A patient with aortic dissection and abdominal aortic aneurysm with fistula

Aneurysm of the abdominal aorta is not uncommon in later life. The frequency of aneurysm rupture varies with aneurysm diameter. In rare cases, the aneurysm may rupture intra-abdominally into surrounding structures and give rise to a fistula. When blood vessels are involved, the commonest form is aortocaval fistula, the presenting symptoms being those of severe right-ventricular heart failure. Although thoracic aorta dissection may be made manifest in acute intense chest pain, it is asymptomatic in up to 50 per cent of cases. The article consists in a case report of asymptomatic thoracic aorta dissection occurring concomitantly with a ruptured abdominal aneurysm the symptoms of which were severe right ventricular heart failure due to an aortocaval fistula causing increased pressure, and severe bilateral oedema of the legs. If the rare complication of an aortocaval fistula could be detected earlier, it might be possible to prevent progression to refractory cardiac failure. The possibility of a fistula should be borne in mind if haematuria is present in a case of abdominal aneurysm or a pulsatile abdominal mass is present in conjunction with a murmur.     

Intravenous rupture of arteriosclerotic aneurysms of the abdominal aorta

Intravenous rupture of abdominal aortic aneurysms occurs infrequently but should be considered with the coexistence of severe congestive failure, anasarca, and abdominal bruits. Six patients are presented with four survivors. In only two patients was the diagnosis considered preoperatively without angiography. Two were variants in that thrombus occluded the fistula, thereby negating findings usually manifested clinically. Diagnosis of this type can be made only during operation when copious venous bleeding ensues with evacuation of the aortic thrombus. Careful fluid management and prompt surgery are prerequisites to obtaining a successful outcome. Repair is accomplished easily by suturing the fistula from the aortic aspect, but care is required to avoid dislodgement of thrombus and atherosclerotic debris resulting in pulmonary embolism.     

Comparative efficacy of chloroquine plus chlorpheniramine and halofantrine in acute uncomplicated falciparum malaria in Nigerian children

A 47-year-old woman on long-term hemodialysis due to a chronic isolated abdominal aortic dissection was admitted to our department with severe abdominal pain. She had not suffered any hematemesis or melena. An emergency laparotomy revealed an abdominal aortic aneurysm with a diameter of 60mm, densely adhered to the ileum. An aortoenteric fistula manifesting as intramural rupture into the ileum was found after infrarenal abdominal aortic and bilateral common iliac cross-clamping. The fistula on the ileac side was nontransmural, but that on the aortic side communicated with the pseudolumen of the abdominal aorta, and contained mural thrombus. The infrarenal abdominal aorta and bilateral common iliac arteries were replaced with a collagen-sealed woven Dacron bifurcated graft. Histological examination of the ileum in this portion showed intramural bleeding and xanthomatous granulation with foam cell infiltration in the thickened subserosa. While it is difficult to diagnose nonpenetrating aortoenteric fistula preoperatively, such a fistula must be considered in a patient with severe abdominal pain, for whom previous abdominal aortic surgery has been performed or when an abdominal aneurysm is observed. To our knowledge, no other case of an aortoenteric fistula presenting as an intramural rupture into the ileum in an isolated abdominal aortic dissection has ever been reported.     

Diagnosis and treatment of abdominal aortic aneurysms

Abdominal aortic aneurysms occur in 5 to 7 percent of people over age 60 in the United States. An aneurysm is defined as a permanent localized dilatation of an artery, with an increase in diameter of greater than 1.5 times its normal diameter. Abdominal aortic aneurysms may be manifested by catastrophic rupture, signs of pressure on other viscera or an embolism originating in the aneurysmal wall, but most cases are asymptomatic. The diagnosis is often made by physical examination of the abdomen, which reveals a pulsatile mass left of the midline, between the xyphoid process and the umbilicus. The diagnosis may be confirmed by B-mode ultrasound. Ultrasound screening should be considered for individuals at risk for abdominal aortic aneurysms. This group includes individuals over age 60 who smoke, have hypertension or have vascular disease. Elective surgical intervention is indicated for most patients with abdominal aortic aneurysms greater than 5 cm in diameter to prevent rupture and death. Smaller abdominal aortic aneurysms should be monitored by regular ultrasound measurements. Screening and identification of abdominal aortic aneurysms by primary care physicians can have a significant impact on patient survival.     

