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.     

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.     

Identification of 1,4-dihydropyridine binding domains within the primary structure of the alpha 1 subunit of the skeletal muscle L-type calcium channel

Damage to the spinal cord in course of the treatment of diseases of the infrarenal aorta is a rare but calamitous complication. The reported incidence is about 0.2%. The neurological loss is usually complete flaccid paraplegia with high mortality and rare full or partial recovery. Between 1980 and 1991, 1070 reconstructive procedures of the infrarenal aorta were performed: 821 due to aneurysm (316 elective procedures [mortality 1.6%] and 505 emergency procedures [mortality 24.5%]) and 249 due to aorto-iliac occlusive disease. Damage to the spinal cord occurred in 2 patients (2/1070, 0.19%). One patient had incomplete paraparesis following repair of an unruptured abdominal aortic aneurysm with gradual return of all neurological symptoms to normal. The second patient developed complete paraplegia following repair of a ruptured infrarenal aneurysm. There war no recovery of the symptoms. The patient died from septicaemia 4 months later.     

Experience of reoperations followed by repairs of abdominal aortic aneurysms

We experienced 8 cases who required reoperations, including 2 re-redo operations, after repairs of infrarenal abdominal aortic aneurysms. Of 8 patients, one patient developed a new aneurysm due to atherosclerosis in thoraco-abdominal aorta involving all visceral arteries and other 7 patients had aneurysmal formations at proximal anastomotic sites, including 3 suprarenal, 2 juxtarenal and 2 infrarenal aortic lesions. Etiology at initial operation in patients who subsequently developed anastomotic aneurysms included vasculo-Beh?et disease in 4, atherosclerosis in 2 and dissecting aortic aneurysms type III due to Marfan syndrome in 1. At reoperation, all who had vasculo-Beh?et disease had ruptures of anastomotic sites and 2 patients underwent repairs of dehiscent patch, 1 extra-anatomic bypass between ascending and abdominal aorta and 1 interposition of graft. One patient who had graft infection after repair of abdominal aortic aneurysm required axillo-femoral bypass with removal of infected graft. A patient who had dehiscence of proximal anastomosis after repair of aortoiliac occlusive disease required interposition of graft. Two patients, Marfan syndrome and aneurysm in thoraco-abdominal aorta, underwent graft replacement of thoraco-abdominal aorta concomitant with reconstruction of all visceral arteries. There were 8 patients who required reoperations for aneurysms at distal anastomotic sites after repairs of abdominal aortic aneurysms. Five patients underwent repairs of new aneurysms, including replacement of total arch in 3, descending aorta in 1 and iliac artery in 1. In all cases, no hospital death was noted, however, late deaths were occurred in vasculo-Beh?et disease, Marfan syndrome and graft infection. Thus, late result depends on etiology of disease. Although patients who requires reoperation after repair of abdominal aortic aneurysms have higher operative risk factors, early and late results are satisfactory compared to initial operations.     

Surgical treatment of thoracoabdominal aortic aneurysms]

Between February, 1981, and April, 1989, 20 patients underwent surgical treatment of thoracoabdominal aortic aneurysms. Most of the patients were operated under temporary external bypass. For Group I and III aneurysms without reconstruction of renal arteries, a modified Crawford's graft inclusion technique was employed to shorten abdominal visceral ischemic time. This modification consists of (1) using adjuncts to perfuse the distal aorta during aortic clamp, (2) starting the first anasistomosis from the distal end of the graft, and (3) shifting the distal aortic clamp on the graft after completing the anastomosis in order to restore abdominal visceral circulation as soon as possible. For Group III and IV aneurysms with reconstruction of renal arteries as well as celiac and superior mesenteric arteries, a modified DeBakey's procedure was employed. This modification consists of (1) using the spiral opening method, (2) doing end-to-end anastomosis at the proximal aortic site, and (3) maintaining the circulation of abdominal organs and spinal cord by using adjuncts during the anastomosis of the proximal end. There were one operative death and two hospital deaths. Paraplegia developed in two cases, one of which was a ruptured case. Renal dysfunction was not found in any case. The survivors were followed from 5 to 103 months, and there was no late death. The results suggest that our modified procedures for thoracoabdominal aortic aneurysms are useful and reliable ones.     

