Surgical treatment of thoracoabdominal aortic aneurysm

Graft replacement for thoracoabdomital aortic aneurysm was performed in 8 patients between 1982 and 1989. Five patients in our series underwent reattachment of the branch vessels to openings made in the graft. Partial bypass or external shunt was used in 6 patients during aortic cross-clamping. Selective blood perfusion to the branch vessels was performed in 5 patients intraoperatively. Neither hospital death nor postoperative paraplegia was found in our series. One patient without selective perfusion of abdominal branch vessels during reattachment to the graft developed an acute jaundice postoperatively, but 4 of the 5 patients receiving selective perfusion of branch vessels developed no complication related to abdominal ischemia. These results suggest that intraoperative blood perfusion of aortic branch might be useful for prevention of anoxic complication of the abdominal organs after surgery of thoracoabdominal aortic aneurysm.     

Technical advances in the surgical management of thoracoabdominal aortic aneurysms]

Thoracoabdominal aortic aneurysmectomy ranks among the major cardiovascular surgical procedures. During the last two decades perioperative results have improved to the point that surgery should be discussed in the vast majority of patients seen with a thoracoabdominal aortic aneurysm. This progress is largely attributable to a variety of technical improvements including: aortic reconstruction using the graft inclusion technique, usually with direct reattachment of aortic branches to the prosthetic graft; distal aortic perfusion; selective use of deep hypothermic circulatory arrest in anatomically complex situations; preoperative visualization of arterial blood supply to the spinal cord using selective arteriography of intercostal and lumbar arteries. Current perioperative mortality is around 10% whereas the spinal cord complication rate is between 5% and 20% according to clinical and anatomical conditions. Future efforts should concentrate on the prevention of spinal cord complications.     

Surgical treatment of aortic arch aneurysms in profound hypothermia and circulatory arrest

BACKGROUND: This study was undertaken to define the factors that influence mortality rate and neurologic outcome after repair of the aortic arch and various portions of the thoracic aorta in patients with profound hypothermia and circulatory arrest. METHODS: Between November 1986 and January 1996, 105 patients were treated surgically for aortic disease involving the transverse aortic arch. Profound hypothermic circulatory arrest and selective brachiocephalic perfusion was used in all patients. In 19 patients retrograde cerebral perfusion was instituted during the period of circulatory arrest. Independent predictors for 30-day mortality and permanent neurologic deficits were evaluated by multiple logistic regression. RESULTS: Thirty-day mortality for the entire group was 19% (20/105); 21.2% for urgent versus 15.4% for elective cases, respectively. Statistical analysis showed that age is the most important factor that significantly influences mortality rate (p < 0.0145) and neurologic outcome (p < 0.006). Variables such as circulatory arrest time (p < 0.24), previous cardiac or aortic operations (p < 0.19), and sex (p < 0.55) failed to show any influence on mortality rate. Permanent neurologic deficits were diagnosed in 12.9% (11/85) of the patients. CONCLUSIONS: The incidence of permanent neurologic dysfunction as well as the mortality rate are predominantly related to the age of the patient. In this patient group, statistical analysis failed to show a direct correlation between duration of circulatory interruption and neurologic outcome.     

Non-surgical treatment of abdominal aortic aneurysms

Percutaneous placement of an endovascular stent, with and without coils, in the treatment of large AAA in animal models is feasible, safe and effective. The covered stent sealed off AAA immediately after stent placement, however, it interrupted blood flow into arteries in the area covered by the stent. The uncovered stent prevented further expansion of the aneurysm and also significantly decreased the incidence of rupture. The long-term patency of branch arteries by the uncovered stent supported the possibility of safely using this approach in humans. Furthermore, either covered stent or uncovered stent with additional coils have the potential for treatment of acute aneurysm rupture or leaking. Most importantly, the aneurysm lumen in our model was gradually replaced by collagen after stent placement which further reduces the risk of aneurysm rupture: and this healing process was enhanced by the addition of coils. If proven safe and effective for humans as well, this technique has the potential for substantially reducing the morbidity and mortality associated with AAA.     

Diagnosis and treatment of abdominal aortic aneurysms

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

Abdominal and thoracoabdominal aortic aneurysm

Most abdominal aortic aneurysms (AAA) and thoracoabdominal aortic aneurysms (TAAA) are asymptomatic and are found on physical exam or incidentally during radiological studies for other indications. These aneurysms are repaired primarily because their risk of rupture increases geometrically as the size exceeds 5 cm. The potential morbidity of intraoperative visceral and spinal ischemia involved with TAAA repair may be reduced with various adjunctive maneuvers.     

