Single-center study comparing short and mid-term results of evar in old and young populations

Abstract Objective: The purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center. Methods: Eighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months). Results: The study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%). Conclusion: Our single-center experience shows that EVAR can be used safely in both young and geriatric patients.

Fatores de risco associados e sobrevida em curto e médio prazo de pacientes submetidos a correção aberta e endovascular de aneurisma de aorta abdominal / Risk factors and short and medium-term survival after open and endovascular repair of abdominal aortic aneurysms

Contexto: Os aneurismas de aorta abdominal (AAA) infrarrenal apresentam alta morbimortalidade associada à ruptura e podem ser tratados por cirurgia aberta ou endovascular. Objetivos: Analisar os fatores de risco e a sobrevida associados aos métodos cirúrgico e endovascular no tratamento do AAA. Métodos: Estudo retrospectivo e longitudinal envolvendo 41 pacientes submetidos à correção endovascular ou aberta do AAA, de forma eletiva ou emergencial, no período de 48 meses. Foi realizada análise de comorbidades pré-operatórias, sobrevida em 30 dias e 1 ano, mortalidade hospitalar, tempo de internação, hemotransfusões, duração da cirurgia e ocorrência de insuficiência renal aguda. A estatística inferencial e a análise de sobrevida foram realizadas considerando intervalo de confiança de 95% e p < 0,05 como significante. Resultados: Dos 41 pacientes, 12 foram submetidos à correção aberta e 29, à endovascular. A maioria eram homens (75%), com média de idade de 71 anos (mín. 56, máx. 90 anos). Não houve diferenças de fatores de risco entre os grupos. A sobrevida global dos pacientes foi diferente para os tratamentos aberto e endovascular, tanto em 30 dias (37 vs. 72%; p = 0,01) quanto em 360 dias (37 vs. 67%; p = 0,01), respectivamente. A sobrevida dos casos eletivos em 30 dias (71 vs. 76%; p = 0,44) e 360 dias (ambas 71%; p = 0,34) foram semelhantes. O reparo endovascular apresentou menor tempo de internação (3,0 vs. 4,4 dias; p = 0,02) e duração da cirurgia (111 vs. 163 min; p = 0,005) quando comparado à cirurgia aberta. Conclusões: Não houve diferença na sobrevida em curto e médio prazo dos pacientes com AAA tratados de forma eletiva pelas técnicas endovascular e cirúrgica. Menor tempo de internação e duração da cirurgia foram observados no tratamento minimamente invasivo

Background: Infrarenal abdominal aortic aneurysms (AAA) are responsible for high rates of rupture-associated morbidity and mortality and can be treated by open or endovascular surgery. Objectives: To analyze risk factors and survival associated with surgical and endovascular AAA treatment methods. Methods: A retrospective, longitudinal study involving 41 patients who underwent endovascular or open AAA repair, whether elective or emergency, over a 48-month period, with analysis of preoperative comorbidities, 30-day and 1-year survival, in-hospital mortality, length of hospital stay, transfusion of blood products, duration of surgery, and development of acute kidney failure. Inferential statistics and survival analysis considered a 95% CI and p < 0.05 as significant. Results: Twelve of the 41 patients were treated with open surgery and 29 with endovascular techniques. The majority were male (75%), with an average age of 71 (range: 56 ­ 90 years). There were no differences in demographic or risk factors between the groups. Overall survival rates for open and endovascular repair were different for both 30 days (37 vs. 72%, p = 0.01) and 360 days (37 vs. 67%, p = 0.01). However, survival rates in elective cases were similar at 30 days (71 vs. 76%, p = 0.44) and 360 days (both 71%, p = 0.34). Endovascular repair showed shorter length of hospital stay (3.0 vs. 4.4 days; p = 0.02) and duration of surgery (111 vs. 163 min; p < 0.01) compared to open repair. Conclusions: There was no difference in short- or medium-term survival of AAA patients treated electively with endovascular or open surgery. Hospital stays and duration of surgery were both shorter with minimally invasive treatment

Quality of life after open surgical versus endovascular repair of abdominal aortic aneurysms

Abstract Objective: This study aims to compare open surgical and endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms in terms of their effects on quality of life, using Short Form-36 (SF-36). Methods: A total of 133 consecutive patients who underwent EVAR or open surgical repair for infra-renal abdominal aorta aneurysm between January 2009 and June 2014 were included in the study. Twenty-six (19.5%) patients died during follow-up and were excluded from the analysis. Overall, 107 patients, 39 (36.4%) in the open repair group, and 68 (63.6%) in the EVAR group, completed all follow-up visits and study assessments. Quality of life assessments using SF-36 were performed before surgery and at post-operative months 1, 6, and 12. Results: The mean duration of follow-up was 29.55±19.95 months. At one month, both physical and mental domains of the quality of life assessments favored EVAR, while the two surgical approaches did not differ significantly at or after six months postoperatively. Conclusion: Despite anatomical advantages and acceptable mid-phase mortality in patients with high- or medium-risk for open surgery, EVAR did not exhibit a quality of life superiority over open surgery in terms of physical function and patient comfort at or after postoperative six months.

