ABSTRACT
A 70-year-old man was admitted suffering from chest and back pain. He was assessed by enhanced computed tomography (eCT) and a thrombosed acute DeBakey type IIIb aortic dissection with an ulcer like projection (ULP) was diagnosed and treated medically. Five days later, he complained suddenly of dyspnea and was diagnosed by eCT as having a pulmonary thromboembolism. Anticoagulant therapy was started reluctantly. The patient's symptoms improved, however, 16 days later he complained of severe chest and back pain. Enhanced CT showed enlargement of the ULP, which was diagnosed as an impending aortic rupture. Open stent-grafting was selected as a less-invasive treatment method. A stent-graft was introduced into the descending aorta via the transected aortic arch and the entry of the ULP was closed. Postoperative course was smooth and uneventful. We consider that open stent-grafting via the aortic arch is an alternative method for repair of acute type B aortic dissection with an ULP in the descending aorta, in cases where direct closure of the intimal tear is difficult.
ABSTRACT
Ruptured abdominal aortic aneurysms (RAAA) can be lethal unless appropriate diagnosis and immediate repair are made. Since advanced age is a surgical risk, however, octogenarians are considered as poorer candidates for elective surgical intervention before rupture. The aims of this study were to clarify the problems and factors that are associated with mortality from RAAA in elderly patients. A retrospective study of all infrarenal RAAA patients (<i>n</i>=126) who presented at our center between 1985 and 2003 is presented. The patients were classified into 2 groups, Group O included 37 RAAA patients (male:female=22:15) aged 80 years old or over, and Group Y included 89 RAAA patients (male:female=70:19) under 80 years old. We analyzed and compared preoperative, operative, and postoperative states between groups. The percentage of cardiopulmonary arrests (CPA) was significantly higher in Group O (14/37, 38%) than in Group Y (24/89, 27%). The other preoperative factors (time to reach hospital, time in shock, blood pressure, base excess, hemoglobin, blood urea nitrogen, creatinine, aneurysmal size) were not significantly different between the groups. The operative factors (operation time, aortic clamp time, the amounts of urine output and bleeding during the operation) were not significantly different between the groups. The rates of postoperative complications did not significantly differ between the groups. In a comparison of all cases, including patients with CPA, the survival rate was significantly lower in Group O (14/37, 37.8%) compared with Group Y (55/89, 61.8%). On the other hand, for the patients who underwent prosthetic graft replacement, the survival rate was equivalent in Group O (14/18, 77.8%) and Group Y (55/75, 73.3%). The mortality rate and percentage of CPA in Group O were significantly higher than in Group Y although the preoperative, operative and postoperative statistics are not significantly different. For patients who undergo prosthetic graft replacement, the survival rate is equivalent. These findings suggest that octogenarian patients cannot withstand the hypovolemic shock that is due to RAAA. We recommend elective operation before rupture in elderly patients with AAA.