperative hemostatic markers, particularly PF 1+2 level and PAI activity, may distinguish acutely symptomatic nonruptured from ruptured AAA. (J Vasc Surg 2002;35:661-5)

Treatment of abdominal aortic anastomotic pseudoaneurysm with percutaneous coil embolization

Intraabdominal anastomotic pseudoaneurysms continue to be a late complication of aortic reconstructive procedures. Early surgical repair is critical but is associated with high operative mortality rates. We present a patient who was diagnosed with a distal anastomotic pseudoaneurysm 13 months after transabdominal repair of a symptomatic abdominal aortic aneurysm. Because of the poor operative risk, the patient was considered for a less invasive approach and underwent coil embolization of the abdominal aortic anastomotic pseudoaneurysm. The patient remains without recurrence of pseudoaneurysm 3.5 years later. (J Vasc Surg 2002;35:811-4.)

Acute phase reactants in patients with abdominal aortic aneurysm

Background: There is increasing evidence that an inflammatory process is present in abdominal aortic aneurysms (AAAs) to varying degrees. The aim of this study was to compare acute phase reactants in patients with asymptomatic AAA, symptomatic AAA without rupture and ruptured AAA. Method: Two hundred and twenty-five consecutive patients treated because of AAA were included in this case-control study. Polynomial logistic regression analysis was applied to compare admission C-reactive protein (CRP) and white blood count (WBC) measured in 111 asymptomatic outpatients, 52 symptomatic patients without rupture and 62 patients with rupture of the aneurysm. We adjusted for the potentially confounding effect of age, sex, haemoglobin levels and aneurysm diameter. Results: Patients with symptomatic AAA and patients with ruptured AAA had significantly elevated CRP ( p=0.002) and WBC ( p<0.0001) levels compared to asymptomatic patients. There was no statistically significant difference in CRP and WBC between patients with symptomatic AAA and ruptured AAA. Median CRP values of asymptomatic, symptomatic and ruptured AAA were <0.5 (interquartile range (IQR) <0.5–0.85), 1.1(IQR <0.5–4.0) and 2.4 mg/dl (IQR 0.65–8.6), respectively, and median WBC values were 6.5 (IQR 5.5–8.0), 8.7 (IQR 6.8–11.2) and 13.2 (IQR 10.5–17.0), respectively. Conclusion: A significant elevation of CRP and WBC could be found in patients who presented with symptoms or rupture of an AAA. These indicators of inflammation were not observed in asymptomatic patients with AAA.

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.

Vascular 16

To assess the outcome for patients with nonoperated asymptomatic and symptomatic abdominal aortic aneurysm (AAA). Patients admitted between January 1995 and December 1999 with an AAA, who did not have surgical repair, were included. Demographic data, aneurysm size, reason for no operation, follow-up duration and cause of death were examined. Survival data were obtained from general practice and hospital records. Cause of death was identified from the General Register Office for Scotland. Of the 758 patients admitted with AAA, 128 had intact lesions and did not undergo operation. These comprised 77 men and 51 women of median (range) age 73 (60–92) years; 75 (59 per cent) had an asymptomatic and 53 (41 per cent) had a symptomatic lesion. The median (range) AAA diameter was 55 (27–85) mm for asymptomatic and 55 (33–100) mm for symptomatic lesions. The commonest reasons for not operating were significant comorbidity in 73 (57 per cent) and small aneurysm size in 32 (25 per cent). Overall, follow-up was for a median (range) of 19 (1–74) months. In the asymptomatic group, 31 (41 per cent) patients were alive, 26 (35 per cent) having died from a cause unrelated to the AAA and 15 (20 per cent) from the AAA; 3 (4 per cent) were lost to follow-up. In the symptomatic group, 18 (34 per cent) were alive, 23 (43 per cent) having died from an unrelated cause and 12 (23 per cent) from the AAA. Of the 127 patients in both groups, only 27 (21 per cent) died from their AAA. Only one-fifth of patients with AAA who were not operated had an aneurysm-related death.