Outcomes of surgery for patients with Behcet's disease causing aortic pseudoaneurysm: a shift from open surgery to endovascular repair

OBJECTIVES: Behcet’s disease is a form of systematic vasculitis that affects vessels of various sizes. Aortic pseudoaneurysm is one of the most important causes of death among patients with Behcet’s disease due to its high risk of rupture and associated mortality. Our study aimed to investigate the outcomes of Behcet’s disease patients with aortic pseudoaneurysms undergoing open surgery and endovascular aortic repair. METHODS: From January 2003 to September 2014, ten consecutive patients undergoing surgery for aortic pseudoaneurysm met the diagnostic criteria for Behcet’s disease. Endovascular repair was the preferred modality and open surgery was performed as an alternative. Systemic immunosuppressive medication was administered after Behcet’s disease was definitively diagnosed. RESULTS: Eight patients initially underwent endovascular repair and two patients initially underwent open surgery. The overall success rate was 90% and the only failed case involved the use of the chimney technique to reach a suprarenal location. The median follow-up duration was 23 months. There were 7 recurrences in 5 patients. The median interval between operation and recurrence was 13 months. No significant risk factors for recurrence were identified, but a difference in recurrence between treatment and non-treatment with preoperative immunosuppressive medication preoperatively was notable. Four aneurysm-related deaths occurred within the follow-up period. The overall 1-year, 3-year and 5-year survival rates were 80%, 64% and 48%, respectively. CONCLUSIONS: Both open surgery and endovascular repair are safe and effective for treating aortic pseudoaneurysm in Behcet’s disease patients. The results from our retrospective study indicated that immunosuppressive medication was essential to defer the occurrence and development of recurrent aneurysms.

Institutional impact of EVAR's incorporation in the treatment of abdominal aortic aneurysm: a 12 years' experience analysis

Abstract Introduction: Endovascular aneurysm repair (EVAR) was introduced as a less aggressive treatment of abdominal aortic aneurysms (AAA) for patients ineligible for open repair (OR). Objective: To analyze EVAR's incorporation impact in the treatment of infra-renal abdominal aortic aneurysms in our institution. Methods: A retrospective study of the patients with diagnostic of infra-renal AAA treated between December 2001 and December 2013 was performed. The choice between EVAR and OR was based on surgeon's experience, considering patient clinical risk and aneurysm's anatomical features. Patients treated by EVAR and by OR were analyzed. In each group, patient's and aneurysm's characteristics, surgical and anesthesia times, cost, transfusion rate, intraoperative complications, hospital stay, mortality and re-intervention rates and survival curves were evaluated. Results: The mean age, all forms of heart disease and chronic renal failure were more common in EVAR group. Blood transfusion, surgical and anesthesia times and mean hospital stay were higher for OR. Intraoperative complications rate was higher for endovascular aneurysm repair, overall during hospitalization complication rate was higher for open repair. The average cost in endovascular aneurysm repair was 1448.3€ higher. Re-interventions rates within 30 days and late re-intervention were 4.1% and 11.7% for endovascular aneurysm repair versus 13.7% and 10.6% for open repair. Conclusions: Two different groups were treated by two different techniques. The individualized treatment choice allows to achieve a mortality of 2.7%. Age ≥80 years influences survival curve in OR group and ASA ≥IV in EVAR group. We believe EVAR's incorporation improved the results of OR itself. Patients with more comorbidities were treated by endovascular aneurysm repair, decreasing those excluded from treatment. Late reinterventions were similar for both techniques.