Surgical treatment of false aneurysms following Bentall's operation

Between January 1973 and June 1993, 157 patients had Bentall's operation and its modifications for the surgical treatment of annuloaortic ectasia and dissecting aneurysm in our institute. Reoperation for false aneurysms following Bentall technique were performed 10 patients. There were 8 males and 2 females. This ages ranged from 29 to 57 years with an average of 41. The interval between initial and subsequent operation was from 3.7 to 18.4 years (median, 8.2 years). Prior to a median sternotomy, femoro vein-femoral artery partial cardiopulmonary bypass was instituted occationaly. Operative technique of repair of coronary detachment were direct closure in 6 and interposition graft technique in 4 patients. There were 2 hospital death caused by rupture at median aternotomy and graft infection. The actuarial freedom from reoperation at 10 years according to technique of coronary reattachment, for the patients with one lane suture was 69%, for those with two lane suture was 95% (p < 0.01), and for those with interposition graft technique was 100%. In conclusions, it was very important for repair of false aneurysms following Bentall procedure to expose aneurysms safely through proper approach. Interposition graft technique was preferable to repair coronary detachment. Our recent surgical results of Bentall procedure improved by the modification of the coronary reimplantation method.     

Results of surgical treatment of ruptured abdominal aortic aneurysms

This paper analyzes results of 5-year surgical treatment of patients with ruptured abdominal aorta aneurysms (1991.-1995.) at the Clinic for Vascular and Transplantation Surgery of the Institute of Surgery in Novi Sad. 105 patients with abdominal aorta aneurysm underwent surgery, whereas in 31 patients there was a suspicion of rupture and it was confirmed by US and CT examination. One of basic factors to decrease mortality in these patients is early diagnosis and surgery before hemorrhagic shock occurs. Results in hemodynamic stabile patients with blood pressure over 100 mmHg and regular diuresis are much better with mortality of 20%. In order to estimate the correlation of hemodynamic state and outcome of the operation, patients were divided into three groups--hemodynamic stable with blood pressure over 100 mmHg and regular diuresis at admission: hemodynamic unstable patients with signs of mild or moderate shock and blood pressure under 100 mmHg and without initial diuresis which was regulated at the beginning of therapy and hemodynamic unstable patients in severe shock and unmeasurable blood pressure. The highest survival rate (10% mortality) and the least complications occurred in the first group of patients. The total mortality of patients after surgery was 48.48%. Timely diagnosis, suspicion of rupture and adequate first and with urgent transfer to a competent surgical institution are key factors in treatment of this disease and its outcome.     

Renal failure after thoracoabdominal aortic surgery

PURPOSE: Renal failure remains a common and morbid complication after complex aortic surgery. This study was performed to identify perioperative factors that contribute to postoperative renal failure. METHODS: The perioperative outcomes of 183 patients who underwent thoracoabdominal aortic surgery with supraceliac clamping were reviewed. During the interval from Jan. 1987 to Nov. 1996, thoracoabdominal aneurysm repair was performed in 154 patients (type I, 49 patients [27%]; type II, 21 patients [11.5%]; type III, 55 patients [30%]; type IV, 29 patients [16%]), suprarenal abdominal aortic aneurysm repair in 17 patients (9%), and visceral/renal revascularization procedures in 12 patients (6.5%). Intraoperative management included thoracoabdominal aortic exposure and clamp-and-sew technique with renal artery cold perfusion whenever the renal arteries were accessible (79% of cases). RESULTS: Relevant clinical features included preoperative hypertension (85%), diabetes mellitus (8%), single functioning kidney (10%), recent intravenous contrast injection (34%), renal insufficiency (creatinine level greater than 1.5 mg/dl; 24%), and emergent operation (19%). Acute renal failure, defined as both a doubling of serum creatinine level and an absolute value greater than 3.0 mg/dl, occurred in 21 patients (11.5%), of whom five required hemodialysis (2.7%). Variables associated with this complication included a preoperative creatinine level greater than 1.5 mg/dl (p = 0.004) and a total cross-clamp time greater than 100 minutes (p = 0.035). The operative mortality risk (within 30 days; 8%) was significantly increased with renal failure (odds ratio, 9.2; 95% confidence interval, 2.6 to 33; p < 0.005). CONCLUSIONS: Renal failure, although uncommon in contemporary practice, greatly increases the risk of early death after thoracoabdominal aortic surgery. The overall incidence of renal failure and dialysis requirement in the present series compare favorably with those reported using other operative techniques, specifically partial left heart bypass and distal aortic perfusion. These data suggest that patients who have preoperative renal insufficiency are prone to postoperative renal failure. Furthermore, regional hypothermic perfusion and minimal clamp times are important elements in the prevention of renal failure after thoracoabdominal aortic surgery.     