Cytokines as Plasma Markers of Abdominal Aortic Aneurysm

The pathogenesis of abdominal aortic aneurysms (AAA) is a complex process in which atherosclerosis and inflammation play a leading role. Cytokines are important mediators of both processes. The aim of our study was to determine whether plasma levels of cytokines which are most involved in AAA pathogenesis can be used as endogenous markers of AAA development, and thus to facilitate the decision on surgical intervention in cases when this is clinically unclear (e.g. small AAA). In the prospective study a total of 90 patients with AAA were examined. These patients were divided into the following groups according to symptoms and AAA diameter: symptomatic AAAs, including ruptures (n=16); asymptomatic AAAs (n=74); AAAs with a diameter of up to 5 cm (n=30), AAAs of 5-8 cm (n=38), and AAAs with a diameter over 8 cm (n=22). The average age of the patients was 70.7 (56-82) years. The male to female ratio was 4:1 (71:19). A control group consisted of 30 healthy individuals of similar age and sex presentation with no manifestation of atherosclerosis. Plasma levels of cytokines were assessed in venous blood by means of radio- or enzymo-immunoassay. Statistical processing of the results was conducted with ANOVA and Wilcoxon tests with Spearman correlation, where p<0.05 was considered to be statistically significant. Plasma concentrations of cytokines were significantly higher in AAA patients than in healthy individuals. In AAA patients the tumour necrosis factor-alpha (TNF-alpha) and interleukin (IL-8) levels were low in large and in symptomatic AAAs. IL-6 levels were increased with increasing AAA diameter and symptoms. IL-8 levels (p<0.05) showed a statistically significant correlation with the diameter, and TNF-alpha (p<0.05) with the symptoms of AAA. IL-1beta, IL-2 and IL-6 did not show any significant changes with different AAA diameter or symptomatology. IL-8 and TNF-alpha can be used as endogenous markers of the process of AAA development, in deciding for either surgical or endovascular treatment of patients when the clinical indication is not entirely clear.

Mortality Rates following Endovascular Repair of Abdominal Aortic Aneurysms

Purpose: To present the perioperative and late mortality following endovascular repair (EVR) of abdominal aortic aneurysms (AAAs). Methods: Data were collected prospectively on 221 patients undergoing AAA EVR over a 4-year period (median 5-month follow-up). Patients were classified preoperatively as high risk with at least 1 of these features: serum creatinine &gt; 150 μmol/L, ischemic heart disease or poor left ventricular function, respiratory function &lt; 50% of predicted normal, ruptured or symptomatic AAA, contraindication to or failed open repair, and age &gt; 80 years. Results: One hundred forty (63.3%) patients were classified as high risk, the most common criterion being cardiac disease (n = 96, 68.6%). There were 25 (11.3%) deaths in the 30-day perioperative period, 22 (15.7%) in the high-risk group compared to 3 (3.7%) in the acceptable-risk group (p = 0.02). The most common causes of perioperative death were multisystem organ failure and myocardial infarction. A further 21 (9.5%) late deaths occurred, 16 (11.4%) in the high-risk group and 5 (6.2%) in the acceptable-risk group (p &gt; 0.1). Conclusions: The mortality of patients at acceptable risk undergoing EVR compares with the best published series for conventional open AAA repair. The perioperative and late mortality in the high-risk patients are substantially higher.

Plasma Endothelin Levels in Patients with Abdominal Aortic Aneurysms

Objectives: endothelin 1,2 plays a significant role in the process of atherogenesis and vascular wall injury. The aim of this study was to assess whether plasma endothelin 1,2 levels were elevated in patients with large or symptomatic abdominal aortic aneurysms (AAAs). Design: a prospective open study. Materials and methods: plasma endothelin 1,2 levels were measured in 65 consecutive patients with infrarenal aortic aneurysms and compared with the levels in 44 healthy volunteer controls. The data for abdominal aneurysm patients was analysed in four subgroups: (i) small aneurysms (<5 cm), (ii) large aneurysms (≥5 cm), (iii) asymptomatic aneurysms and (iv) symptomatic aneurysms. Comparisons were made between endothelin 1,2 levels in aneurysm patients and controls and between the different aneurysm subgroups. Results: a highly significant difference (p<0.0001) was found between aneurysm patients and controls. Patients with large aneurysms had significantly higher levels than patients with small aneurysms (p<0.01). There was no statistical difference in endothelin 1, 2 levels between symptomatic and asymptomatic patients; however, the highest levels were found in large, symptomatic aneurysms and the lowest in small, asymptomatic aneurysms. Conclusions: plasma endothelin 1,2 is an endogenous marker of aneurysm diameter. Further studies are required to determine whether it relates to the rate of growth of aneurysms.

