Cyanamide-induced granulocytopenia

BACKGROUND: The appropriate management of patients who are older than 80 years of age and who present with an abdominal aortic aneurysm (AAA) remains controversial. While it appears that elective repair can be performed safely, appropriate management of these patients in the emergency situation is unclear. The purpose of the present study was to examine the results obtained in treating this elderly group in the elective and emergency setting, by operation and conservative techniques at St George Hospital, Kogarah. METHODS: Between January 1987 and December 1994 85 patients older than 80 years of age were treated for AAA. These patients were divided into four groups: I, elective presentation/no surgery; II, elective presentation/elective surgical repair; III, emergency presentation/surgical repair; and IV, emergency presentation/conservative treatment. We examined age, sex, size of AAA, mode of presentation, type of treatment, length of survival and cause of death. RESULTS: The mean age of the total group (n = 85) of patients was 84 years (range: 80-94). The mean AAA diameter for this group was 5.6 cm (95% CI: 5.2-6 cm). The diameters for group I (n = 40), II (n = 22), III (n = 16) and IV (n = 7) were 4.9 cm (4.4-5.5, 95% CI), 5.7 (4.9-6.5 CI), 7.0 (6.1-7.7 CI) and 6.2 (5.2-7.2 CI), respectively. The median survival for groups I, II, III and IV was 18, 38.5, 0.25 and 0 months, respectively. Group II had a longer survival than any other group (P = 0.015), and group IV had a shorter survival than the total group (P = 0.001). However, the length of survival was no different for III versus IV (P = 0.146). Deaths in each group were due to the following reasons. I: cardiopulmonary events (14), rupture (3), malignancy/sepsis (3); II: cardiopulmonary events (3), rupture (thoracic aneurysm) (2), malignancy (I); III: rupture (10), malignancy (I); and (IV): rupture (6), malignancy (1). CONCLUSIONS: Elective surgical repair offers the best management option for AAA in patients older than 80 years of age. Death may still occur from progression of aneurysmal disease at other sites. An aggressive surgical approach to the management of haemodynamically unstable patients in this age group is of questionable benefit.     

Adverse events after endoluminal repair of abdominal aortic aneurysms: a comparison during two successive periods of time

PURPOSE: The aim of this study was to document the incidence rate of adverse events after endoluminal repair of abdominal aortic aneurysms (AAAs) during two successive periods of time. METHODS: One hundred ninety patients (175 men, 15 women; mean age, 72 years) underwent endoluminal repair of AAAs in a 5(1/2)-year period. Adverse events were documented prospectively for all the patients throughout this interval. An adverse event was defined as any of the following events: a death within 30 days, a conversion to open repair, the need for further intervention (either open or endovascular), the need for hemodialysis, a failure to cure the AAA, and wound complications. The patients were divided into two groups those who underwent operation in the initial 3-year period (group I; n = 75) and those who underwent operation in the subsequent 2(1/2)-year period (group II; n = 115). The results were analyzed for total adverse events for both periods of time and for difference in incidence rates within categories of adverse events between the two groups. RESULTS: Eight patients (4.2%) died in the perioperative period. The endoluminal repair failed in 17 patients (8.9%), which necessitated a primary conversion to open repair at the original operation. In 88 patients, 110 adverse events occurred. There was no significant difference in the incidence rates of adverse events in patients in group I (37/75) and group II (51/115). Apart from primary conversion (P =.007), there was no significant difference in the incidence rates of adverse events between group I and group II within the following categories: perioperative (within 30 days) deaths, primary conversion, secondary conversion, supplementary endoluminal repair, intervention for lower limb ischemia, hemodialysis necessitated, failure to cure the AAA as a result of persistent endoleak, and wound complications. CONCLUSION: Despite improvements in technology and increasing experience, adverse events continue to occur in a relatively high proportion of patients (45%) who undergo endoluminal repair of AAA. Reporting the incidence rates of adverse events provides a more accurate picture of the morbidity rates of the endoluminal method rather than simply listing the procedures as successes or failures. The similarity in the incidence rates of adverse events in patients in group I and group II suggests that there are inherent risks in the endoluminal method rather than iatrogenic complications that occur during the learning curve with a new technique.     