Results of Open and Endovascular Abdominal Aortic Aneurysm Repair According to the E-PASS Score

Abstract Introduction: Endovascular repair (EVAR) of abdominal aortic aneurysm has become the standard of care due to a lower 30-day mortality, a lower morbidity, shorter hospital stay and a quicker recovery. The role of open repair (OR) and to whom this type of operation should be offered is subject to discussion. Objective: To present a single center experience on the repair of abdominal aortic aneurysm, comparing the results of open and endovascular repairs. Methods: Retrospective cross-sectional observational study including 286 patients submitted to OR and 91 patients submitted to EVAR. The mean follow-up for the OR group was 66 months and for the EVAR group was 39 months. Results: The overall mortality was 11.89% for OR and 7.69% for EVAR (P=0.263), EVAR presented a death relative risk of 0.647. It was also found a lower intraoperative bleeding for EVAR (OR=1417.48±1180.42 mL versusEVAR=597.80±488.81 mL, P<0.0002) and a shorter operative time for endovascular repair (OR=4.40±1.08 hoursversus EVAR=3.58±1.26 hours,P<0.003). The postoperative complications presented no statistical difference between groups (OR=29.03% versusEVAR=25.27%, P=0.35). Conclusion: EVAR presents a better short term outcome than OR in all classes of physiologic risk. In order to train future vascular surgeons on OR, only young and healthy patients, who carry a very low risk of adverse events, should be selected, aiming at the long term durability of the procedure.

Mejores resultados en ruptura de aneurismas de aorta abdominal manejados con reparación endovascular: Algoritmo sugerido / Improved outcome of ruptured abdominal aortic aneurysms managed with endovascular repair: A suggested algorithm

Antecedentes: El propósito de este estudio es comparar la morbilidad y la mortalidad tanto de la reparación abierta (RA) como endovascular de la ruptura del aneurisma aórtico abdominal(rAAAs); y de presentar un algoritmo para el tratamiento y evaluaciones de la tomografía computarizada (CT) para determinar el uso de un balón oclusivo supra-celíaco. Métodos: Una revisión gráfica retrospectiva se realizó de los rAAAs tratados ya sea con reaparicióna cielo abierto (RA), ya sea con reparación aórtica endovascular (EVAR) entre junio de 1998 y junio de 2009. Se informaron las co-morbilidades, los datos peri-procedimientos y tanto la morbosidad como la mortalidad. Las TC se revisaron desde el uso inicial del balón oclusivo (Marzo de 2001) a fin de evaluar el hematoma retroperitoneal. Se desarrolló un algoritmo para determinarcuándo el balón oclusivo se debería implementar. El test exacto de Fisher, el t-test, y el test log rank fueron los que se utilizaron para el análisis estadístico.Resultados: Entre junio de 1998 y junio de 2009, 105 pacientes, 75 (71.4%) hombres, edad promedio de 74 años (rango 47-93) presentaron un rAAA y a 69 (65.2%) se les realizó la reparación a cielo abierto. 87 pacientes (82.9%) fueron sintomáticos y 25 (23.8%) tenían un AAA conocido. El tiempo medio transcurrido entre el diagnóstico y el tratamiento fue de 5 a 6 horas, 4.5 horas para la RA y de 8 horas para EVAR. El test rank log mostró una mejoría en la supervivencia con EVARa pesar del tiempo promedio más prolongado desde el diagnóstico al tratamiento. (p=0.02). Se administraron casi tres veces más concentrados de hematíes en el cohorte de reparación a cielo abierto (RA), 6.3 unidades y en EVAR 2.2 unidades. Se utilizaron vasopresores perioperatorios en el 57.1% de los casos, dos veces más en la RA, 69.6%, que con EVAR 33.3%. Se utilizó el balón oclusivo aórtico en el 27,6% de los casos, dos veces más frecuente en RA que en EVAR (41,7% verus 20,3%)...

