Laparoscopically assisted abdominal aortic aneurysm repair. A report of 10 cases

BACKGROUND: Laparoscopic surgery decreases postoperative pain and length of hospital stay. Whether laparoscopically assisted abdominal aortic aneurysm (AAA) repair can be safely and reliably performed is unknown. This prospective study was designed to establish the feasibility of laparoscopically assisted AAA repair and its effects on intraoperative and postoperative variables. METHODS: With IRB approval, 10 patients with infrarenal AAA requiring a tube graft underwent laparoscopically assisted AAA repair. The procedure consisted of laparoscopic dissection of the aneurysm neck and iliac vessels. Then, through an 8-11-cm minilaparotomy, a standard endoaneurysmorrhaphy was performed. Data included laparoscopic and total operative times, blood loss, fluid requirements, duration of nasogastric suction (NGT), and lengths of intensive care unit (ICU) and postoperative hospital stays. RESULTS: Laparoscopically assisted AAA was completed in nine of 10 patients. The first patient was converted to a standard incision because the aneurysm neck could not be adequately dissected. Laparoscopic and total operative times were 1.8 +/- 0.4 and 4.5 +/- 0.7 h, respectively. Mean blood loss was 1 +/- 0.6 l. Intraoperative fluid requirement was 6.6 +/- 1.3 l. The duration of NGT suction was 1.8 +/- 1.0 days. The ICU stay was 2.1 +/- 0.8 days and hospital stay was 6.7 +/- 2.5 days. There were two minor complications and no deaths. CONCLUSIONS: Laparoscopically assisted AAA repair is technically feasible with acceptable blood loss, operative time, morbidity, and mortality. Potential advantages may be early removal of the NGT and shorter ICU and hospital stays. Prospective randomized trials are needed to determine if laparoscopically assisted AAA repair is advantageous.     

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.     

Utility of transesophageal echocardiography and pulmonary artery catheterization during laparoscopic assisted abdominal aortic aneurysm repair

BACKGROUND: Advanced laparoscopic procedures are more commonly performed in elderly patients with cardiac disease. There has been limited data on the use of pulmonary artery catheters (PAC) and transesophageal echocardiography (TEE) to monitor hemodynamic changes. METHODS: We prospectively studied eight patients undergoing laparoscopic assisted abdominal aortic aneurysm repair. All patients had a PAC and all but one had an intraoperative TEE. Data included heart rate (HR), temperature (temp), pulmonary artery systolic (PAS) and diastolic (PAD) pressures, mean arterial pressure (MAP), central venous pressure (CVP), pulmonary capillary wedge pressure (PCWP), cardiac index (CI), mixed venous oxygen saturation (MVO2), and oxygen extraction ratio (O2Ex) and was obtained prior to induction, during insufflation, after desufflation, during aortic cross-clamp, and at the end of the procedure. End diastolic area (EDA), a reflection of volume status, was measured on TEE. ANOVA was used for data analysis. RESULTS: No changes were noted in HR, temp, PAS, PCWP, CI, MVO2, and O2Ex. PAD and CVP were greater during insufflation compared with baseline and aortic cross-clamp without associated changes in EDA. MAP was higher at baseline compared with all other times during the procedure. CONCLUSIONS: Insufflation increased PAD and CVP. However, volume status as suggested by EDA and PCWP did not change. These data question the reliability of hemodynamic measurements obtained from the PAC during pneumoperitoneum and suggest that TEE may be sufficient for evaluation of volume status along with the added benefit of timely detection of ventricular wall motion abnormalities.     

Chyloperitoneum--an infrequent complication of abdominal aortic aneurysm repair

Purkinje cells of the cerebellum are particularly susceptible to hypoxia. In these cells tetraploidy has been demonstrated. Therefore, a link between the susceptibility of cells of the cerebellum to hypoxia and the amount of DNA seems probable.     