Tissue-separating capacity of growth cartilages

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

Initial experience with endovascular aneurysm repair: comparison of early results with outcome of conventional open repair

PURPOSE: To determine the safety, effectiveness, and problems encountered with endovascular repair of abdominal aortic aneurysm (AAA). Initial experience with endoluminal stent grafts was examined and compared with outcome for a matched concurrent control group undergoing conventional operative repair of AAA. METHODS: Over a 3-year period, 30 patients underwent attempts at endovascular repair of infrarenal AAA. Of the 28 (93%) successfully implanted endografts, 8 were tube endografts, 8 bifurcated grafts, and 12 aortouniiliac grafts combined with femorofemoral bypass. Most of the procedures were performed in the past year because the availability of bifurcated and aortoiliac endografts markedly expanded the percentage of patients with AAA who might be treated with endoluminal methods. The follow-up period ranged from 1 to 44 months, with a mean value of 11 months. RESULTS: Endovascular procedures demonstrated significant advantages with respect to reduced blood loss (408 versus 1287 ml), use of an intensive care unit (0.1 versus 1.75 days), length of hospitalization (3.9 versus 10.3 days), and quicker recovery (11 versus 47 days). Although the total number of postoperative complications was identical for the two groups, the nature of the complications differed considerably. Local and vascular complications characteristic of endovascular repair could frequently be corrected at the time of the procedure and tended to be less severe than systemic or remote complications, which predominated among the open surgical repair group. On an intent-to-treat basis, 23 (77%) of the 30 AAAs were successfully managed with endoluminal repair. The seven (23%) failures were attributable to two immediate conversions caused by access problems, three persistent endoleaks, one late conversion caused by AAA expansion, and one late rupture. CONCLUSIONS: Although less definitive than those for conventional operations, these early results suggest that endovascular AAA repair offers considerable benefits for appropriate patients. The results justify continued application of this method of AAA repair, particularly in the treatment of older persons at high risk.     

Importance of intercostal artery reattachment during thoracoabdominal aortic aneurysm repair

PURPOSE: We studied the relationship of neurologic deficit to ligation, reimplantation, and preexisting occlusion of intercostal arteries to determine which arteries and consequent management are most critical to outcome in thoracoabdominal aortic aneurysm repair. METHODS: From February 1991 to July 1996, 343 patients with thoracoabdominal aortic aneurysms underwent repair by one surgeon. In this study, only Crawford types I, II, and III (n = 264) were considered. Of these, 110 (42%) were type I, 116 (44%) type II, and 38 (14%) type III. The adjuncts of distal aortic perfusion and cerebrospinal fluid drainage were used in 164 patients (62%). Data were analyzed by contingency table and by multiple logistic regression. RESULTS: Early neurologic deficit occurred in 23 patients (8.7%), and late deficit in 10 patients (3.8%). Neurologic deficit in patients with at least one reimplantation and no ligation of arteries T11 or T12 occurred in 19 of 147 (12.9%). Neurologic deficit for occlusion of the same arteries occurred in 11 of 111 (9.9%), whereas for ligation of T11 and T12 neurologic deficit occurred in three of six (50%; reimplantation, p < 0.03; occlusion, p < 0.006). In addition, reimplantation of intercostal arteries T9 or T10 was significantly associated with reduced late neurologic deficit in multivariate analysis (p = 0.05). No other intercostal artery status was associated with modification of the neurologic deficit rate. Multivariate analysis showed type II aneurysms and acute dissections to be significantly associated with an increased risk of postoperative neurologic deficit (p < 0.0009, 0.002, respectively). Adjuncts were protective (p < 0.007), most often in types II and III (14.1% neurologic deficit in type II with adjunct, 35.3% without; 0% in type III with adjunct, 20% without). CONCLUSION: Patients with patent arteries at the T11/T12 level have highly variable outcomes depending on whether the arteries are reattached or ligated. Our data suggest that reimplantation of thoracic intercostal arteries T11 and T12 is indicated when these arteries are patent. Reimplantation of T9 and T10 lowers the risk of late neurologic deficit, probably by decreasing the spinal cord's vulnerability to changes in blood and cerebrospinal fluid pressure in the days after surgery. Adjuncts lower overall risk and provide adequate time for targeted intercostal artery reimplantation.     