One-Stage Coronary Bypass and Abdominal Aortic Aneurysm Repair

A group of 29 patients with simultaneous coronary disease and abdominal aortic aneurysm were treated two protocols: Group I, 16 patients had coronary bypass surgery and then abdominal aortic aneurysm repair at a later date. This required two hospitalizations and two separate surgeries. Group II, 11 patients, underwent coronary bypass surgery and repair of abdominal aortic aneurysm (AAA) in one sitting. Group III, 2 patients, had PTCA prior to AAA repair. There were 3.1 bypass grafts implanted (Group I), vs 2.9 (Groups II) (ns). All abdominal aneurysms were infrarenal and 22 patients had straight tube graft replacement (76%), and seven bifurcated grafts. Two patients with angina also had symptomatic AAA. Period of hospitalization, morbidity, mortality, time of total recovery, hospital costs, and apprehension of patients were analyzed. There was one death in Group I. In this group, the total recovery time was 4.8 months vs 2.4 months for Group II. Hospitalization time was 16.2 days in Group I vs 8.2 days in Group II. The hospital costs were significantly higher in Group I with an average of $58,950 vs $46,553 in Group II. No deaths occurred in Group II. It is recommended that if a patient with severe coronary disease requiring surgery also presents with an AAA of more than 5 cm, he/she should have both conditions operated on in one session rather than staggering the procedures. It saves time, cost, anxiety, and is well tolerated.

Failure to demonstrate Chlamydia pneumoniae in symptomatic abdominal aortic aneurysms by a nested polymerase chain reaction (PCR)

To investigate whether Chlamydia pneumoniae is present in symptomatic abdominal aortic aneurysms (AAA). After optimisation of DNA extraction procedures an inhibitor-controlled nested polymerase chain reaction (PCR) amplifying fragments of the gene encoding the C. pneumoniae specific major outer membrane protein was performed on 124 wall-specimens from 20 patients with symptomatic AAA. None of the specimens contained C. pneumoniae-specific DNA. Minor inhibition of the PCR was noticed especially in media specimens. Using a sensitive and specific nested PCR, we were not able to detect C. pneumoniae in symptomatic AAA. The failure to detect C. pneumoniae in symptomatic AAA, combined with previously reported positive findings in atherosclerotic lesions, supports the hypothesis that AAA and atherosclerosis might be two different disease entities.

A critical approach for longitudinal clinical trial of stretch PTFE aortic grafts

Adaptation of new clinical products should be based upon thorough scientific evaluation of properties and performance in vitro and in vivo. Developmental animal research experimentation is classically carried out by the manufacturer with eventual government approval. However, objective data needs to be recorded during clinical trials including handling characteristics, bleeding, tensile strength, kinking, seamline break, dilatation, anastomotic deterioration, patency, and incorporation. Since April 1991, 1010 stretch polytetrafluoroethylene (PTFE) aortic grafts have been implanted at our institution and data were recorded prospectively. Six hundred and seven were for elective abdominal aortic aneurysms, 46 for symptomatic abdominal aortic aneurysms, 58 for ruptured abdominal aortic aneurysms, 17 for elective thoracoabdominal aneurysms, 3 for ruptured thoracoabdominal aneurysms and the remainder were for various aortoiliac pathology. Average age of the patients was 69 (range: 10-95), 66% were males, 25% were diabetics. Overall operative mortality was 5.8% (2.9% in elective cases and 26.6% in emergent cases). There were 23 occlusions; 21 were revised and 2 were replaced with axillofemoral bypasses. Estimated blood loss was 784 cc in elective cases and 1918 cc in emergent cases. Grafts were followed by duplex ultrasound or CT scan every 3 months during the first year and every 6 months thereafter. There were no graft dilatations or false aneurysms in this series. There was one graft infection and no perigraft seromas or anastomotic deteriorations during this follow up. Follow up was complete in 94% of these patients. In conclusion, stretch PTFE graft has acceptable handling characteristics, no excessive bleeding at the suture line and had no anastomotic or graft dilatation. This graft material was suitable for thoracic, visceral, renal and abdominal aortic reconstructions.