Ruptured abdominal aortic aneurysm

In the years 1990-1994, 43 patients with ruptured abdominal aortic aneurysms (RAAA) were operated on at the Department of Vascular Surgery of the Na Homolce Hospital in Prague. Men outnumbered women, average patient age was 70 years. The mean delay between onset of symptoms and hospital admission counted 27 hrs. Prior to transportation, one half to two thirds of patients went through at least two types of confirmative evaluation (CAT, ultrasound, angiography) and/or were referred via two or more hospital departments. In two thirds of patients profound shock with oligoanuria and hypotension were found. Anuria/hypotension proved to occur in a significantly lower rate in later survivors compared to later dead (11.8% vs. 23.5%: p < 0.05). Persistent hypotension during surgery together with eventual resuscitation as well as free blood found within the abdominal cavity showed up as further ominous factors. Renal failure was the leading postoperative complication (51.2%) with 27.9% of patients requiring hemodialysis after repair. Sepsis (25.6%), pneumonia (20.9%) and hemorrhage (13.9%) followed. Twenty-six patients were lost (60.5%) either within the first hours and days after surgery because of irreversible hemorrhagic shock or between the second and fourth week due to the sequels of organ failure and sepsis. In our cohort, regardless of age, sex, concomitant disease or the type of surgery, the patient's status on admission determined his/her further destiny. Urgent transfer to a specialized center going hand in hand with prompt and effective reanimation steps are the patient's only hope for survival.     

Autologous blood transfusion: the benefits to the patient undergoing abdominal aortic aneurysm repair

The clinical benefits of using intraoperative autologous blood transfusion during abdominal aortic aneurysm bypass surgery become increasingly apparent when use of autologous and homologous blood transfusions is compared. That homologous blood transfusions carry some risk is widely recognized. When autologous blood is used as a sole source of blood transfusion, the risk of transmission of infectious agents and potential immunologic side effects are avoided. A prospective randomized pilot study comparing autologous and homologous blood transfusion in patients undergoing elective infrarenal abdominal aortic aneurysm bypass surgery was undertaken. The purpose of this study was to determine whether autologous blood salvaged intraoperatively may serve as an alternative to homologous blood by comparing the rate of postoperative infection and duration of hospital stay for patients receiving autologous versus homologous blood transfusions. Fifty patients undergoing abdominal aortic aneurysm bypass surgery were prospectively randomly assigned to receive either a homologous or an autologous blood transfusion, with 27 receiving a homologous blood transfusion and 23 receiving an autologous blood transfusion. The data from this study show that the length of hospital stay of patients receiving an autologous blood transfusion intraoperatively was reduced by a mean of 3 days and the risk of postoperative complications such as a systemic inflammatory response or sepsis, was reduced by more than 50%.     

Screening for abdominal aortic aneurysm

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

Influence of abdominal aortic aneurysm size on the feasibility of endovascular repair

The specificity and potency of glucocorticoids to lower serum calcium (Ca) in rats after parathyroidectomy (PTX) and adrenalectomy (ADX) were examined. Rats fasted overnight were given sc injections of various steroids immediately after the operations. The fall in serum calcium 5 h after PTX-ADX in rats given hypocalcemic doses of corticosterone was compared to that after injection of a test steroid. At high doses, progesterone, estradiol, testosterone, and aldosterone were inactive, whereas glucocorticoids were consistently hypocalcemic. These results indicate that the Ca-lowering effect is specific for steroids with glucocorticoid activity. Potency estimates were made by comparing the dose-response of natural and synthetic glucocorticoids to that of corticosterone, the major glucocorticoid in rats. The mean potency of hydrocortisone was 8.2 times that of corticosterone. Prednisolone was about 9.6, triamcinolone 33, betamethasone 109, and dexamethasone 301 times as potent as corticosterone. Thus, the use of the calcium-lowering action as a bioassay has provides a specific and rapid in vivo method to compare potencies of glucocorticoids consistent with those obtained by anti-inflammatory and glycogen deposition assays. The importance of this interesting calcitonin-like action of glucocorticoids in normal physiology of calcium metabolism is not yet established.     