Guidelines for the use of carotid endarterectomy: current recommendations from the Canadian Neurosurgical Society

OBJECTIVE: To assess preoperative diagnosis of intra-abdominal acute diseases manifesting as a RAAA and determine treatment options. DESIGN: Retrospective review, with a mean follow-up period of 4 years. SETTING: Vascular Department, Medical School, University "Federico II" of Naples, Italy. METHODS: In 12 patients (8.7%) with clinical suggestion of RAAA were found other intra-abdominal acute lesions, associated with asymptomatic aortic aneurysm in 10 of them and absence in one; the remainder had an intact common iliac artery aneurysm. Sonography was performed in the operating room in 5 patients (41.6%) in shock, 4 hemodynamically stable patients (33.3%) had CT scanning or MRI investigations, while 3 (25%) underwent surgery directly. INTERVENTIONS: Three patients were not operated; one half of patients were submitted to emergency laparotomy and in the remaining 3 patients a preoperative preparation was made. Simultaneous aneurysm repair and nonvascular procedures were performed in 4 patients; nonvascular operations alone were carried out in 5 patients. 4 patients underwent a successful later treatment of their aneurysms: two aneurysmectomy and two endoluminal stenting were done within 4 months. RESULTS: Weight loss and fever were found at 58.3% and 50% of patients with concomitant intra-abdominal acute diseases; both were present in 41.6%. Noninvasive imaging techniques detected associate lesions in 6 of 8 patients (75%) and absence of aneurysm in one having a bleeding adrenal mass. There were three in-hospital deaths: one patient died of metastatic disease without operation and two after surgery (22.2%). Two late deaths from cancer cachexia occurred at 11 months and 3.6 years. CONCLUSIONS: Atypical findings, such as weight loss and fever may be suggestive of coincident lesions in patients with suspected RAAA. Noninvasive assessment may identify associated diseases simulating aneurysmal rupture, without a delay in the treatment. A selective policy of medical or operative therapy may be effective to minimize risk of complications and mortality rate.     

Analysis of risk factors in patients operated for abdominal aortic aneurysm

BACKGROUND: The incidence of the associated risk factors on the early results of elective repair of abdominal aortic aneurysms has been evaluated in a series of 270 consecutive patients. Clinical, hematological and instrumental data concerning cardiovascular, pulmonary and metabolic diseases have been collected for each patient, as well as the type and the results of the surgical procedure. METHODS: The graft was straight aortic in 82 cases (30.3%), aorto-bisiliac in 130 (48.1%) and aorto-bifemoral in 58 cases (21.6%); the 237 uneventful patients (87.8%) have been discharged 8 days after the operation (mean) and 24 (8.9%) underwent to coronary-aortic bypass graft (CABG) previously. RESULTS: Postoperative complications have been observed in 33 patients (12.2%): 24.3% pulmonary, 21.2% cardiac and 15.1% renal and among these 13 patients died (4.8% of the complete series and 39.4% of those with complications) because of pulmonary (38.4%), cardiac (30.7%) and renal causes (23.3%) mainly. Despite the complications occurred mainly in patients with associated risk factors, the multivariate analysis has shown that only the chronic obstructive pulmonary disease (COPD) plays a fundamental role (p < 0.005). On the contrary, among the patients died not one single risk factor reached statistical significance, although the COPD was close (p = 0.1). CONCLUSIONS: These data underline the need of a careful evaluation and treatment of associated diseases in patients undergoing elective repair for an AAA; namely a screening for asymptomatic coronary artery disease, since the CABG can significantly reduce morbility and mortality rates, and for COPD. In addition a more careful monitoring of patients with long clamping time could reduce the possible related renal complications. Up to now, since the surgical procedures is already standardized, the precise diagnosis and treatment of associated risk factors represent the winning strategy for the achievement of better results.     

Popliteal aneurysm: surgical treatment is mandatory before complications occur

Between 1972 and 1995, surgical repair was undertaken for 94 popliteal aneurysms diagnosed in 71 patients (69 men and 2 women) with a mean age of 66 years. Ninety-one femoropopliteal bypasses, 2 lumbar sympathectomies and one primary amputation were performed. Postoperative results of 28 elective bypasses performed for asymptomatic aneurysms (AA) were compared with 63 revascularisations needed for symptomatic aneurysms (SA) secondary to thrombosis (31%), embolization (30%), venous or nerve compression (13%), or rupture (2.1%). Occlusion of at least one tibial vessel was documented angiographically in 40% of the asymptomatic aneurysms and in 80% of the symptomatic aneurysms. No significant difference was observed between 5-year graft-patency of asymptomatic aneurysms (64%, mean followup 30 months +/- 37.2) and symptomatic aneurysms (50%, mean followup 39 months +/- 40.9). Furthermore, 5-year graft patency was not influenced by the number of patent tibial vessels in either of these populations. No statistically significant difference between these two groups was observed with respect to morbidity (AA: 10.7%, SA: 19%), or early reintervention (AA: 7.1%, SA: 9.5%). However, 12 secondary amputations were needed, all of which were performed after repair of a symptomatic aneurysm (19%, p < 0.05). No postoperative mortality was observed after an elective bypass while 3 patients (4.8%) with symptomatic aneurysms died after an emergency surgery. Ischemic symptoms persisted in 56% of patients who were initially symptomatic. Surgical correction should therefore be performed once the diagnosis of a popliteal aneurysm has been established in order to prevent amputation and late sequelae.     