Clinical aspects and treatment of inflammatory abdominal aortic aneurysms

An increasing number of inflammatory abdominal aortic aneurysms are reported today, although it is not clear whether these are nosologically independent lesions or a particular evolution of atherosclerotic aneurysms with enhanced phlogistic processes and fibrous reaction. Several pathogenetic theories have been proposed (microfissuration, autoimmunity, lymphatic stasis); clinical symptoms are characterised by the frequent involvement of contiguous retroperineal structures (in particular the urinary excretory tract and duodenum) which may be dislocated or compressed by the neoformation. CT or NMR appear to be the instrumental tests which give the most reliable diagnosis regarding the suspected inflammatory nature of the aneurysm. A correct pre-operative diagnosis is particularly important given that the morphological peculiarities (fibrosis and tenacious synechiae) add considerable pitfalls and difficulties to the operation. In this respect, the use of special technical devices, such as minimum dissection, permit a marked reduction of perioperative complications.     

Surgical treatment of traumatic aneurysms of the peripheral vessels

The article analyzes the surgical treatment of 64 patients with traumatic aneurysms of the extremity vessels. In late terms (from 1 to 8 years) the main blood flow was found to recover in 46 to 53 patients. An analysis of near and late results showed an expediency of recovery of the main blood flow after ablation of arterial and arterio-venous aneurysms with the help of a circular suture or plasty with autovenous tubular grafts. In arterio-venous shunts the best method was found to be liquidation of the shunt by ligation or suturing it with an apparatus for suturing the vessels.     

Surgical treatment for acute aortic arch dissection

The authors describe 2 patients with Takayasu's arteritis in whom lupus anticoagulant was positive and the titer of anticardiolipin antibody was elevated. One patient developed diffusely stenotic and occlusive changes in the multiple larger arteries. Histology of the small-sized arteries in another patient showed occlusive vasculitis without thrombosis, in addition to the findings in large-sized arteries compatible with Takayasu's disease. These findings are uncommon in Takayasu's arteritis. These findings suggest that antiphospholipid antibodies may have contributed to the pathogenesis of the extensive vasculopathy and may have triggered vasculitis in these patients.     

Surgical treatment of vertebral and posterior inferior cerebellar artery aneurysms

Geochelone carbonaria hemoglobin (Hb) was analyzed by polyacrylamide gel electrophoresis (PAGE) and purified by ion exchange chromatography on CM-cellulose. Seven fractions were obtained using fresh Hb preparations. CM-cellulose chromatography of Hb reacted with iodoacetamide, showed one minor (HbI) and one major band (HbII). Analysis of the molecular masses of recently collected Hb and of aged solutions determined by gel filtration showed that polymerization increased with the duration of storage. The reaction with oxidized glutathione changed the electrophoretic pattern of Hb, and highlighted the bands corresponding to glutathionyl-Hb. The presence of these bands in fresh Hb solutions and in alkylated preparations suggests that they may occur in vivo. PAGE under dissociating conditions showed that the hemolysate contained 3 different polypeptide chains (G1, G2 and G3). Both Hb components shared the G1 globin chain with HbI containing G1 and G2 and HbII, G1 and G3 chains.     

Surgical treatment of internal carotid and posterior communicating artery aneurysms

Saccular aneurysms of the subarachnoid segment of the internal carotid artery (ICA) are very common. Although some of the aneurysms arising from the subarachnoid ICA have earned the reputation of easy to treat surgically, aneurysms in this region may be complex and quite difficult to repair. Even a simple aneurysm associated with the posterior communicating artery may harbor surprises for the unwary or inexperienced surgeon. This article details the pertinent anatomy of the subarachnoid internal carotid artery and associated saccular aneurysms, provides a guide to their diagnosis and surgical treatment, and briefly reviews some of the published surgical results. Pitfalls and technique tips are highlighted.     

Preservation of masculine sexual functions after treatment for abdominal aortic aneurysms

Preserving sexual function is an important objective in the treatment of aneurysms of the abdominal aorta in men. METHOD: Two groups of patients with normal sexual function were operated for aneurysms of the abdominal aorta. In group 1 (n = 22) a small opening in the infra-renal aorta was made for insertion of an aorto-bi-iliac prosthesis; in 4 of them, the aneurysm was not opened but simply excluded. In group 2 (n = 22), the aorta was opened longitudinally for insertion of an aorto-aortic tube. RESULTS: Sexual function was totally abolished after operation in 9% of the patients in group 1 and in 36% of those in group 2. Sexual functions were totally preserved in 50% of the patients in group 1 and in 36% of those in group 2, but the differences were not statistically significant. CONCLUSIONS: 1) It is not always possible to guarantee maintained sexual function after operation for aneurysms of the abdominal aorta and the patients should be advised thereto; 2) aortobi-iliac prostheses with limited opening of the aorta in the upper part of the aneurysm or exclusion of the aneurysm led to a higher rate of preservation than aorto-aortic tubes with total opening of the aneurysm and should be preferred in men with normal sexual function.     