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.     

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.     

Intravascular coagulation in surgical procedures on the abdominal aorta

A prospective study was performed on 32 consecutive patients undergoing elective operations on the abdominal aorta. Dacron prosthetic grafts were used to replace resected abdominal aortic aneurysms or to bypass aorta-iliac occlusive disease. Complete coagulation studies were performed preoperatively, immediately postoperatively and 24 hours postoperatively. Twenty to 30 per cent of the patients had significant postoperative alterations in prothrombin time, partial thromboplastin time and platelet count. Fibrin monomer, fibrin split products and plasminogen were abnormal in 40 to 80 per cent of the patients postoperatively. Results of preoperative studies showed no significant abnormalities. One of the 32 patients had mild clinical evidence of disseminated intravascular coagulation postoperatively, which was treated with 5 units of heparin per kilogram per hour. Results of the study indicate that aortic grafting procedures frequently produce intravascular coagulation, either local or disseminated. In most patients, this is offset by activation of the fibrinolytic system. However, clinically significant sequelae may result, requiring prompt recognition and treatment.     

Factors associated with psychotic symptoms in Alzheimer''s disease

BACKGROUND: The incidence of abdominal aortic aneurysm (AAA) has increased steadily during the past 30 years. METHODS: Trends in the incidence and surgical intervention for AAA in Western Australia were reviewed for the interval 1985-1994. A population-based health database was used to link morbidity and mortality records of all patients aged 55 years or more who died from rupture or were admitted and treated surgically for AAA. Three groups were separated for analysis: patients with a ruptured AAA, those admitted for elective repair and those admitted as an emergency with an acute (non-ruptured) aneurysm. RESULTS: There was a decline in the incidence of both emergency and elective procedures for AAA after 1992. While the mortality rate from ruptured AAA has also fallen since 1991, the overall case fatality rate for ruptured AAA has fallen by only 1.3 per cent (from 80.7 to 79.3 per cent). CONCLUSION: The decline in mortality rate and emergency procedures may result from a fall in the incidence of ruptured AAA, due to an increasing rate of elective surgery before 1992. The decline in elective procedures from 1992 may be due to a fall in the prevalence of AAA owing to high rates of elective surgery, or to a fall in the incidence of the disease itself.     

Pre-operative classification of abdominal aortic aneurysms with spiral CT: the axial source images revisited

OBJECTIVE: The differentiation of supra-, juxta- and high infrarenal abdominal aortic aneurysms (AAA), which is essential for good surgical management, remains problematic. This prospective study assessed the value of highly overlapping vs. contiguous axial spiral computed tomography (CT) reconstructions in the pre-operative assessment of AAA. PATIENTS AND METHODS: Thirty-five patients with abdominal aortic aneurysms were studied with spiral CT (10 mm collimation, pitch 1). Axial reconstructions were performed at 2 and 10 mm increments and compared with surgical findings. Using each protocol, the aneurysms were classified as infra-, juxta- or suprarenal. Observers also assessed visualization of main and accessory renal artery origins and identification of other surgically relevant vascular anomalies. RESULTS: The 2 mm protocol correctly identified 29/31 infrarenal, 3/3 juxtarenal and 1/1 suprarenal aneurysms; two infrarenal aneurysms were overestimated as suprarenal. The 10 mm protocol correctly classified 25/31 infrarenal, 3/3 juxtarenal and 1/1 suprarenal aneurysms; five infrarenal aneurysms were overestimated as juxtarenal (n = 3) or suprarenal (n = 2) and one case was equivocal. Correct classification was thus 94% using the 2 mm protocol and 83% with the 10 mm protocol (P = 0.063). All 70 main renal artery origins were visualized with the 2 mm protocol, while the 10 mm protocol missed six (P = 0.03) The 2 mm protocol identified 10 accessory renal arteries, four of which were missed by the 10 mm protocol. Both protocols demonstrated five surgically relevant venous anomalies. CONCLUSION: Spiral CT with highly overlapping axial reconstructions correctly classified 94% of abdominal aortic aneurysms; overlapping reconstructions were particularly useful in differentiating high infrarenal from juxtarenal aneurysms.     