Natural history of the residual infrarenal aorta after infrarenal abdominal aortic aneurysm repair

PURPOSE: We determined the natural history of the residual native infrarenal aortic segment after conventional abdominal aortic aneurysm (AAA) repair. METHODS: For the retrospective arteriographic case series, 800 hundred translumbar aortograms (TLAs) were obtained for 272 patients, before and after conventional AAA repair. The main outcome measures were changes in the aortographic diameter and the length of the infrarenal aortic segment, corrected and uncorrected for magnification by normalization to the first lumbar vertebral body height. RESULTS: The mean follow-up time from the preoperative TLA to the most recent postoperative TLA was 42 months (range, 1 to 257 months). Vertebral body height did not change (p = 0.35). The length of the native infrarenal aorta cephalad to the proximal anastomosis increased a mean of 3 mm, from 23 to 26 mm (p = 0.001). However, in 115 patients (43%), this aortic segment elongated more than 5 mm, and in 63 patients (24%), it elongated more than 10 mm. The native residual infrarenal aorta above the proximal anastomosis dilated a mean of 1 mm, from 23 to 24 mm (p = 0.001), but in 21 patients (8%), it dilated more than 5 mm. There was a weak positive correlation between the increase in residual native aortic diameter and duration of follow-up. There was a negative correlation between this increase and the initial size. The diameters of the proximal anastomosis and proximal graft did not change. Marked variability in the changes in aortic dimensions was observed. CONCLUSIONS: A mean period of 42 months after conventional AAA repair, the native infrarenal aortic segment elongates and dilates. Although such enlargement is statistically significant, the average increase appears to be small. However, residual aortic cuff diameter increased more than 5 mm and neck length more than 10 mm in a significant number of patients, with potentially serious implications for endovascular treatment of AAA.     

Computerised axial tomography of abdominal aortic aneurysm. Report of 5 cases

Purple sulfur bacterium Thiocapsa roseopersicina strain BBS requiring vitamin B12 may grow in the dark in media containing no other organic compounds. Under such conditions the cells oxidize sulfide and thiosulfate with the use of O2 and assimilate carbon dioxide. After 10--30s assimilation of NaH14CO3 about 60% of radioactivity is found in phosphorylated compounds characteristic for the reductive pentose phosphate cycle. The possibility of the function of this cycle in the dark in the presence of O2 is confirmed by the capacity of cells grown under such conditions to synthesize ribulose-1,5-diphosphate carboxylase. All this evidence suggests the ability of T. roseopersicina to change from phototrophy to aerobic chemolithoautotrophy.     

Selective screening for abdominal aortic aneurysm

Coagulase-negative staphylococci (CNS) are common causes of infection in patients undergoing chronic ambulatory peritoneal dialysis (CAPD). Their ability to survive intracellularly within peritoneal macrophages and to persist within the peritoneum during antibiotic therapy has led to the development of drug resistance during treatment. Strains of Staphylococcus epidermidis (SE) and Staphytococcus haemolyticus (SH) have been isolated from patients with CAPD during treatment with ciprofloxacin. The respective MIC values pre-and post-therapy were SE-0.25 and 128 mg/L and SH-0.50 and 64 mg/L. The susceptibility of each isolate to opsonophagocytosis was measured in vitro using isolated polymorphonuclear leucocytes (PMN) derived from fresh human blood donations. The bacteria were radiolabelled during growth, opsonised in either 1 or 10% serum and their uptake measured No differences were seen between the pre- and post therapy isolates when using 10% serum as opsonic source (18 vs. 21%); with 1% serum the corresponding values were lower (5 and 8% respectively). Similarly their ability to generate a respiratory burst as measured by chemiluminescence (CL) in the phagocytic cells was not diminished in the strains which had developed resistance to ciprofloxacin. The mean CL response to the strains isolated at outset of therapy ranged from 0.35-0.45 cpsc, and to the resistant strains following therapy from 0.36-0.50 cpsc. It is clear from the present investigation that although the bacterial strain became at least 10 times more resistant to ciprofloxacin during therapy, no change in their susceptibility to phagocytosis occurred refuting the idea that the emergence of drug resistant strains during therapy results in "super-bugs" of greater virulence.     