Hypogastric arterial aneurysms associated with abdominal aortic aneurysms

The purpose of this study was to compare the physiological responses of professional and elite road cyclists during an incremental cycle ergometer test. Twenty-five elite cyclists (EC; 23+/-1 yr) and 25 professional cyclists (PC; 25+/-2yr) performed a ramp protocol (increases of 25 W x min(-1)) during which the following parameters were measured: oxygen consumption (VO2), pulmonary ventilation (VE), ventilatory equivalents for oxygen and carbon dioxide (VE x VO2(-1) and VE x VCO2(-1), respectively), respiratory exchange ratio (RER), ventilatory thresholds 1 and 2 (VT1 and VT2, respectively), blood lactate, and electromyographic activity (EMG) of the vastus lateralis. Significant differences existed between the two groups mainly at submaximal intensities, since both VT1 and VT2 occurred at a higher exercise intensity (p<0.001) in PC than in EC (VT2: 80.4+/-6.6 vs 87.0+/- 5.9% VO2max in EC and PC, respectively). Lactate levels showed a similar response in both groups at low-to-moderate intensities (< 300 W), and thereafter blood lactate was significantly higher in EC. Finally, the "electromyographic threshold" (EMGT) occurred at a significantly higher intensity (p < 0.05) in PC when compared to EC (64.7+/-14.2 vs 56.0+/-14.9% VO2max, respectively). It was concluded that, in comparison with EC, PC exhibit some remarkable physiological characteristics such as a high VT2, an important reliance on fat metabolism even at high power outputs, and several neuromuscular adaptations.     

Surgical treatment of aortic rupture by blunt chest trauma

During a ten-year period, seven patients with traumatic rupture of the thoracic aorta were operated upon. Four patients of them were operated within one week. Chest X-rays and chest computed tomography could not always reveal the exact diagnosis of aortic rupture. Intravenous digital subtraction angiography was useful to confirm the diagnosis. The repair of the rupture was accomplished with the adjunct of left heart bypass using Bio-pump, which was useful to reduce the bloodloss with a limited systemic heparinization. Another three patients were diagnosed to have chronic post-traumatic aneurysm of the thoracic aorta and underwent aortic replacement with prosthetic graft. One of seven patients died at seventh postoperative day because of cerebral contusion, the associated lesion of an automobile accident. It is stated that the aortic rupture is immediately fatal in approximately 80% of individuals, and most of remaining 20% die within 2 weeks unless the lesion is repaired. Therefore immediate operative intervention is recommended when the aortic rupture is strongly suspected. Chronic post-traumatic aneurysms should be resected because it has become apparent that the majority of patients with this lesion will develop complication, such as sudden rupture.     

Endovascular treatment of abdominal aortic aneurysms. Morphology of aneurysms as one of the deciding indicating factors

Endovascular treatment of aneurysms of the abdominal aorta is based on intravascular bridging of the aneurysm using of an endovascular prosthesis. The prosthesis must be safely anchored above and below the sac of the aneurysm in the non-dilated artery. Therefore the indication of endovascular treatment depends on the morphology of the aneurysm. The objective of the work was to analyse the morphology of the aneurysm with regard to the possibility of endovascular treatment. The morphology of the aneurysm was evaluated with regard to the angiographic examination and examination by computed tomography. The following parameters were investigated: diameter and length of the proximal and distal neck, diameter of the sac in two planes, diameter and tortousity of the iliac arteries, tortousity of the infrarenal aorta. A total of 70 patients with aneurysms of the abdominal aorta were examined. The patients were divided into three groups according to the morphology of the aneurysm. I. infrarenal aneurysms not affecting common iliac artery (n = 20) 28.5%, II. infrarenal aneurysms affecting common iliac artery (n = 38) 54.2%, III. juxtarenal aneurysms regardless of the affection of common iliac arteries (n = 12) 17.1%. Of the total of 70 examined patients 24 (34.2%) with infrarenal aneurysm and 6 (8.57%) with juxtarenal aneurysm were suitable for endovascular treatment.