A unique method of closure for an aortocaval fistula in association with a ruptured abdominal aortic aneurysm: report of a case

We report herein the case of a 78-year-old man in whom an aortocaval fistula caused by spontaneous rupture of an abdominal aortic aneurysm (AAA) was successfully treated by a unique surgical technique. The aortocaval fistula had been revealed by an aortography after the patient presented with high-output heart failure. During the operation, massive bleeding from the fistula was evident. The fistula measured 2 cm in diameter, and was located between the right posterior wall of the AAA and the inferior vena cava (IVC). Direct suturing of the defect in the IVC failed to close the fistula because the tissue around it would not hold together due to degeneration. However, the bleeding was finally able to be controlled by plugging the fistula with isolated and properly trimmed omentum packed within the excluded aneurysmal sac. Unfortunately, the patient died due to respiratory failure on the 201st postoperative day. A pathological autopsy revealed that the aortocaval fistula had been closed by fibrous tissue and that the IVC was patent. Although such a drastic operative measure to repair an aortocaval fistula has never before been reported, it could be an alternative when direct closure proves unsuccessful.     

Improved prognosis of thoracic aortic aneurysms: a population-based study

CONTEXT: Managing thoracic aortic aneurysms identified incidentally by increased use of computed tomography, echocardiography, and magnetic resonance imaging is problematic, especially in the elderly. OBJECTIVE: To ascertain whether the previously reported poor prognosis for individuals with thoracic aortic aneurysms has changed with better medical therapies and improved surgical techniques that can now be applied to aneurysm management. DESIGN: Population-based cohort study. SETTING AND PATIENTS: All 133 patients with the diagnosis of degenerative thoracic aortic aneurysms among Olmsted County, Minnesota, residents between 1980 and 1994 compared with a previously reported cohort of similar patients between 1951 and 1980. MAIN OUTCOME MEASURES: The primary clinical end points were incidence, cumulative rupture risk, rupture risk as a function of aneurysm size, and survival. RESULTS: In contrast to abdominal aortic aneurysms, for which men are affected predominately, 51% of thoracic aortic aneurysms were identified in women who were considerably older at recognition than men (mean age, 75.9 vs 62.8 years, respectively; P= .01). The overall incidence rate of 10.4 per 100000 person-years (95% confidence interval [CI], 8.6-12.2) between 1980 and 1994 was more than 3-fold higher than the rate from 1951 to 1980. The cumulative risk of rupture was 20% after 5 years. Seventy-nine percent of ruptures occurred in women (P= .01). The 5-year risk of rupture as a function of aneurysm size at recognition was 0% for aneurysms less than 4 cm in diameter, 16% (95% CI, 4%-28%) for those 4 to 5.9 cm, and 31% (95% CI, 5%-56%) for aneurysms 6 cm or more. Overall 5-year survival improved to 56% (95% CI, 48%-66%) between 1980 and 1994 compared with only 19% between 1951 and 1980 (P<.01). CONCLUSIONS: In this population, elderly women represent an increasing portion of all patients with clinically recognized thoracic aortic aneurysms and constitute the majority of patients whose aneurysm eventually ruptures. Overall survival for thoracic aortic aneurysms has improved significantly in the past 15 years.     

