Evaluation of the surgical risk in surgery of aneurysms of the abdominal aorta. Therapeutic deductions. Apropos of a retrospective study of 250 surgically treated aneurysms

A retrospective study of 250 patients operated upon for infrarenal abdominal aorta aneurysm provided data for evaluation of the surgical risk as a function of three developmental situations: asymptomatic aneurysms, aneurysms evolving by subacute symptomatology and ruptured aneurysms. Mortality varied as a function of group, being 3% for the asymptomatic group, 21% for evolving aneurysms and 69% for ruptured aneurysms. Perioperative mortality was related to age and cardiovascular risk factors. Various clinical and pathologic aspects as well as means of follow up review are discussed, allowing definition of therapy as a function of previous clinical status and evolution of the aneurysm.     

The mortality of abdominal aortic aneurysm.

During a five year period 153 patients presented with abdominal aortic aneurysms and 135 received grafts. The mortality was 4.2% (3 of 71) for elective cases, 16.7% (2 of 12) for acute cases (the preoperative diagnosis of rupture found to be incorrect) and 55.8% (29 of 52) for patients with ruptured aneurysms. For patients with ruptured aneurysms there was a trend towards larger amounts of blood and colloid infusion in patients who died compared with those who survived, but there was no statistically significant difference either for the amount transfused, or for age, distance of referral, preoperative blood pressure, operating theatre time, or seniority of operating surgeon, between the two groups. It is possible that increased attention to cardiac and renal disease might reduce mortality following elective surgery. Measures to reduce the high mortality from ruptured aneurysm must be early detection and treatment of intact aneurysms, rapid diagnosis of rupture and expeditious surgery with minimal blood loss and the accurate exclusion of rupture in acute cases to achieve the same mortality as elective surgery.     

Treatment of ruptured and unruptured internal carotid artery aneurysms.

A consecutive series of 95 patients with a total of 131 intracranial cerebral aneurysms came under observation from 1972-1978. Of these, 78 patients had operations for 106 aneurysms. Over half of the patients (41) had operations for an aneurysm of the intracranial internal carotid artery; there were 16 incidental "asymptomatic" aneurysms also found. There was no surgical mortality in this group. Medical treatment, including bed rest, antihypertensive treatment and administration of epsilon amino caproic acid followed by microsurgical obliteration of the aneurysm offers the best results for the treatment of ruptured and unruptured aneurysms.     

Management of solitary iliac aneurysms.

Eleven patients with isolated iliac artery aneurysms, presenting over a 10 year period, have been reviewed. Ten patients underwent surgery, of whom 3 had ruptured their aneurysms. Four patients had a solitary aneurysm, while the remaining 6 had 14 aneurysms between them. There was no operative mortality but 2 patients died of late vascular complications (after 4 and 12 months), 1 after proximal ligation only of an internal iliac artery aneurysm, and 1 after proximal and distal ligation and bypass of the common/external iliac artery for an aneurysm involving both the common and internal iliac arteries. Five patients had internal iliac artery aneurysms, and in 4 of these distal control was not achieved. Four patients died from unrelated disease (after 2-6 years). Safe control of internal iliac artery aneurysms cannot be achieved without distal internal iliac control.     

Surgery of incidental intracranial aneurysms

A series of nine patients with an unruptured asymptomatic aneurysm not associated with a ruptured aneurysm is discussed. Three had giant aneurysms. Two patients had bilateral aneurysms of the middle cerebral artery. Five had solitary aneurysms of the middle cerebral artery. One had an aneurysm of the anterior communicating artery. One had an ophthalmic aneurysm. All aneurysms were clipped. Two operations were necessary in the two patients with bilateral aneurysms. There was no mortality and no significant morbidity. Clipping of the aneurysm is recommended for those patients who have no other serious illness that significantly increases the surgical risk. If a combination of pituitary tumor and aneurysm is found, a subfrontal instead of transsphenoidal approach should be considered so as to treat both the tumor and aneurysm at the same operation.     

Unruptured intracranial aneurysms in elderly patients.