Routine pulmonary artery catheterization does not reduce morbidity and mortality of elective vascular surgery: results of a prospective, randomized trial

OBJECTIVE: The authors determined whether the preoperative placement of a pulmonary artery catheter (PAC) with optimization of hemodynamics results in outcome improvement after elective vascular surgery. SUMMARY BACKGROUND DATA: The PAC commonly is used not only in patients who are critically ill, but also perioperatively in major elective surgery. Few prospective studies exist documenting its usefulness. METHODS: One hundred four consecutive patients were randomized to have a PAC placed the morning of operation (group I) or to have a PAC placed only if clinically indicated (group II). Group I patients were resuscitated to preestablished endpoints before surgery and kept at these points both intraoperatively and postoperatively. Group II patients received standard care. RESULTS: There was one death in each group. An intraoperative or postoperative complication developed in 13 patients in group I versus 7 patients in group II (p = not significant). Group I patients received more fluid than did group II patients (5137 +/- 315 mL vs. 3789 +/- 306 mL; p < 0.003). There was no significant difference in either overall or surgical intensive care unit length of stay. Only one patient in group II required a postoperative PAC. CONCLUSIONS: Routine PAC use in elective vascular surgery increases the volume of fluid given to patients without demonstrable improvement in morbidity or mortality.     

Influence of birth weight on educational outcomes at age 9: the Miami site of the Infant Health and Development Program

BACKGROUND: The Quality of Surgical Care Project (QSCP) was established in May 1996, to evaluate surgical outcomes and where indicated, recommend changes to improve the quality of surgical care in Western Australia (WA). The purpose of this study is to establish benchmark standards in WA for operative mortality, 5-year survival and length of stay in all patients who were surgically treated for aneurysm of the abdominal aorta (AAA) in WA. METHODS: The WA Linked Database was used to link the morbidity and mortality records of all patients admitted and surgically treated for AAA in WA from 1985 to 1994. The linked chains of de-identified hospital morbidity and death records were selected using diagnostic and procedure codes pertaining to AAA. Three groups were separated for analysis: those admitted for rupture, those admitted for elective repair, and those who were admitted to hospital as an emergency without mention of rupture but who underwent repair for AAA. Independent analysis for gender and patients 80 years or more were included in the study. Patients were excluded from the study if they were less than 55 years of age. RESULTS: A total of 1475 cases (1257 males, 218 females) were identified. The mean age in elective cases was 70.4 years in males and 72.4 years in females, and for rupture the mean ages were 71.9 and 74.8 years, respectively. Median length of stay for males was 12 days for elective cases. Admission type or age did not significantly influence length of stay. Thirty-day mortality in males was 4.4% for elective repair and 36.7% for ruptured AAA and 5-year survival was 71.7 and 47.7%, respectively. The overall case fatality rate for ruptured AAA was 79.3% which included those cases who died from rupture without being admitted to hospital. CONCLUSIONS: These community-wide data provide a realistic measure of surgical performance for open repair of AAA. The outcomes for elective and rupture repair for AAA compare favourably with standards reported by international centres of excellence. They also support the use of this procedure in patients over 80 years of age with rupture. This information can be used for ongoing audit purposes and as a benchmark for the introduction of new treatment modalities.     