Abdominal aortic aneurysms in sheep: prevention of rupture with endoluminal stent-grafts

PURPOSE: The authors evaluated the ability of an aortic balloon-expandable endovascular stent-graft to prevent rupture in a model of spontaneously rupturing abdominal aortic aneurysms in sheep. MATERIALS AND METHODS: Aneurysms were created in 16 sheep by inserting a 60 x 18-mm segment of the left internal jugular vein, end-to-end anastomosed, to the sectioned infrarenal abdominal aorta. The sheep were randomly assigned into two groups; eight animals underwent endovascular implantation of an 80 x 12-mm balloon expandable stent-graft (group A), and eight were only followed up (group B). RESULTS: In group B, seven of eight animals had died of aneurysmal rupture by 3 months. In group A, six of the eight aortic aneurysms were immediately excluded, and six animals were alive at 3 months without rupture. The 3-month survival rate was 100% in group A and 12% in group B (P = .0023). Macro- and microscopic analysis of the section of the aorta in which the stent-graft had been placed revealed rapid retraction of the aneurysmal sac. CONCLUSION: Placement of an endovascular stent-graft induced regression of a branchless aneurysm and prevented rupture.     

Aortocaval fistula. Diagnosis using spiral x-ray computed tomography with 2D and 3D reconstructions

We report a case of arteriovenous fistula due to spontaneous rupture of an aortic aneurysm into the inferior vena cava. This is a rare complication of atheromatous aneurysm, often difficult to diagnose as the clinical presentation may be obscure. Although aortography is the reference diagnostic investigation, spiral CT acquisition with 3D and 2D reformation allowed visualization of the arteriovenous communication and provided an accurate diagnosis.     

Retroperitoneal approach for repair of inflammatory aortic aneurysms

Inflammatory aortic aneurysms (IAAs) are characterized by a markedly thickened aortic wall and dense perianeurysmal fibrosis. The presence of such inflammation and subsequent organ adherence makes surgical repair of IAAs more challenging than repair of simple atherosclerotic aneurysms. From March 1987 to June 1994, twelve patients underwent surgical repair of an IAA by a single surgeon. Ten patients were men (83%) and the mean age was 68.3 years (range 58 to 93 years). All patients except one were symptomatic with back or abdominal pain, yet none had evidence of aneurysm rupture at operation. Preoperatively 90% (9/10) of the patients had an elevated erythrocyte sedimentation rate (ESR), 100% (12/12) had a predictive CT scan, and all patients with aortic wall pathology specimens had their diagnosis confirmed. Six patients had a left flank retroperitoneal surgical approach, five had a transabdominal approach, and one had ligation and extra-anatomic reconstruction. The choice of repair technique was based on the degree and anatomic distribution of perianeurysmal fibrosis. The 30-day operative mortality rate was 0%. Mean follow-up was 56.3 months. Aortoduodenal fistula occurred in one patient 5 months after transperitoneal repair. Technical difficulties encountered during subsequent transperitoneal repairs led to the evolution of a policy in which the retroperitoneal approach was preferred in all patients with CT evidence of IAA. It is concluded that IAA represents a spectrum of retroperitoneal fibrosis and inflammation that is best treated surgically via a retroperitoneal approach.     

Expansion pattern and risk of rupture of abdominal aortic aneurysms that were not operated on

OBJECTIVE: To analyse the outcome of selective management of patients with abdominal aortic aneurysms, the expansion patterns of the aneurysms, and the factors that influenced the rate of rupture. DESIGN: Retrospective study. SETTING: Malm? General Hospital, Lund University, Malm?, Sweden. SUBJECTS: 155 patients (96 men and 59 women) with abdominal aortic aneurysms who were not selected for operation for whatever reason were included in the study immediately after their first ultrasound scan. MAIN OUTCOME MEASURES: Mortality, expansion rate (mm/year) measured on ultrasound scan, and rate of rupture of aneurysm. RESULTS: Median aneurysmal diameter was 40 mm (range 20-80), and length (n = 106) 70 (range 28-140). The patients were followed up for a median of 3.4 years (range 0-10.2). A total of 107 patients died and in 21 the aneurysms ruptured (4 were operated on and survived). Thirteen patients were re-evaluated and operated on electively. Ultrasonography was repeated in 98 patients, the median expansion rates (mm/year) were 3.1 (diameter) and 1.9 (length). There was a significant linear relationship between initial size (diameter and length) and rate of expansion of diameter. The risk of rupture was greater in larger aneurysms that were expanding more quickly. The cumulative mortality was not affected by the 21 aneurysms that ruptured. CONCLUSION: Selective management of patients with aortic aneurysms is justified.     