Fatal colonic ischaemia after stent graft for aortic aneurysm

The development of new technology has led to renewed interest among both surgeons and radiologists in the treatment of infrarenal aortic aneurysms by endovascular techniques. Parodi and Palmaz pioneered the endovascular repair of aortic aneurysms using a straight stent graft. 1 Chuter et al. developed a means of deploying a bifurcated graft via the transfemoral route 2 and other series have been reported recently. 3 However, all new techniques have a learning curve. We report a case of fatal internal iliac artery embolism associated with insertion of a stent graft used to treat a symptomatic abdominal aortic aneurysm.

The influence of age on operative mortality and long-term relative survival following emergency abdominal aortic aneurysm operations

To study operative mortality and long-term survival following emergency operations for abdominal aortic aneurysm. Retrospective survey in a university hospital. Two hundred and twenty-seven patients with median age 72 years, (17% women). Founded on data from the Norwegian Registrar's Office, operative mortality and long-term survival was estimated using the life-table method. Expected survival for demographically matched subgroups was calculated from death rate tables issued by the Norwegian Central Bureau of Statistics. Operative mortality was 41% for the 175 patients with ruptured aneurysms and 17% for the 52 with imminent rupture. The 6-year survival rate was 61% for all the successfully operated patients, and not different from that of a demographically matched population. For the patients of 72 years or older the 6-year survival rate was 53%. This was equal to that of an age and sex matched population. The younger patients had an observed 6-year survival rate of 64%, which was significantly lower than the expected of 84%. The standard mortality rate for this group was 2.25. No statistically significant difference in long-term survival was detected between the two age groups. Age at the time of the operation for a symptomatic abdominal aortic aneurysm does not seem to influence long-term survival. Consequently, younger patients experience a higher relative mortality compared to the older.

Ten-year experience with abdominal aortic aneurysm repair in octogenarians: Early results and late outcome

This study was undertaken to determine the mortality and morbidity rates associated with abdominal aortic aneurysm (AAA) repair in octogenarians and to identify factors that may influence survival in this age group. One hundred fourteen patients (mean age 83 years) were admitted consecutively with 106 infrarenal and eight juxtarenal AAAs from 1984 through 1993. Ninety-four AAAs were asymptomatic, whereas 20 patients with symptoms had 11 intact and nine ruptured AAAs. The mean AAA diameter was 6.7 cm. Repair consisted of aortic bifurcation grafts in 77 patients (67%), tube grafts in 35 (31%), and extraanatomic procedures in 2 (2%). A total of 29 patients (25%) had undergone previous coronary artery bypass (24 patients) or transluminal coronary angioplasty (five patients) either incidentally or as a preliminary procedure before resection of their AAAs. The 30-day mortality rate for the entire series was 14%, but it declined from 23% (11/48) during the first 5 years to 8% (5/66) during the second 5 years of the study period (p = 0.028). Fatal complications occurred in nine (9.6%) of the 94 patients with asymptomatic AAAs and in seven (35%) of the 20 patients who had symptomatic AAAs (p = 0.008). Considering only patients with asymptomatic AAAs, the early mortality rate in the second 5 years (4%) improved significantly (p = 0.038) in comparison to that (17%) for the first 5 years of the study period. The cumulative 5-year survival rate of 48% for 97 available operative survivors was not quite so good as that (59%) for the normal male population of the United States at the age of 80 years (p < 0.0001). Nevertheless, the 5-year survival rate was 80% for 27 operative survivors who received previous myocardial revascularization compared with 38% for 70 others who did not (p = 0.0077). Multiple Cox-regression analysis identified the perioperative homologous blood requirement (p = 0.03) and a history of previous myocardial revascularization (p = 0.03) as significant independent factors influencing late survival. Repair of AAAs in properly selected octogenarians is safe and durable. When otherwise indicated, it should not be withheld on the basis of advanced age alone. Prior treatment of severe coronary artery disease is associated with enhanced late survival, but patient selection probably is an important consideration in this respect.