A total of 556 patients with 769 intracranial aneurysms, of which 256 were unruptured and 513 were ruptured, were included in the present study. The patients were divided into three age groups: those aged 59 years or younger, those aged 60 to 69 years, and those aged 70 years or older. Small aneurysms of 4 mm or less in diameter were more common in the series of unruptured aneurysms than in the ruptured aneurysms. The rupture rate in anterior communicating artery aneurysms was the highest, and it increased with age. A follow-up study was performed on 47 patients with 55 unruptured aneurysms, and only one giant basilar artery aneurysm ruptured during the average follow-up period of 5.2 years. Direct operation was performed on 52 patients with unruptured aneurysms. While the surgical mortality rate was 0%, the morbidity rate was 6% (three of 52 cases), which was not directly related to the patients' age. When considering surgery for unruptured aneurysms, rupture rate of aneurysms at each site is one of the most important factors, especially in elderly patients.     

Surgery for abdominal aortic aneurysms. A survey of 656 patients

Between 1979 and 1988, 656 patients were operated upon for abdominal aortic aneurysm. Elective operation was performed in 287 patients (44%) and acute operation in 369 patients. A ruptured aneurysm was found in 218 patients (33%). Patients with arteriosclerotic heart disease, hypertension, impaired renal function or chronic pulmonary disease showed an increased perioperative mortality. Development of postoperative cardiac and renal complications could not be related to previous cardiac or renal diseases. The major postoperative complications were renal failure in 81 patients (12%), pulmonary insufficiency in 77 patients (11%) and cardiac complications in 96 patients (13%). Failure of one or more organs occurred in 153 patients (23%) and the mortality rate for patients with multiorgan failure was 68%. Complications leading to reoperation occurred in 93 patients (14%). The perioperative mortality was 18.8%. The mortality for elective cases was 4.8%, for symptomatic cases 17.2% and 37% for ruptured aneurysms. The five-year survival rate was 48% for ruptured aneurysms, 70% for symptomatic cases and 75% for elective cases. After six months the life expectancy in these three groups of patients were identical and comparable to the expected survival for a sex and age matched control population.     

Open Repair of Pararenal Aortic Aneurysms: Operative Management, Early Results, and Risk Factor Analysis

Surgical treatment of pararenal aortic aneurysms, if compared to open surgical repair of infrarenal aneurysms, is technically more demanding and characterized by problems related to organ ischemia. To better define challenges, risks, and results, we analyzed our experience with the treatment of pararenal aortic aneurysms. Between January 1993 and March 2005, 119 consecutive patients underwent surgery for pararenal aneurysms at our institution. A prospective analysis of results was performed. According to their localization, we treated 85 juxtarenal aneurysms and 34 suprarenal aneurysms. One hundred and three patients underwent primary repair of an atherosclerotic aneurysm, four patients underwent surgical repair of an anastomotic pseudoaneurysm, and eight patients underwent correction of an aneurysm of the pararenal aorta proximal to a previous infrarenal anastomosis. Four patients underwent emergency operation for a ruptured aneurysm. In the juxtarenal aneurysm group, the 30-day mortality rate was 4.7% (4/85) including three patients with ruptured aneurysm. In the suprarenal aneurysm group, the 30-day mortality rate was 2.9% (1/34). Preoperative renal insufficiency was present in 16 patients, respectively in 7 patients with juxtarenal aneurysms and in 9 patients with suprarenal ones. In 22 patients, we registered a transient increase in creatinine levels with return to baseline levels by discharge. Four patients required long-term dialysis. In three patients, a short period of dialysis was required. Clamping time longer than 30 min was associated with a higher risk of transient postoperative deterioration of renal function (p = 0.0073). Preoperative renal insufficiency was associated with a higher risk of persistent postoperative deterioration of renal function (p < 0.0001). Morbidity and mortality of elective surgery for pararenal aneurysms is acceptable. One of the main risks of this surgery is renal morbidity. Preoperative renal insufficiency and long periods of renal ischemia are associated with a higher risk of postoperative deterioration of renal function that is often, but not always, reversible. Nowadays, pararenal aneurysm repair is a safe procedure, especially if performed electively.     