Endovascular abdominal aortic aneurysm repair. First experiences regarding 20 patients in Eindhoven

OBJECTIVE: Evaluation of the early results of endovascular abdominal aortic aneurysm (AAA) repair. DESIGN: Prospective cohort study. SETTING: Catharina Hospital, Eindhoven, the Netherlands. METHODS: Operative results and complications following endovascular AAA repair in 20 consecutive patients were surveyed. The early results consisted of the procedural outcome and the events during a mean follow-up of 6.6 months (range: 1-12 months). Nine patients had a considerably increased operation risk (American Society of Anesthesiology (ASA) class III of IV). Criteria for success were absence of endoleak and of further expansion of the aneurysm. RESULTS: Three of the nine patients in bad general shape suffered an episode of cardiac failure after the operation. In the other patients there were no serious systemic complications. No patient died. Sixteen patients (80%) had a successful immediate AAA exclusion. In two patients a second endovascular procedure was required to seal an endoleak. In one patient the procedure was converted to an open reconstruction because of a persistent endoleak, while in another patient a small midgraft endoleak was treated conservatively. Ultimately 18 patients (90%) had a successful endovascular AAA repair. CONCLUSION: Endovascular AAA repair is feasible with a high success rate and a low complication rate. This method is expected to gain an important place in future AAA repair. Longer follow-up is needed to study late complications, among which occurrence of early and late endoleaks is the most important.     

Chronic rupture of abdominal aortic aneurysms

INTRODUCTION: Rupture of abdominal aortic aneurysms (RAAA) can take place in one of the 4 following ways: 1. "Open" rupture in the free peritoneal cavity; 2. "Closed" rupture with formation of retroperitoneal haematoma; 3. Rupture into surrounding cavity structures, such as veins and bowels; 4. In rare cases rupture is effectively "sealed of" by the surrounding tissue reaction, and retroperitoneal haematoma is "chronically" contained [1]. The terms "sealed" [2], "spontaneously healed" [3], "leakig" [4] RAAA, were also used in the previous papers connected to this situation. The "sealed" rupture was first described by Szilagyi and associates in 1961 [2]. In their case the rupture was small and haemorrhage was effectively encircled by the tissue surrounding the aortic wall. The slow rate of blood loss contributed to the patient's haemodinamically stable condition. Christenson et al. reported a case of "spontaneously healed" RAAA [3]. Rosenthal and associates described 2 patients who had aortic aneuryms that ruptured several months before repair and contributed to the term "leaking AAA" [4], while Jones et al. introduced the term "chronic contained rupture" [1]. The aim of this paper is the presentation of 5 such patients. CASE REPORT: Between December 1, 1988 and May 30, 1997 411 patients with abdominal aortic aneurysms (AAA) have been operated at our institute. Of this number 137 (33%) had RAAA, while 5 patients (12%) had a contained RAAA (CRAAA). CRAAA were found in 3 male and two female patients, average age 62 years. All of them had a previously proved AAA and initial symptoms lasted for days or months before the admission. In all patients haematocrit, pulse rate and arterial tension during the admission, were normal. All typical signs of RAAA were absent in these patients. Patient 1. A 56-year-old man, smoker, with previous history of arterial hypertension had an isolated episode of abdominal pain and collapse 30 days before the admission. Physical examination revealed a pulsatile abdominal mass. Doppler ultrasonography identified an infrarenal AAA, with right lobular extraaneurysmal mass which displaced the inferior vena cava (ICV). Angiographically (Figure 1a) an unusual saccular intrarenal AAA was detected, while simultaneous cavography (Figure 1b) confirmed the-dislocated inferior vena cava to the right. The intraoperative finding showed infrarenal CRAAA with organized retroperitoneal haematoma between AAA, ICV and duodenum. After aortic cross clamping and aneurysmal opening, the rupture at the right posterior aneurysmal wall was discovered. The partial aneurysmactomy and aortobilliar bypass procedure with bifurcated knitted Dacron graft (16 x 8 mm), were performed. The patient recovered very well. After a 4-year follow-up period the graft is still patent. Patient 2. A 72-year-old woman with low back pain, fever and disuric problems was urgently admitted to the Institute of Urology and Nephrology. The standard urological examination (X-ray, intravenous pyelography, retrograde urography, kidney Duplex ultrasonography) excluded urological diseases. However, intrarenal AAA an a giant aneurysm of the right common iliac artery, were found. The proximal dilatation of the right excretory urinary system was also found by retrograde urography. The patient was transported to our Institute 20 days after the initial symptoms. Translumbar aortography (Figure 3) showed the right common iliac artery aneurysm and gave the false negative picture of normal abdominal aorta because of parietal thrombosis of AAA. The intraoperative finding showed chronic rupture of the posterior wall of the right common artery aneurysm. The retroperitoneal haematoma compressed the right ureter. Both aneurysm have been resected and replaced by bifurcated Dacron graft (16 x 8 mm). The patient recovered successfully. After a 2-year period of follow-up the graft is still patent. Patient 3. (ABSTRACT TRUNCATED)     