Basic science of abdominal aortic aneurysms: emerging therapeutic strategies for an unresolved clinical problem

Abdominal aortic aneurysms (AAAs) are an increasingly common and potentially lethal condition. Surgical repair of AAA is now yet performed quite safely, yet ruptured AAAs still carry mortality rates of 50% to 70%. Ultrasound screening may help identify unsuspected AAA, thereby allowing elective repair. Because AAAs too small to warrant operation still expand progressively, therapeutic approaches to suppress AAA growth would be welcome. Current concepts indicate that AAAs arise through pathophysiologic process distinct from occlusive atherosclerosis and dominated by degenerative changes in the elastic media. These include marked alterations in elastin and collagen, chronic inflammation, and features of autoimmunity, medial neovascularization, and a decrease in vascular smooth muscle cells. Proteinases associated with mononuclear inflammatory cells, particularly matrix metalloproteinases, likely mediate the degradation of structural proteins in the aortic wall. Experimental studies demonstrate that similar processes occur in an elastase-induced rodent model of AAA, providing a means by which to develop novel therapeutic strategies for this disease. Pharmacologic inhibitors of matrix metalloproteinases act to suppress aortic elastin degradation and limit the growth of experimental AAA in vivo, suggesting at least one approach that may be useful in clinical application. Further developments can be expected to increase knowledge of the pathophysiology underlying aortic aneurysm disease, ultimately providing new therapies for small AAAs based on sound understanding of disease mechanisms.     

Optimal exposure of the proximal abdominal aorta: a critical appraisal of transabdominal medial visceral rotation

PURPOSE: Adequate exposure of the upper abdominal aorta and its branches is a necessary prelude to safe and durable reconstruction of this aortic segment. Although a variety of approaches to this exposure have been described, few outcome data are available to assess the benefits and limitations of the different exposure options. In this series we report the results of the transabdominal medial visceral rotation (MVR) approach to exposure of the paramesenteric and pararenal aorta. METHODS: One hundred eight operations were performed in 104 patients, representing 19.5% of all aortic reconstructions during a 5.5 year interval. Most patients had hypertension (n = 77, 71.3%) or a history of smoking (n = 83, 76.9%). Heart disease was present in one third of patients (n = 33) and a similar proportion had abnormal renal function (elevated creatinine level) before operation (n = 40, 37.0%). One third of patients (n = 34) had undergone previous aortic or aortic branch reconstruction. Eighty percent of procedures were elective (n = 87). Seventy-one patients (65.7%) required renal revascularization, usually for hypertension or elevated creatinine levels, whereas 37 patients (34.3%) underwent visceral reconstruction, most often for symptoms of chronic mesenteric ischemia. Only 22 patients required isolated infrarenal aortic repair. Most of the aortic lesions were aneurysmal (n = 42). Eighty percent of procedures (n = 88) required suprarenal or more proximal aortic clamping. The most frequently used reconstruction techniques were bypass (n = 39, 36.1%), endarterectomy (n = 18, 16.7%), or both (n = 23, 21.3%). RESULTS: There were four intraoperative deaths (3.7%) and 15 postoperative deaths (13.9%). All intraoperative deaths and four postoperative deaths were related to hemorrhage and its complications. Visceral infarction was the most frequent cause of postoperative death. The intraoperative complications that were determined to be related to the medial visceral rotation approach included splenic injury (n = 23, 21.3%), one aortic injury, and one adrenal injury. The aortic injury was associated with substantial intraoperative bleeding and subsequent death. The postoperative complications resulting from MVR included pancreatitis (n = 5), which contributed to death in two patients, and possibly some of the cases of visceral infarction not associated with visceral reconstruction. The other common postoperative complications, cardiac (n = 25, 24.0%), pulmonary (n = 32, 30.8%), renal (n = 20, 19.2%), and infectious (n = 17, 16.3%), were attributed to the procedures performed. CONCLUSIONS: Transabdominal MVR exposure of the upper abdominal aorta provides unrestricted access to the visceral branch-bearing segment of the aorta and places no limitations on the choice of arterial reconstruction technique. The associated morbidity and mortality rates are typical of patients undergoing these complex vascular repairs, but the frequency of splenic injury and postoperative pancreatitis is increased.     