Antioxidant depletion during aortic aneurysm repair

Ischaemia-reperfusion injury generates oxygen-derived free radicals leading to local and distant damage. A simple method of following oxidative activity is to measure the consumption of endogenous scavenging antioxidants; an enhanced chemiluminescent assay was used to study this phenomenon in 21 patients undergoing surgery for abdominal aortic aneurysm (AAA). Samples of peripheral venous blood were taken before induction of anaesthesia and then from a central venous line and the inferior mesenteric vein before, during, and after clamping of the aorta. Further specimens were taken from the central line at 2, 6 and 24 h after operation. Antioxidant concentration in the peripheral, central and inferior mesenteric blood were similar, indicating that anaesthesia and surgical dissection had no effect. Levels decreased significantly in central and inferior mesenteric blood during and after clamping, but returned to normal by 24 h. These results confirm ischaemia-reperfusion phenomena in AAA repair.     

Role of magnetic resonance angiography for assessment of abdominal aortic aneurysm before endoluminal repair

BACKGROUND: A detailed knowledge of the morphology of the aorta and iliac arteries is an important prerequisite for successful endoluminal abdominal aortic aneurysm (AAA) repair. The best method of preoperative evaluation remains to be determined. METHODS: A prospective study was undertaken between January 1994 and July 1995 to assess the ability of computed tomography (CT), magnetic resonance angiography (MRA), colour duplex imaging and intra-arterial digital subtraction angiography (IA-DSA) to visualize AAA morphology. RESULTS: Eighty-two consecutive patients (64 men, 18 women) with AAA were assessed with MRA, contrast-enhanced CT, colour duplex imaging and IA-DSA. Median age was 74 (range 59-87) years and median AAA diameter was 5.7 (range 3.5-9.7) cm. Five patients were unable to tolerate CT or MRA examination. Seventy-seven patients underwent both CT and MRA. Of these, 55 also had a colour duplex scan and 32 underwent arteriography. The scans were assessed by an independent blinded observer. MRA was significantly better (P < 0.01) at visualizing AAA morphology compared with CT and colour duplex imaging. There was no statistically significant difference between MRA and arteriography. CONCLUSION: MRA is useful in patient selection for endoluminal AAA repair, as it avoids use of iodinated contrast medium and ionizing radiation.     

Ruptured abdominal aortic aneurysm: the internist as diagnostician

PURPOSE: To define the clinical features and assess the frequency and causes of missed diagnoses of ruptured abdominal aortic aneurysm (AAA) in patients initially presenting to internists. PATIENTS: All identified patients with ruptured AAA presenting to internists during a 7 1/2-year period at a large academic medical center. METHOD: Chart review. RESULTS: We identified 23 patients with a ruptured AAA presenting to internists. Most had abdominal pain and tenderness, back or flank pain, and leukocytosis, whereas anemia and profound hypotension (systolic blood pressure below 90 mm Hg) were uncommon at presentation. In 14 cases (61%), the diagnosis of ruptured AAA was initially missed. Nine patients had an interval of 24 hours or more between presentation to the internist and surgery or death. The diagnosis was not made until after shock developed in nine patients who were hemodynamically stable at presentation. Of 17 patients who underwent surgery, 7 of 8 with preoperative shock died, compared with 2 deaths in 9 patients (p < .02) without shock. All six patients who did not have surgery died, yielding an overall mortality of 65% for the series. Ruptured AAAs were most frequently misdiagnosed as urinary tract obstruction or infection, spinal disease, and diverticulitis. Chart review revealed a general lack of physician awareness of the syndromes of contained rupture of AAA and symptomatic unruptured AAA. CONCLUSIONS: In patients with ruptured AAA who present to internists, the diagnosis is often delayed or missed and this appears to adversely effect survival. Internists should familiarize themselves with the presentation and management of ruptured AAA.     