Simultaneous coronary artery bypass grafting and abdominal aneurysm repair decreases stay and costs

BACKGROUND: Patients with large (> or = 5.0 cm) abdominal aortic aneurysms (AAA) frequently have marked associated coronary artery disease. We hypothesized that a single operation for coronary artery bypass grafting (CABG)/AAA would provide equivalent, if not improved, patient care while decreasing postoperative length of stay and hospital costs compared with staged procedures. METHODS: Eleven patients to date have undergone a combined procedure at our institution. Ten underwent CABG followed by AAA repair, whereas one patient received an aortic valve replacement before aneurysm repair. We performed a retrospective analysis comparing the postoperative length of stay and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. RESULTS: No operative mortality has been reported. There were no episodes of neurologic deficit or cardiac complication after these procedures. The postoperative length of stay was significantly decreased for the CABG/AAA group compared with the combined postoperative length of stay for the AAA plus CABG group (7.44+/-0.88 days versus 14.10+/-2.00; p = 0.012). Total hospital costs were also significantly decreased for the CABG/AAA group compared with total hospital costs for the AAA plus CABG group ($22,941+/-$1,933 versus $34,076+/-$2,534; p = 0.003). CONCLUSIONS: A single operation for coronary revascularization and AAA repair is safe and effective. Simultaneous CABG and AAA repair substantially decreases postoperative length of stay and hospital costs while avoiding possible interim aneurysm rupture and repeat anesthesia.     

EMT defibrillation does not increase survival from sudden cardiac death in a two-tiered urban-suburban EMS system

BACKGROUND: The aim of this article was to analyze the perioperative mortality and stroke risk rates and late benefits of carotid endarterectomy (CE) contralateral to an occluded internal carotid artery (ICA), on the basis of our surgical experience from July 1990 to June 1996. METHODS: In 57 (14.7%) of 336 patients undergoing 388 CEs, the contralateral ICA was occluded (group I). All operations were performed under general anesthesia with selective shunting based on electroencephalographic criteria. Shunting was used in 36 (63.1%) of 57 revascularizations in group I and 47 (14.2%) of 331 operations performed on the remaining 279 patients with patent contralateral ICAs (group II) (p < 0.001). RESULTS: Perioperative strokes occurred in two patients (3.5%) in group I and three patients (1%) in group II (difference not significant). The only perioperative death, which occurred in one patient (1.7%) in group I, was the result of a perioperative stroke; two patients (0.7%) in group II died within 30 days of operation (difference not significant). Life-table cumulative stroke-free rates at 1, 3, and 5 years were 95%, 95%, 95% in group I and 98.8%, 98.2%, and 98.2% in group II, respectively (p = 0.272). Life-table cumulative survival rates at 1, 3, and 5 years were 97.5%, 94.2%, and 78.1% in group I and 99.2%, 94.8%, and 71.7% in group II, respectively (p = 0.306). CONCLUSIONS: The results of this analysis indicate that CE contralateral to an occluded ICA can be performed with acceptable perioperative mortality and stroke risk rates and late stroke-free and survival rates comparable to those seen in patients without contralateral ICA occlusion who have undergone operation. Nevertheless, we think it is misleading to imply that the risks of operating on the two groups are the same. Moreover, because no late stroke-related death occurred in patients with contralateral ICA occlusion, it would appear that superior late stroke-free rates did not translate into a prolonged survival advantage.     

Influence of gender on cardiac risk and survival in patients with infrarenal aortic aneurysms