Fetal cells in maternal blood: recovery by charge flow separation

PURPOSE: To screen patients with abdominal aortic aneurysm for popliteal aneurysm and investigate cardiovascular and genetic risk factors associated with aneurysmal disease at more than one site (generalised aneurysmal disease). SUBJECTS, DESIGN AND SETTING: All patients referred to the Regional Vascular Surgical Service at Charing Cross Hospital with unruptured abdominal aortic aneurysm between 1989 and 1993 were screened for popliteal aneurysms, using ultrasonography. MAIN OUTCOME MEASURES: Palpation of a popliteal aneurysm or ultrasonographic detection of popliteal dilatation, where the ratio maximum popliteal fossa diameter/suprageniculate popliteal diameter was > or = 1.5, in relation to cardiovascular and genetic risk factors. RESULTS: Clinical examination detected popliteal aneurysms in only 11/232 patients (5%), but ultrasonography demonstrated the presence of popliteal aneurysm in a further 13 patients, 24/232 in total (10%). Multivariate regression identified four independent factors associated with popliteal dilatation disease: age (p = 0.046), height (p = 0.006), systolic hypertension (p = 0.037) and triglyceride concentration (p = 0.009). Generalised aneurysmal disease and systolic blood pressure were associated with polymorphic variation in the fibrillin-1 gene, but not with variations in the apolipoprotein B and type III collagen genes. CONCLUSIONS: Few patients with abdominal aortic aneurysm (10%) also have popliteal aneurysms: the risk of popliteal dilatation increases with age, height, systolic blood pressure, triglyceride concentration and fibrillin genotype. The strong interaction between fibrillin genotype and blood pressure may contribute to the familial tendency to aortic aneurysm.     

Infrarenal aortic dimensions in siblings of patients with infrarenal abdominal aortic aneurysm or aortoiliac occlusive disease

OBJECTIVE: To compare the dimensions of the infrarenal aorta and the prevalence of undiagnosed infrarenal abdominal aortic aneurysms in the siblings of patients operated on for either infrarenal abdominal aortic aneurysm or aortoiliac occlusive disease. DESIGN: Prospective screening study. SETTING: University hospital, Finland. SUBJECTS: 220 siblings of patients operated for either abdominal aortic aneurysm or aortoiliac occlusive disease. INTERVENTIONS: Abdominal aortic ultrasound. MAIN OUTCOME MEASURES: Anteroposterior and transversal diameters of infrarenal and suprarenal aorta. RESULTS: There was a group of 5 siblings (4 men and 1 woman, aged 59 years or more) among the aneurysm patients who had a disposition to infrarenal aneurysm formation defined as a dilatation of 30 mm or more. This contrasted with none among the siblings of the patients with aortoiliac occlusive disease (p = 0.07, 95% confidence interval 0.49 to 165.3). The two factors affecting the diameter of the infrarenal aorta were age and sex. The aortic dimensions tended to be bigger in the siblings of the aneurysm patients but the differences were not significant. The ratio of infrarenal to suprarenal diameter was bigger in the siblings of the aneurysm patients also after excluding the cases with detected dilatations (p = 0.05) and in the multivariate analysis the only factor explaining this difference was the type of the disease of the proband. CONCLUSIONS: The screening of male siblings (over 55 years old) of patients with infrarenal abdominal aortic aneurysms might be justified.     

Consumption coagulopathy associated with a case of an abdominal aortic aneurysm

Consumption coagulopathy with clinical symptoms reveals aortic arterial aneurysms in less than 5% of cases. The authors report a case of abdominal aortic aneurysm: surgical repair is able to remove the hemostasis abnormalities for a long time. Implications of the consumption coagulopathy are analyzed: diagnosis, preoperative correction of the coagulopathy, surgical technique.     