The surgical experience and a one to sixteen year follow-up of 277 abdominal aortic aneurysms

Between 1960 and 1975, 277 patients with abdominal aortic aneurysms were operated on at the West Virginia University Medical Center. One hundred ninety-three aneurysms were intact lesions and eighty-four were ruptured. Operative mortality for elective resection was 8.8 per cent and for ruptured aneurysms 66.7 per cent. Mortality associated with ruptured abdominal aortic aneurysms was best related to shock and advanced age. Ninety-nine per cent of patients underwent long-term follow-up which ranged from thirteen months to thirteen years and four months (mean, 4 years and 9 months). At present 61 per cent of patients surviving elective resection and 50 per cent of those surviving operation for ruptured aneurysm are alive.     

Ruptured abdominal aortic aneurysm: factors influencing operative mortality

Of fifty-eight consecutive patients surgically treated for aneurysm of the abdominal aorta, twenty were emergency cases following the rupture. Associated diseases were found in 85 per cent of patients; hypertension being the most common. Fifty per cent of patients were in shock on admission. The duration between rupture and operation was three hrs to two weeks with the average of 115.5 hrs. In six patients, the diagnosis of abdominal aortic aneurysm was known for over six months. The operative mortality rate in case of ruptured abdominal aortic aneurysm was 45 per cent. The most important determinants of survival were the incidence of shock on admission, the incidence of associated disease, the known duration of the aneurysm, and the time interval from rupture to admission. The intraoperative factors most influencing survival were the type of rupture, intraoperative hypotension, and total blood loss. Comparison of the mortality rate in elective surgery of abdominal aortic aneurysms (5.3 per cent) with that in ruptured aneurysms (45.0 per cent) suggests the necessity for early elective operations whenever abdominal aortic aneurysms are diagnosed.     

Thoracoabdominal aneurysm resection after previous infrarenal abdominal aortic aneurysmectomy.

Thoracoabdominal aneurysms in 51 patients were repaired over 5 years ending in February 1991. Fourteen (27%, 14 of 51) patients had a prior infrarenal aneurysm resection (PRA); their data are analyzed separately. The average age of patients who had undergone PRA was 67 years (range: 56 to 86 years). The mean aneurysm diameter was 8.6 cm (range: 5 to 12 cm), and the mean time interval between initial aneurysm surgery and subsequent resection of the thoracoabdominal aneurysm was 8.5 years (range: 2 to 17 years). Three patients in the PRA group were operated on emergently, two because of clinical evidence of rupture; the other patients underwent elective repair. Early mortality (30 days) in the PRA group was significantly related to age (72 years or older versus younger than 72 years: 75% versus 10%, p = 0.04), proximal extent of aneurysm (above diaphragm versus below diaphragm: 50% versus 0%, p = 0.05), ruptured aneurysm (ruptured versus nonruptured: 100% versus 16%, p = 0.06), and a cardiac history of myocardial infarction (57% versus 0%, p = 0.03), congestive heart failure (66% versus 0%, p = 0.01), or arrhythmia (80% versus 0%, p = 0.005). Similar results were seen with the entire group of patients with thoracoabdominal aneurysms except that the proximal extent of the aneurysm was not related to mortality. These results demonstrate that thoracoabdominal aneurysm resection after prior infrarenal aneurysmectomy is not associated with increased mortality or morbidity.     

Survival improvement following aortic aneurysm resection.

Abdominal aortic aneurysm resections were performed on 298 patients between January, 1966 and December, 1973. The results were compared with 186 resections previously reported between 1955-1965. Hospital mortality rates for elective resections were 13% in 1955-1965, 8.4% in 1966-1973, and 4.2% in the 113 patients treated during the last 3 years. Urgent resections for intact aneurysms, previously associated with a 36% mortality, resulted in a 6% mortality rate in 1966-1973. The emergency resection mortality rate for ruptured aneurysm, originally 69%, was reduced to a present day over-all mortality of 55%, and 42% for the last 3 years. Calculated actuarial survival at 5 years was 65% for urgent (intact), 60% for elective and 40% for emergency (ruptured) groups. Atherosclerosis remains the major deterrent to long-term survival with myocardial infarction and stroke causing 43% of deaths occurring within 5 years. Improved survival appeared secondary to better operative technique, postoperative patient monitoring, increased surgical experience, and more elective resections of smaller, asymptomatic aneurysms than in 1955-1965. With present day low mortality rates, elective resection should be recommended in all patients without significant medical contraindications.     

