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

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

Perianeurysmal retroperitoneal fibrosis. An unusual cause of renal failure

Retroperitoneal fibrosis causing ureteral obstruction in association with an abdominal aortic aneurysm has been reported infrequently. However, the clinical presentation of patients with this entity and the histopathologic findings at surgery are similar to those in patients with idiopathic retroperitoneal fibrosis. We describe a patient with perianeurysmal fibrosis and bilateral ureteral obstruction who presented with severe renal failure. The diagnosis of an abdominal aortic aneurysm with perianeurysmal fibrosis was made only at the time of surgery to repair bilateral ureteral obstruction. Previous case reports of perianeurysmal fibrosis are reviewed, and possible pathogenetic mechanisms are discussed. It is important to consider the presence of an occult abdominal aortic aneurysm in patients suspected of having retroperitoneal fibrosis because of the serious prognostic and therapeutic implications.     

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.     

Tamoxifen for retroperitoneal fibrosis

Retroperitoneal fibrosis, either idiopathic or associated with aortic inflammatory aneurysm, is a chronic fibrotic disease that causes progressive obstruction of ureters and vessels around the lower abdominal aorta. Treatment is often difficult (surgery) or hazardous (steroids). We report a case of a woman with retroperitoneal fibrosis associated with aortic inflammatory aneurysm, who was successfully treated with oral tamoxifen.     

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.     

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.     

Potential influence of intraluminal thrombus on abdominal aortic aneurysm as assessed by a new non-invasive method

Intraluminal thrombus may play a role in abdominal aortic aneurysm pathogenesis and rupture. The purpose of this work was to demonstrate the feasibility of a new non-invasive method for the determination of the biomechanical features of the aortic wall and luminal boundary in abdominal aortic aneurysm containing intraluminal thrombus. Automated ultrasonographic measures of infrarenal aortic cross-sectional area (A) were obtained on-line along with non-invasive arterial pressure (p) from eight patients of mean (s.e.m.) age 74(3) years, with abdominal aortic aneurysm (mean dimensions 5.9(0.4) x 5.3(0.5) cm) containing intraluminal thrombus. Luminal boundary and abdominal aortic aneurysm wall were scanned separately. Compliance (C) was computed as C = (Amax - Amin)/[Amax(Pmax - Pmin)], where 'max and 'min' represent maximum and minimum values, respectively. Mean compliance was lower for the abdominal aortic aneurysm wall alone than for the luminal surface enclosed by intraluminal thrombus: 4.0(0.9) x 10(-4)/mmHg versus 9.8(1.7) x 10(-4)/mmHg (P < 0.01). Intraluminal thrombus area was nearly constant over the cardiac cycle, indicating that the thrombus is virtually incompressible. This noninvasive method to assess biomechanical features of abdominal aortic aneurysm has potential to further the understanding of the influences of intraluminal thrombus on aneurysm disease.     

EEG recordings during episodes of palinacousis and palinopsia]

Stent-graft placement was performed in 2 patients with saccular aortic aneurysm. A Dacron-covered nitinol stent-graft was deployed in the thracoabdominal and infrarenal abdominal aorta. These procedures were successfully performed. The aneurysm disappeared on intraoperative angiogram immediately after deployment. Follow-up CT showed thrombosis or disappearance of aortic aneurysm. Distal embolization occurred in one patient, who required resection of the small bowel on the following day and renal dialysis due to renal infarction. Both patients were still alive one and a half years and one year after the procedure, respectively. Stent-graft placement is a feasible alternative to surgery for aortic aneurysm in selected patients.     

Activation of coagulation and fibrinolysis in patients with abdominal true aortic aneurysm associated with disseminated intravascular coagulation

Two cases of abdominal true aortic aneurysm (AAA) associated with disseminated intravascular coagulation (DIC) were reported. Case 1 was an 81-year-old male who was admitted because of hematoma on the left leg and in whom was found by MRI an aortic aneurysm of 14 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia, hypofibrinogenemia and increased level of FDP. DIC was well controlled by surgical repair of the aneurysm after the administration of a small dose of heparin. Case 2 was a 60-year-old male who was admitted because of lumbago and hematoemesis and in whom was found by CT and echography an aortic aneurysm of 5.5 cm in diameter. Coagulation studies indicated DIC by revealing thrombocytopenia and an increased level of FDP. On the 2nd hospital day, he suddenly died due to the rupture of the aortic aneurysm. In most of 9 cases with AAA without DIC, plasma levels of thrombin-antithrombin III complex, plasmin-alpha 2 plasmin inhibitor complex and FDP-D dimer were also elevated. These findings indicate that the coagulation and fibrinolysis systems were generally activated in patients with AAA, and that DIC tends to occur in patients with a giant aortic aneurysm or an impending ruptured aneurysm.     

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

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

A successful case of infrarenal abdominal aortic replacement against acute abdominal organ failures and ischemia of bilateral lower limbs following the operation of DeBakey IIIb-type dissecting aneurysm

We experienced a successful surgical case, who was a 52-year-old man suffered from acute abdominal organ failures and ischemia of bilateral lower limbs following aortic arch replacement against DeBakey IIIb-type dissecting aneurysm. We investigated the abdominal blood flow by DSA via true lumen, which seemed to be obstructed by the increase in blood flow to false lumen. Therefore, to increase in blood flow to true lumen, we performed an urgent infra-renal abdominal aortic replacement successfully.     