The role of gammadelta T cells in induction of bacterial antigen-specific protective CD8+ cytotoxic T cells in immune response against the intracellular bacteria Listeria monocytogenes

PURPOSE: To study the relation between abdominal aortic aneurysms and chronical obstructive pulmonary disease (COPD), in particular the suggested common elastin degradation caused by elastase and smoking. METHODS: A cross-sectional population study and a prospective cohort study of small abdominal aortic aneurysms was performed in a community setting. All previous diagnoses recorded in a hospital computer database were received for 4404 men 65 to 73 years of age who had been invited to a population screening for abdominal aortic aneurysm. One hundred forty-one men had AAA (4.2%). They were asked to participate in an interview, a clinical examination, and collection of blood sample. Men with an abdominal aortic aneurysm 3 to 5 cm in diameter were offered annual ultrasound scans to check for expansion. RESULTS: Among patients with COPD 7.7% had abdominal aortic aneurysms (crude odds ratio=2.05). The adjusted odds ratio, however, was only 1.59 after adjustment for coexisting diseases associated with abdominal aortic aneurysm (P=.13). The mean annual expansion was 2.74 mm per year among patients with COPD, 2.72 among patients without COPD, and 4.7 mm among patients who used oral steroids compared with 2.6 among patients who did not use steroids (P < .05). Concentration of serum elastin peptide and plasma elastase-alpha1-antitrypsin complexes correlated negatively with forced expiratory volume in the first second (FEV1) among patients with COPD. However, multivariate regression analysis showed that concentration of serum elastin peptide, therapy with beta-agonists, and FEV1 correlated positively with degree of expansion but that concentration of plasma elastase-alpha1-antitrypsin complexes and serum alpha1-antitrypsin did not influence expansion, suggesting that elastase plays an important role in the pathogenesis of COPD but not of abdominal aortic aneurysm. CONCLUSION: The high prevalence of abdominal aortic aneurysm among patients with COPD is more likely to be caused by medication and coexisting diseases rather than a common pathway of pathogenesis.     

Surgical treatment of coronary artery aneurysm with rupture into the right atrium

Considering the increasing number of patients with chest pain who undergo routine coronary artery arteriography, coronary artery aneurysm may be found more frequently. To know how to manage these aneurysms, we must understand their possible complications. The aneurysms can produce symptoms of angina or acute myocardial infarction by total thrombosis of the aneurysm and vessel, embolism to the distal vessel, or progressive enlargement and encroachment upon the distal vessel until it is occluded. Moreover, the aneurysm may enlarge and rupture into the free pericardium or produce a fistula by eroding into a chamber of the heart. The case described herein may represent the first reported case of a coronary artery aneurysm eroding into a cardiac chamber and causing an arteriovenous fistula. The treatment of choice is resection of the aneurysm, closure of the fistula, and re-establishment of continuity of the distal coronary artery with a saphenous vein bypass graft.     

Fate of the excluded abdominal aortic aneurysm sac: long-term follow-up of 831 patients

PURPOSE: Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed. METHODS: From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed. RESULTS: The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 +/- 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted. CONCLUSION: Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.     

Endoleaks after endovascular graft treatment of aortic aneurysms: classification, risk factors, and outcome

PURPOSE: Incomplete endovascular graft exclusion of an abdominal aortic aneurysm results in an endoleak. To better understand the pathogenesis, significance, and fate of endoleaks, we analyzed our experience with endovascular aneurysm repair. METHODS: Between November 1992 and May 1997, 47 aneurysms were treated. In a phase I study, patients received either an endovascular aortoaortic graft (11) or an aortoiliac, femorofemoral graft (8). In phase II, procedures and grafts were modified to include aortofemoral, femorofemoral grafts (28) that were inserted with juxtarenal proximal stents, sutured endovascular distal anastomoses within the femoral artery, and hypogastric artery coil embolization. Endoleaks were detected by arteriogram, computed tomographic scan, or duplex ultrasound. Classification systems to describe anatomic, chronologic, and physiologic endoleak features were developed, and aortic characteristics were correlated with endoleak incidence. RESULTS: Endoleaks were discovered in 11 phase I patients (58%) and only six phase II patients (21%; p < 0.05). Aneurysm neck lengths 2 cm or less increased the incidence of endoleaks (p < 0.05). Although not significant, aneurysms with patent side branches or severe neck calcification had a higher rate of endoleaks than those without these features (47% vs 29% and 57% vs 33%, respectively), and patients with iliac artery occlusive disease had a lower rate of endoleaks than those without occlusive disease (18% vs 42%). Endoleak classifications revealed that most endoleaks were immediate, without outflow, and persistent (71% each), proximal (59%), and had aortic inflow (88%). One patient with a persistent endoleak had aneurysm rupture and died. CONCLUSIONS: Endoleaks complicate a significant number of endovascular abdominal aortic aneurysm repairs and may permit aneurysm growth and rupture. The type of graft used, the technique of graft insertion, and aortic anatomic features all affect the rate of endoleaks. Anatomic, chronologic, and physiologic classifications can facilitate endoleak reporting and improve understanding of their pathogenesis, significance, and fate.     