Current status of abdominal aortic aneurysm therapy

We report a patient who developed oesophageal stricture after accidental ingestion of acid. During one of the oesophageal dilation sessions, a Savary-Gillard guide-wire got entrapped in the stomach and had to be removed surgically. A Foley catheter, placed for feeding purposes, migrated into the proximal small intestine causing acute intestinal obstruction. The balloon of the Foley catheter had to be punctured using a sclerotherapy needle and the catheter withdrawn.     

Bifurcated endovascular grafting for abdominal aortic aneurysm

Tottering mice inherit a recessive mutation of the calcium channel alpha1A subunit that causes ataxia, polyspike discharges, and intermittent dystonic episodes. The calcium channel alpha1A subunit gene encodes the pore-forming protein of P/Q-type voltage-dependent calcium channels and is predominantly expressed in cerebellar granule and Purkinje neurons with moderate expression in hippocampus and inferior colliculus. Because calcium misregulation likely underlies the tottering mouse phenotype, calcium channel blockers were tested for their ability to block the motor episodes. Pharmacologic agents that specifically block L-type voltage-dependent calcium channels, but not P/Q-type calcium channels, prevented the inducible dystonia of tottering mutant mice. Specifically, the dihydropyridines nimodipine, nifedipine, and nitrendipine, the benzothiazepine diltiazem, and the phenylalkylamine verapamil all prevented restraint-induced tottering mouse motor episodes. Conversely, the L-type calcium channel agonist Bay K8644 induced stereotypic tottering mouse dystonic at concentrations significantly below those required to induce seizures in control mice. In situ hybridization demonstrated that L-type calcium channel alpha1C subunit mRNA expression was up-regulated in the Purkinje cells of tottering mice. Radioligand binding with [3H]nitrendipine also revealed a significant increase in the density of L-type calcium channels in tottering mouse cerebellum. These data suggest that although a P/Q-type calcium channel mutation is the primary defect in tottering mice, L-type calcium channels may contribute to the generation of the intermittent dystonia observed in these mice. The susceptibility of L-type calcium channels to voltage-dependent facilitation may promote this abnormal motor phenotype.     

Coronary revascularization and abdominal aortic aneurysm repair in a patient with Beh?et's diseases

Beh?et's disease is a systemic disease characterized by oral aphta, genital ulcer, and ocular lesion. Arterial involvement is an uncommon complication of Beh?et's disease, and it most frequently affects the abdominal aorta followed by the femoral artery and the pulmonary artery. Coronary lesions in Beh?et's disease have been little reported in the literature. In this communication, we present a case with coronary artery stenosis and with subsequently developed supra-renal abdominal aortic aneurysm. The coronary lesions were revasculized with gastroepiploic artery, right internal mammary artery, and saphenous vein graft. Abdominal aortic repair was performed with partial cardiopulmonary stand by, because of the risk of coronary ischemia during the cross clamp including the celiac artery. To our knowledge, this is the first report of successful repair of combined lesions of the coronary and the abdominal aorta in a patient with Beh?et's disease.     

Thoracoabdominal aortic repair without using assisted bypass

A 41-year-old man, who had undergone descending aortic repair following rupture of the DeBakey type III aortic dissection, underwent thoracoabdominal aneurysm repair 1 year after the first surgery. The operation was performed by partial-clamping and single crossclamping without using assisted bypass or shunt, in order to minimize bleeding ensuing the re-thoracotomy and dissection between lung and the graft.