Exposure to environmental and mainstream tobacco smoke and risk of spontaneous abortion

The present nationwide, multicenter clinical study was carried out in 26 departments of surgery to define the incidence and attendant mortality of intestinal infarction following abdominal aortic surgery, and to identify patients at risk of it. The data consist of 1752 patients who underwent abdominal aortic reconstruction during 1991-1993 as recorded in the Finnish national vascular registry (FINNVASC). Among the 1752 operations, 27 patients treated at 14 different hospitals had intestinal ischemia, and the complete patient records of all 27 cases were reanalyzed. The incidence of bowel infarction was 1.2%. Among patients operated on for a ruptured aneurysm it was 3.1%, whereas 1.0% of patients with nonruptured aneurysm and 0.6% of those operated on for aortoiliac occlusive disease developed intestinal infarction. In 14 patients (67%) the lesion affected the left colon. The overall 30-day mortality rate was 13% but reached 67% among those with intestinal infarction. We conclude that acute intestinal ischemia with bowel infarction is an infrequent but serious complication of abdominal aortic surgery. It is mainly related to surgery due to aneurysmal disease, and patients with occlusive aortoiliac disease present ischemic complications in the intestines less often. Hypotensive patients being treated for ruptured aneurysm are at greatest risk of intestinal ischemia.     

A prospective study to define the optimum rescreening interval for small abdominal aortic aneurysm

A prospective study of 99 patients with small abdominal aortic aneurysms was undertaken using serial ultrasound to assess the optimum screening interval. Fifty-three patients had aneurysms measuring 2.5-3.9 cm and 46 patients aneurysms of 4.0-4.9 cm. Aneurysms measuring 2.5-3.9 cm were screened annually and those > 4.0 cm every 6 months. There were eight deaths in the 2.5-3.9 cm group, none attributable to a ruptured aneurysm and five patients have had their aneurysm repaired. Nine patients died in the 4.0-4.9 cm group, one with a ruptured aneurysm measuring 5.6 cm at her previous screening visit and who was unfit for operation. No other patient had an aneurysm which ruptured between scans. There were seven elective repairs in this group. No patient died following elective operation in either group. The mean growth rate of aneurysms in the 2.5-3.9 cm group was 2.2 mm in the first year, 2.8 mm in the second and 1.8 mm in the third. Corresponding growth rates in the 4.0-4.9 cm group were 2.7 mm, 4.2 mm and 2.2 mm. This study supports a policy of annual screening for aneurysms measuring 2.5-3.9 cm and 6-monthly screening for those > or = 4.0 cm.     

Long term relative survival after surgery for abdominal aortic aneurysm in western Australia: population based study