Pelvic radiation therapy as a risk factor for ischemic colitis complicating abdominal aortic reconstruction

Ischemic colitis is an infrequent but potentially devastating complication of abdominal aortic reconstruction. Identification of patients with predisposing risk factors for the development of ischemic colitis can guide intraoperative measures to preserve or restore colonic blood flow during aortic surgery. Previous radiation therapy for pelvic malignancy may be one such predisposing risk factor. Two cases are presented in which ischemic colitis complicated abdominal aortic reconstruction in the setting of previous pelvic irradiation. In the months after radiation therapy for prostate cancer, one patient underwent infrarenal abdominal aortic aneurysm repair. Ischemic infarction of the sigmoid colon developed acutely after surgery and required emergent sigmoid colectomy. The second patient underwent reconstruction of an infrarenal abdominal aortic aneurysm after having had radiation therapy for a bladder tumor. Despite an initial satisfactory result, the patient's abdominal pain and diarrhea progressively worsened and he eventually required sigmoid colectomy for severe ischemic colitis. In both of these patients, the inferior mesenteric arteries were patent and had not been reimplanted. The association of pelvic radiation therapy with ischemic colitis after aortic reconstruction should focus attention to the operative details for maintaining the colonic circulation in these patients. Reimplantation of the inferior mesenteric artery in particular may prevent both the acute and the insidious variants of this complication in patients who undergo aortic surgery and decrease the incidence of this complication in patients with a history of radiation therapy to the pelvis.     

Presentation and treatment of spontaneous aortocaval fistula

BACKGROUND: Spontaneous rupture of abdominal aortic aneurysm into the inferior vena cava is rare. The clinical presentation is highly variable, and the diagnosis can be difficult, often being made only at operation. The aortocaval fistula results in a large left-to-right shunt, which can cause cardiac failure. Once the diagnosis is made, treatment is by surgical closure of the fistula and repair of the aneurysm with a graft. METHODS: This is a retrospective review of a single surgeon's experience with aortocaval fistula complicating abdominal aortic aneurysms. RESULTS: Over a 15-year period, we had five patients with spontaneous aortocaval fistula who were treated operatively. Preoperative diagnosis was made in two, suspected in one, and not made in two, one of whom died (the only perioperative death in the series). CONCLUSIONS: Spontaneous aortocaval fistulas are uncommon, and their preoperative recognition is difficult. Hematuria in association with an abdominal aortic aneurysm should raise the suspicion of an aortocaval fistula. Surgical correction is possible, with survival rates comparable to those associated with rupture of aneurysms into the retroperitoneum. Early operative control of the fistula is important to optimize the preload to the heart.     

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.     

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

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

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

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

Abdominal aortic resection in thoracic dissection

Dissection nearly always begins in the thorax, but it commonly extends into the abdominal aorta, which may become the focal point of the disease. We report five patients who illustrate the surgical management of this disease variant. Clinical manifestations included retroperitoneal rupture, expanding false aneurysm, and lower aortic occlusion. All patients had an aortic bifurcation graft, with reentry of the false lumen at the renal level. Two patients also had thoracic-aortic resection or plasty or both. Although one patient had thoracic aortic rupture at the five-year interval, these abdominal aortic resections provided effective palliation in all. This successful experience in managing complex dissections shows that when aortic dissection extends into the abdomen, resection of the distal aorta with a reentry procedure may be appropriate therapy.     

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.     

Preparation for upper gastrointestinal endoscopy: opportunity or inconvenience?

A 59-year-old man, who manifested lower back pain, was admitted with sepsis and disseminated intravascular coagulation (DIC). A computed tomographic scan showed a slight thickening of the abdominal aortic wall. A blood examination revealed pancytopenia. Myelodysplastic syndrome was diagnosed after bone marrow aspiration and a chromosome analysis. Sepsis due to a Staphylococcus aureus infection and DIC subsided after medical treatment; however, an aortobifemoral bypass was performed upon the detection of a localized rupture of a mycotic abdominal aortic aneurysm 1 month later. The patient is still alive 2 years after operation despite the presence of a hematological disorder.     

Surgery of abdominal aortic aneurysm and concomitant disease of the digestive tract

The incidence of intra-abdominal diseases associated with abdominal aortic aneurysm is increasing, and it is difficult to decide whether to operate the abdominal disease first, the aneurysm first or both simultaneously. Variables used in decision analysis include type, stage and life expectancy of the cancer, rupture rate of abdominal aortic aneurysm. Symptomatic lesion should be treated first. Absolute indication for operation initially on the aneurysm is the presence of symptoms of rupture. Aortic abdominal aneurysmectomy combined with surgical removal of an intestinal disease may present severe risks as infection of the graft and anastomotic leakage, especially during lower abdominal surgery. In this paper authors present four cases of AAA which had intra-abdominal surgical disease. They were treated by one-stage operation with no complications. Criteria to assess timing of surgical treatment of abdominal surgical diseases concomitant to AAA are discussed.