PURPOSE: To determine whether gender distinction influence the cardiac risk or survival rates associated with surgical treatment of infrarenal abdominal aortic aneurysms (AAAs). METHODS: From 1983 to 1988, graft replacement of intact AAAs was performed in 490 men (84%) and in 92 women (16%) who had no history of myocardial revascularization before the discovery of their AAAs. Patients of both genders were comparable with respect to mean age (68 years) and the prevalence of coronary artery disease (CAD) by standard clinical criteria (men, 73%; women, 65%). Preoperative coronary angiography was obtained in 471 of the 582 patients (men, 81%; women, 80%) during this particular study period. Preliminary coronary bypass was warranted on the basis of existing indications in 111 (24%) of these 471 patients (men, 25%; women, 18%), including 104 (31%) of the 337 who had clinical indications of CAD (men, 32%; women, 26%) but only 7 (5.2%) of the 134 who did not (men, 6%; women, 4%). Follow-up data were collected during a mean interval of 53 months (men, 54 months; women, 48 months) and were analyzed by Kaplan-Meier survival analysis and Cox proportional hazards models. RESULTS: Twenty-nine perioperative deaths (5.0%) occurred in conjunction with AAA repair (men, 5.1%; women, 4.3%), and 126 early and late deaths have occurred (men, 22%; women, 22%). Survival rates for the series were found to correlate with age (p < 0.001), the serum creatinine level (p < 0.001), and the coronary angiographic classification (p < 0.001). No significant differences were identified between the gender cohorts. The cardiac mortality rate for AAA resection was only 1.8% in the 111 patients who had preliminary coronary bypass, but five additional perioperative deaths (4.5%) related to renal failure or sepsis occurred in this group. However, 5-year survival rates for patients receiving preliminary bypass (men, 82%; women, 75%) were closely comparable with those for patients found to have only mild to moderate CAD by angiography (men, 86%; women, 82%). CONCLUSION: We conclude that men and women with AAAs have similar cardiac risks and survival rates associated with surgical treatment. Our results also illustrate that the potential benefit of coronary intervention for severe CAD in patients of either gender must be considered in the context of long-term outcome and the early mortality rate of AAA repair.     

Impact of retrograde cerebral perfusion with posterolateral thoracotomy on distal arch aneurysm repair

BACKGROUND: Repair of distal aortic arch aneurysms is difficult to accomplish through a median sternotomy or left thoracotomy, and stroke and respiratory disorders often become lethal complications with the use of circulatory arrest. We investigated the use of retrograde cerebral perfusion with a posterolateral thoracotomy in the repair of distal arch aneurysms. METHODS: Thirty-eight patients underwent repair of a distal arch aneurysm. They were divided into three groups according to the method of surgical repair used. Sixteen patients (group I) underwent proximal anastomosis of the graft with the use of an aortic cross-clamp. Eight patients (group II) underwent open proximal anastomosis with the use of retrograde cerebral perfusion (oxygenated blood perfusion through a superior vena cava cannula) and a median sternotomy and anterolateral thoracotomy. Fourteen patients (group III) also underwent open anastomosis with the use of retrograde cerebral perfusion (cerebral perfusion through blood returned to the right atrium with the patient in the Trendelenburg position) and a posterolateral thoracotomy. RESULTS: The operative mortality rate in group I was 25.0%; 4 of 16 patients died of stroke, myocardial infarction, and intestinal necrosis. In group II, 3 of 8 patients (37.5%) died of respiratory failure and aortic dissection. In group III, only 1 of 14 patients (7.1%) died, as a result of heart failure. CONCLUSIONS: The use of retrograde cerebral perfusion with a posterolateral thoracotomy is an alternative method that minimizes the risk of stroke and respiratory failure during distal aortic arch operations.     

Impact of ultrafiltration on blood use for atrial septal defect closure in infants and children

BACKGROUND: Infants and children undergoing open cardiac operations have a high incidence of blood product transfusion. Ultrafiltration has been shown to reverse hemodilution and improve myocardial function and hemodynamics after cardiopulmonary bypass (CPB). METHODS: The effect of ultrafiltration on the amount of blood transfusion and hospital charge in 39 consecutive patients who underwent elective atrial septal defect repair was examined. Patients in group I (n=26) had a conventional cardiopulmonary circuit prime with blood, whereas 13 patients had bloodless prime (group II). Ultrafiltration was used immediately after weaning from CPB in group II. The patients in group I received blood products after discontinuation of CPB to achieve a hematocrit of 30%. The amount of blood product used, hematocrit immediately after CPB and on arrival in intensive care unit, postoperative hemodynamics and saturations, total operating room charge, blood charge, hospital stay, and hospital charge were compared. RESULTS: Mean body weight (15.8 kg in group I versus 17.5 kg in group II) and preoperative hematocrit values (35.6% in group I versus 34.2% in group II) were similar. Mean hematocrit immediately after CPB was 22% and 14% in group I and II, respectively (p < 0.0001). The mean hematocrit upon arrival to the intensive care unit was 34% in group I and 22% in group II (p < 0.0001). The amount of blood product transfusion was 32 mL/kg in group I and 3 mL/kg in group II patients (p < 0.0001). The patients in group II had significantly less blood bank charges; however, operating room charges and total hospital charges were similar between the two groups. CONCLUSIONS: Elective atrial septal defect repair was performed with no blood product transfusion without increased morbidity or hospital stay. Ultrafiltration can be used to reverse hemodilution resulting from a bloodless CPB prime without an increase in hospital charge.     