Endovascular grafts and other catheter-directed techniques in the management of ruptured abdominal aortic aneurysms

Abdominal aortoiliac aneurysms that are ruptured and treated with open surgical repair have high morbidity and mortality rates. We have employed endovascular approaches to treat this entity since 1994. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guidewire into the supraceliac aorta and arteriography. If aortoiliac anatomy was suitable, an endovascular graft repair was performed. If the anatomy was unfavorable, the aneurysm was repaired in a standard open fashion. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 36 patients so managed, 30 underwent endovascular graft repair and six required open repair. Four patients died within 30 days (operative mortality = 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques, including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. These techniques should become widely used for the treatment of ruptured aneurysms.     

Management and urgent repair of ruptured visceral artery aneurysms

Five patients were treated for ruptured visceral artery aneurysms during the last 9 years, including two splenic and three pancreaticoduodenal aneurysms. The average size of aneurysm was 2.6 cm (range: 1.5-5 cm). All patients underwent open surgical treatment. There was one operative death. After a mean follow-up of 46.6 months, there were no cases of mortality or secondary complications. The authors conclude that operative treatment of ruptured visceral artery aneurysms is durable.     

Concurrent treatment of acute pancreatitis and multiple visceral artery aneurysms using endovascular techniques

Multiple aneurysms involving the celiac axis are extremely rare. Celiac artery aneurysms account for only 4% of all visceral aneurysms with 40% having concomitant aneurysms such as gastroduodenal artery (GDA) aneurysms. Development of a GDA aneurysm is associated with pancreatitis. If a GDA aneurysm ruptures, traditional repair is through open surgical techniques with significant morbidity and mortality as up to 50% occur in the setting of chronic pancreatitis. However, a ruptured GDA aneurysm causing pancreatitis has not been described previously. We report a case of successful endovascular treatment of a ruptured GDA aneurysm and concomitant celiac artery aneurysm leading to the resolution of acute pancreatitis.     

Emergency operation in patients with symptomatic abdominal aortic aneurysms

To assess the need for routine preoperative computerized tomography scanning to discern patients with rupture among those presenting with acutely symptomatic abdominal aortic aneurysms, a retrospective review was performed. During a 5-year period, all patients presenting with symptomatic aneurysm underwent emergency operation without preoperative computerized tomography. The mortality rate was not significantly different among patients with symptomatic, intact aneurysms undergoing emergency operation (3 percent) and those without symptoms having elective operation (5 percent). The mortality rate of patients with ruptured aneurysms was 68 percent. We concluded that the addition of preoperative computerized tomography to the clinical evaluation would not have improved these results. Furthermore, since it is expensive and delays emergency operation in patients with ruptured aneurysms, computerized tomography seems rarely indicated in symptomatic patients with obvious aneurysms.     

A decade of experience with abdominal aortic aneurysm repair in octogenarians.

BACKGROUND: Should abdominal aortic aneurysms (AAA) be electively repaired in octogenarians? METHODS: This was a retrospective review of patients' charts over a ten-year period starting in January 1995. This study was conducted at St. Francis Hospital, Roslyn, New York, which is a tertiary referral center. All octogenarians who underwent AAA repair (elective and emergent) were included in this study (mean age 82.9 years). A total of 71 such patients were identified. Sixty-two patients had elective surgery and nine patients had emergent repair of the ruptured AAA. It was hypothesized before the study was conducted that AAA could be repaired in octogenarians with acceptable morbidity and mortality in an institution with vast experience in dealing with this disease. RESULTS: The mean aneurysm diameter was 6.73 cm. Twenty patients (28%) received bifurcated grafts, while 51 patients (72%) received tubular grafts. Four patients had coronary artery bypass graft before aneurysm surgery. Forty-four patients (62%) were male and 27 (38%) were female. The thirty day mortality rate after elective AAA repair was 1.4%, whereas after the repair of ruptured aneurysms was 44.4%. CONCLUSIONS: We concluded that the elective repair of abdominal aneurysms in most octogenarians is a safe and life-prolonging procedure if performed in an experienced tertiary center.     