OBJECTIVE: To determine the long term relative survival of all patients who had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. DESIGN: Population based study. SETTING: Western Australia. SUBJECTS: All patients who had had surgery for abdominal aortic aneurysm in Western Australia during 1985-94. MAIN OUTCOME MEASURES: Morbidity and mortality data of patients admitted and surgically treated for abdominal aortic aneurysm in Western Australia during 1985-94. Elective, ruptured, and acute non-ruptured cases were analysed separately. Independent analyses for sex and patients aged 80 years or more were also undertaken. Postoperative (>30 days) relative survival was assessed against age and sex matched controls. RESULTS: Overall, 1475 (1257 men, 218 women) cases were identified. The crude five year survival after elective surgery, including deaths within 30 days of surgery, was 79% for both men and women. When compared with a matched population the five year relative survival after elective surgery was 94.9% (95% confidence interval 89.9% to 99.9%) for men but only 88.0% (76.3% to 99.7%) for women. The five year relative survival of those aged 80 years and over was good: 116.6% (89.1% to 144.0%) compared with 92.4% (87.7% to 97.0%) for those under 80 years of age (men and women combined). Cardiovascular disease caused 57.8% of the 341 deaths after 30 days. CONCLUSION: In a condition such as abdominal aortic aneurysm, which occurs in elderly patients, relative survival is more clinically meaningful than crude survival. The five year relative survival in cases of elective and ruptured abdominal aortic aneurysm was better in men than in women. This is probably because of greater comorbidity in women with abdominal aortic aneurysm and this deserves more attention in the future. The long term survival outcome in octogenarians supports surgery in selected cases.     

Screening for abdominal aortic aneurysm

In spite of increasing number of elective resections of abdominal aortic aneurysms (AAA) the mortality or ruptured AAA is increasing. The advantages of elective operations are obvious; the lethality is 2-6% while the lethality of ruptured AAA is 75-95%. However, AAA seldom causes symptoms before rupture. Ultrasonographic screening for AAA takes 10 minutes per scan, and the sensitivity and specificity are high. Ultrasonographic screening for AAA is a reliable, safe and inexpensive method for screening, and screening for AAA is discussed worldwide. One point four percent of deaths among men from 65 to 80 year of age are caused by ruptured AAA. Screening men over 65 for AAA can theoretically prevent a substantial number of deaths. Our calculations predict one prevented AAA-death per 200-300 scans for a cost of about 4000 DKK per saved year of life. However, cost-benefit analyses are based on uncertain assumptions concerning prevalence, incidence and risk of rupture. Therefore a randomized trial screening of 65-73 year old males is taking place in the County of Viborg in Denmark.     

Long-term survival and late complications after repair of ruptured abdominal aortic aneurysms

PURPOSE: Long-term survival and late vascular complications in patients who survived repair of ruptured abdominal aortic aneurysms (RAAA) is not well known. The current study compared late outcome after repair of RAAA with those observed in patients who survived elective repair of abdominal aortic aneurysms (AAA). METHODS: The records of 116 patients, 102 men and 14 women (mean age: 72.5 (8.3 years), who survived repair of RAAA (group I) between 1980 to 1989 were reviewed. Late vascular complications and survival were compared with an equal number of survivors of elective AAA repair matched for sex, age, surgeon, and date of operation (group II). Survival was also compared with the age and sex-matched white population of west-north central United States. RESULTS: Late vascular complications occurred in 17% (20/116) of patients in group I and in 8% (9/116) in group II. Paraanastomotic aneurysms occurred more frequently in group I than in group II (17 vs. 8, p = 0.004). At follow-up, 32 patients (28%) were alive in group I (median survival: 9.4 years) and 53 patients (46%) were alive in group II (median survival: 8.7 years). Cumulative survival rates after successful RAAA repair at 1, 5, and 10 years were 86%, 64%, and 33%, respectively. These were significantly lower than survival rates at the same intervals after elective repair (97%, 74%, and 43%, respectively, p = 0.02) or survival of the general population (95%, 75%, and 52%, respectively, p < 0.001). Coronary artery disease was the most frequent cause of late death in both groups. Vascular and graft-related complications caused death in 3% (3/116) in group I and 1% (1/116) in group II. Cox proportional hazards modeling identified age (p = 0.0001), cerebrovascular disease (p = 0.009), and number of days on mechanical ventilation (p = 0.01) to be independent prognostic determinants of late survival in group I. CONCLUSIONS: Late vascular complications after repair of RAAA were higher and late survival rates lower than after elective repair. These data support elective repair of AAA. As two-thirds of the patients discharged after repair of RAAA are alive at 5 years, aggressive management of RAAA remains justified.     