Detection of human herpesvirus 8 DNA in Kaposi''s sarcoma lesions and peripheral blood of human immunodeficiency virus-positive patients and correlation with serologic measurements

PURPOSE: We reviewed our experience with a clinical pathway instituted in December 1993 for all nonurgent abdominal aortic aneurysm (AAA) surgery. METHODS: We analyzed a reference group of 49 consecutive pre-pathway AAA patients (group I) and the 44 patients enrolled in the first year of the pathway (group II). On the basis of the interim review of data collected during the first year, pathway modifications were made, and 34 patients enrolled after these modifications (group III) were also analyzed. RESULTS: Comparison of groups I and II showed that institution of the pathway resulted in a marginally significant reduction in mean charges of 14.7% (p = 0.09), and a slight fall in mean length of stay (LOS) (13.8 vs 13.1 days, NS) and mortality rate (4.1% vs 2.3%, NS). For group II, a significant correlate (p < 0.05) of increased charges was fluid overload as diagnosed by chest radiograph. This recognition led to active efforts to reduce perioperative fluid administration. Comparison of groups II and III revealed that the practice modifications led to marked reduction in the incidence of fluid overload (73% vs 24%; p < 0.01), mean charges (30.4% reduction; p < 0.05), mean LOS (13.1 vs 10.2 days; p < 0.05), and median LOS (11 vs 8 days). Multiple regression analysis of all pathway patients showed that preoperative renal insufficiency is a significant predictor of both increased LOS (p < 0.01) and charges (p < 0.01), but that age, sex, and coronary disease were not predictive. Of the postoperative parameters analyzed, important correlates of increased charges were acute renal failure (p < 0.01) and fluid overload (p < 0.01). CONCLUSIONS: Institution of a clinical pathway for AAA repair resulted in significant charge reduction and a slight reduction in stay. Practice modifications based on interim data analysis yielded further significant reductions in charges and LOS, with overall per-patient charge savings (group I vs III) of 40.6% (p < 0.05) and overall LOS reduction of 3.5 days (p < 0.05). The reduction in actual charges was seen despite an overall increase in the hospital rate structure. Comparing groups I, II, and III, we found no indication of increasing mortality rate. Ongoing analysis has identified correlates of increased charges, potentially permitting identification of high-cost subgroups and more focused cost-control efforts. Rather than restricting management, clinical pathways with periodic data analysis may improve quality of care.     

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

BACKGROUND: This study reviews the results of infrarenal abdominal aortic aneurysm (AAA) surgery over 21 years (1 January 1976 to 31 December 1996). METHODS: A prospectively gathered database was analysed. RESULTS: 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. CONCLUSIONS: 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.     

Topical anesthesia: Proxymetacaine versus Amethocaine for clear corneal phacoemulsification

BACKGROUND: The risk of rupture of large abdominal aortic aneurysms (AAAs) remains uncertain. This study aimed to provide data to help decide whether or not to operate on high-risk patients. METHODS: Clinicians were asked to refer all patients with an AAA, even if unfit or elderly. One hundred and ninety-two patients with an intact AAA of 5 cm or greater in diameter were seen in 9 years; 59 had no elective operation and follow-up data were available for 57 at a minimum of 2 years. Initial AAA diameters were 5.0-5-9 cm (n=25) and 6.0 cm or more (n=32). Survival curves were constructed for both groups. RESULTS: At the end of the study 50 of 57 patients had died. Median survival was 18 (range 1-90) months. Twenty (35 per cent) suffered rupture at a median interval of 18 (range 1-38) months. The risk of rupture within 3 years was 28 (95 per cent confidence interval 12-49) per cent for 5.0-5.9-cm AAAs and 41 (24-59) per cent for AAAs of 6 cm or greater. In 133 elective AAA operations in fit patients the 30-day mortality rate was 3 per cent. CONCLUSION: The risk of rupture within 3 years of diagnosis of an AAA of 5 cm or greater exceeds the expected operative mortality rate for fit patients. However, the majority of patients unfit for surgery died from other causes, and only a few would have benefited from aneurysm repair.