Ruptured arteriosclerotic aneurysm of the splenic artery

A case of arteriosclerotic aneurysm of the splenic artery with rupture into the transverse colon resulting in secondary perforation of the cecum is presented. Symptomatology, diagnosis and treatment of aneurysms of the splenic artery are briefly illustrated. Aneurysm of the splenic artery must be suspected by the presence of uncharacteristic upper abdominal pain and the annular calcification in the left upper quadrant on roentgenogram. The diagnosis is verified by arteriography. Operation of all symptomatic splenic artery aneurysms is recommended. Asymptomatic aneurysms measuring more than 3 cm in diameter and aneurysms with radiographic evidence of enlargement, should be operated too.     

Continuous spinal analgesia. Comparison between patient-controlled and bolus administration of plain bupivacaine for postoperative pain relief

The purpose of this study was to examine the changing trends in surgical management of patients with abdominal aortic aneurysms at a tertiary care teaching hospital over the past 40 years, by analysis of demographic data, perioperative variables and outcomes on all patients having abdominal aortic aneurysm surgery between 1955 and 1993. Some 1604 abdominal aortic aneurysms were assessed. The annual rate of abdominal aortic aneurysm surgery increased from 17.6 to 67.8 cases per year. The non-ruptured to ruptured abdominal aortic aneurysm ratio increased from 2.4:1 in the first decade to 3.4:1 in the last 5 years. In non-ruptured abdominal aortic aneurysm repairs, the following variables changed over the four decades: patients age over 80 years increased (2.4% to 8.0%; P<0.04), concomitant lower-limb occlusive disease increased (12.2% to 23.7%; P<0.02), prevalence of smaller aneurysms (4-6 cm) increased (16.0% to 54.2%; P<0.0001); intraoperative hypotension decreased (9.0% to 0.7%; P<0.0001), postoperative hemorrhage decreased (8.2% to 0.0%, P<0.0001), postoperative leg ischemia decreased (5.7% to 1.1%; P<0.02) and postoperative amputation rate decreased (3.2% to 0.0%; P<0.03). There was a significant decrease in perioperative mortality (17.0% to 3.4%; P<0.0001). For ruptured aneurysms, early operation (within 1 h of admission) increased from 8.7% to 55.8% (P<0.0001), prevalence of intraoperative hypotension decreased (50.0% to 23.5%; P<0.001), and major venous injury decreased (18.0% to 5.2%; P<0.05). Mortality, however, did not decrease significantly (54.2% to 44.2%; P=0.32). In conclusion, there was a significant decrease in mortality and morbidity associated with non-ruptured abdominal aortic aneurysm repair over the four decades studied. In addition, older patients with smaller aneurysms and more co-morbid conditions were operated on during this period. Mortality for patients operated on for ruptured abdominal aortic aneurysm repair has not changed significantly.     

Rupture of an abdominal aortic aneurysm following acute descending thoracic aortic dissection. Case report

The coexistence of an abdominal aortic aneurysm and an acute aortic dissection seems to be rare and only a few reports are to be found in the literature. We report a case of a patient with acute aortic dissection of the descending thoracic aorta that caused rupture of a pre-existing abdominal aortic aneurysm. The literature is also thoroughly reviewed.