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.     

Posterolateral retroperitoneal approach and exclusion technique in therapy of infrarenal aortic aneurysm: initial experiences

Although the infrarenal aorta is a retroperitoneal structure, the surgical access has been transperitoneal especially when dealing with infrarenal aneurysms. After the opening of the sack a tube-or bifurcated graft is implanted. With the posterolateral retroperitoneal (RP) approach described by G.M. Williams in 1980 access to the aorta can be gained without opening the peritoneal cavity. With the non resective exclusion technique the intraoperative blood loss is minimized. This method is routinely used in Albany N.Y. for the treatment of infrarenal aneurysms. We describe here our first experiences with 44 RP excluded aortic aneurysms. Despite the small number of cases we can confirm the advantages described in the larger series of Sicard et al. and Leather and Shah: the RP approach and the exclusion technique can be routinely used for infrarenal aneurysms. It is associated with a smoother and shorter postoperative period (8 to 10 days).     

Preliminary clinical outcome and imaging criterion for endovascular prosthesis development in high-risk patients who have aortoiliac and traumatic arterial lesions

PURPOSE: This report reviews our preliminary experience of prospective treatment of arterial lesions with endoluminal grafts in a Food and Drug Administration (FDA)-approved, investigator-sponsored Investigation Device Exemptions study. The utility and accuracy of various imaging methods, including angiography, cinefluoroscopy, computed tomography (CT), intravascular ultrasonography (IVUS), and duplex scanning, in performing the procedures was also assessed. METHODS: Thirty-one patients were evaluated; 17 patients were treated, including 11 with abdominal aortic aneurysms, one with an aortic occlusive lesion, two with iliac artery aneurysms, and three with traumatic arteriovenous fistulas. Twelve of the 14 patients who had aorta and iliac artery lesions were high-risk. The mean follow-up of patients treated was 9 months (range, 6 to 15 months). RESULTS: Aortoaortic endoluminal interposition procedures were not successful for treating abdominal aortic aneurysms early in the study (n = 3). Aortoiliac endoluminal bypass, contralateral iliac artery occlusion, and femorofemoral bypass procedures were successful in seven of eight subsequent cases (88%), with no incidence of endoleaks at either the proximal or distal fixation sites using the deployment methods described in this report. The 30-day operative mortality rate on follow-up evaluations for patients who underwent aortoiliac procedures was 14% (two of 14). Other major complications included transient renal failure in three patients that required short-term (two to eight times) dialysis, one arterial perforation and one dissection, and one prolonged intubation. No myocardial infarctions or strokes occurred. After major complications or identification of limitations in the study, the protocol was modified with the approval of the FDA to help avoid the recurrence of the same problems. There were no deaths or complications in the trauma cases. CONCLUSIONS: Contrast-enhanced CT (axial images and spiral reconstructions) was the most accurate method to determine candidacy for aortoiliac procedures and to choose the site for deployment of the devices. Angiographic scans were misleading in several patients regarding the critical determinants of patient candidacy and device deployment, particularly regarding the presence of a distal aortic neck. Cinefluoroscopy was used in all patient and was particularly useful for determining the continuity of vascular structures and the anatomy of branch arteries and for enabling precise positioning of stent devices. Determination of fixation sites and assessing dimensional information by cinefluoroscopy and angiography were limited by inaccuracies produced by image magnification, parallax, and uniplanar views. IVUS was used to determine the morphologic features of vascular structures (i.e., calcium, thrombus), to perform real-time observation of the expansion of devices, and to assure firm fixation of balloon-expanded stents before the procedures were completed. Duplex scanning was very helpful in assessing and identifying precisely the location of arteriovenous fistulas before intervention and provided assessment at follow-up intervals. Three-dimensional reconstruction imaging technologies such as spiral CT were particularly helpful for assessing the morphologic features of vascular anatomy before the intervention and at follow-up intervals, whereas 3-D IVUS provided a similar real-time perspective during the procedure.