The value of computed tomography in the management of symptomatic abdominal aortic aneurysms

The use of computed tomographic (CT) scanning in the diagnosis of ruptured abdominal aortic aneurysm is controversial because the delay created by the procedure, it has been argued, may increase overall mortality. However, if emergency surgery can be avoided in the medically compromised patient, surgical results may improve. To assess the value of CT scanning, we studied the 1983 to 1988 records of 65 hemodynamically stable patients with abdominal aortic aneurysms, who underwent diagnostic CT scanning for acute abdominal or back pain. Twenty-one patients had a history of severe cardiac, renal, or pulmonary disease. The average duration of the examination was 63 minutes; no episodes of hypotension occurred. Subsequently, 17 of 18 patients with ruptured aneurysms had emergency surgery, with 31% morbidity and 29% mortality. Of 44 patients found to have nonruptured aneurysms, 13 had other causes for their pain, nine were not considered surgical candidates, and 24 had elective aneurysmectomies, with 8% morbidity and 0% mortality. In three patients CT scanning excluded the diagnosis of aneurysm. Additional information provided by CT scanning enhanced the safety of the perioperative management of four patients with rupture and 14 without. In conclusion, the delay imposed by obtaining a preoperative CT scan in patients with possible ruptured aneurysm did not adversely affect patient outcome, and the information obtained from it aided significantly in both preoperative and intraoperative management.     

显微手术和介入治疗急性期颅内动脉瘤破裂的对比性研究

目的 比较显微外科手术和血管内介入治疗急性期颅内动脉瘤破裂的疗效和相关并发症。方法 82例破裂性颅内动脉瘤，均在蛛网膜下腔出血急性期(72h以内)行外科治疗，其中行显微手术瘤颈夹闭40例，血管内电解可脱性弹簧圈栓塞治疗42例。对两组疗效和并发症进行对比分析。结果 显微手术组，完全夹闭率92．5％，手术相关并发症4例，死亡2例。弹簧圈栓塞组，完全闭塞率71．4％，栓塞组相关并发症6例，死亡1例。在前循环动脉瘤中，栓塞组完全闭塞率与手术组完全夹闭率相比较，显微手术组结果优于栓塞组。临床随访6个月，两者预后良好者均达95．0％。结论 显微瘤颈夹闭术和血管内栓寒治疗均是颅内动脉瘤治疗的有效方法。     

Audit of 200 consecutive aortic aneurysm repairs carried out by a single surgeon in a district hospital: results of surgery and factors affecting outcome.

It has been suggested that surgery for abdominal aortic aneurysm (AAA) be confined to designated centres. A prospective audit of 200 consecutive AAA repairs at a district general hospital was performed between 1981 and 1990. The 30-day mortality rates for elective, symptomatic and ruptured aneurysm repair were 1.4%, 3.5% and 30%, respectively. The major factor affecting outcome after the mode of presentation was the age of the patient, with 30-day mortality rates for emergency treatment increasing from 21% (age range 60-69 years) to 42% (age range 70-79 years). This mortality rate for ruptured aneurysms is an underestimate, with two-thirds of patients with rupture dying before reaching hospital and some patients dying in hospital undiagnosed. The major contribution to improved overall mortality would therefore be detection before rupture (usually by ultrasound) and improved diagnostic accuracy. Many patients with ruptured aneurysms had symptoms for only a short period before presentation (42% for less than 6 h) and required urgent surgery (26% reached theatre within 1 h). These two factors make long-distance transfer of these patients an unrealistic option. The concentration of this type of surgery in relatively few centres will distance the patient from their relatives and reduce the opportunity for the majority of junior doctors to acquire an understanding of the presentation, natural history and management of aortic aneurysms. This understanding when combined with a screening programme is likely to have a far greater impact on the overall mortality from AAA than restricting the centres for surgical treatment.