Antecedentes: O propósito deste estudo é comparar a morbilidade e a mortalidade tanto da reparação aberta (RA) quanto endovascular, utilizadas no tratamento da ruptura do aneurisma aórtico abdominal (rAAAs); e de apresentar um algorítmo para o tratamento e avaliações da tomografiacomputarizada (CT) para assim determinar o uso de um balão para oclusão supra-celíaca. Métodos: Realizou-se uma revisão gráfica retrospectiva das rAAAs tratadas, seja com reparação a céu aberto (RA), ou com reparação aórtica endovascualar (EVAR) entre os meses de junho de1998 e junho de 2009. Informaram-se as comorbilidades, os dados periprocedimentos , além da morbidade e mortalidade. As TC foram revisadas desde o uso inicial do balão oclusivo (março de 2001) com o objetivo de avaliar o hematoma retroperitoneal. Desenvolveu-se um algorítmo para determinar quando o balão oclusivo deveria ser implementado. Para esta análise estatística, utilizaram-se o teste exato de Fisher, o t-test, e o test log Rank. Resultados: Entre junho de 1998 ejunho de 2009, 105 pacientes, 75 (71.4%) homens, com média de idade de 74 anos (média 47-93) apresentaram uma rAAA e em 69 (65.2%) realizou-se uma reparação a céu aberto. 87 pacientes (82.9%) foram sintomáticos e 25 (23.8%) tinham um AAA conhecido. O tempo médio transcorrido entre o diagnóstico e o tratamento foi de 5 a 6 horas, 4.5 horas para a RA e de 8 horas para aEVAR. O test rank log mostrou uma melhoria na sobrevivência com a EVAR, apesar do tempo médio mais prolongado do diagnóstico ao tratamento. (p=0.02). Administraram-se quase três vezes mais concentrados de hematies no grupo de reparação a céu aberto (RA), 6.3 unidades e no grupo EVAR, 2.2 unidades. Utilizaram-se vasopressores perioperatórios em 57.1% dos casos: 33.3% com EVAR e 69.6% com a RA, ou seja, duas vezes a mais. Utilizou-se o balão oclusivo aórtico em 27.6 % dos casos, duas vezes mais frequente nos casos da RA do que nos de EVAR (41.7 % versus 20.3%)...

Background: The purpose of this study is to compare morbidity and mortality of open and endovascular repair of ruptured abdominal aortic aneurysms (rAAAs); and present a treatment algorithm and assessment of computer tomography (CT) to determine usage of a supra-celiac occlusive balloon.Methods: Restrospective chart review was done of rAAAs treated with open (OR) or endovascular aortic repair (EVAR) between June 1998 and June 2009. Comorbidities, periprocedural data, and postoperative morbidity and mortality were recorded. CTs were reviewed from the initial use of the occlusive balloon (March 2001) to assess the retroperitoneal hematoma. An algorithm was developed determining when the occlusive balloon should be implemented. Fisher’s exact test, and log rank test were used for statistical analysis. Results: Between June 1998 and June 2009, 105 patients, 75 (71.4%) males, mean age of 74.0 years (range 47-93), presented with a rAAA and 69 (65.2%) received open repair. Eighty-seven patients(82.9%) were symptomatic and 25 (23.8%) had a known AAA. Mean time elapsed between diagnosis to treatment was 5.6 hours, 4.5 hours for OR and 8.0 hours for EVAR. Log rank test showsimproved survivability with the EVAR despite higher mean time from diagnosis to intervention (p=0.02). Nearly three times as much packed red blood cells were given in open repair cohort, O,6.3 units and EVAR, 2.2 units. Perioperative vasopressors were used in 57.1% of total cases, more than 2 times as often for O, 69.6%, and EVAR, 33.3%. Aortic occlusive balloon was used in 27.6% of cases, twice as often in EVAR (41.7% versus 20.3%)...

Open abdominal aortic aneurysm repair in the era of endovascular repair / Reparación abierta de la aorta abdominal en la era de la reparación endovascular

OBJECTIVES: The development of minimally invasive techniques for abdominal aortic aneurysm (AAA) repair and the establishment of specialized centres have resulted in improved patient outcomes. This study examines open AAA repair at a non-specialized centre where advanced techniques are not practised. METHODS: We conducted a retrospective analysis on a cohort of 83 patients presenting for AAA repair to a non-specialized hospital, the University Hospital of the West Indies (UHWI). The end points assessed included operative (30-day) mortality, postoperative complications, duration of operation, blood loss, intensive care unit (ICU) stay and overall hospital stay. RESULTS: The overall operative mortality was 9.4% (23% for ruptured aneurysms and 5% for unruptured aneurysms). Mean operating time, blood loss, ICU stay and hospital stay were 326 ± 98 minutes, 2420 ± 1397 mls, 3 ± 5 days and 9 ± 5 days, respectively with no significant differences noted between ruptured and unruptured aneurysms. Mean aneurysm diameter was 6.13 ± 1.59 cm. CONCLUSION: Mortality rates for open aneurysm repair at the UHWI are consistent with findings in the current literature. Open AAA repair remains a safe treatment option in this environment. Continued improvements need to be made with respect to minimizing blood loss and operation duration, particularly in repairs of unruptured aneurysms.

OBJETIVOS: El desarrollo de técnicas mínimamente invasivas para la reparación del aneurisma aórtico abdominal (AAA) y el establecimiento de centros especializados para esos fines, han traído consigo el mejoramiento de los resultados clínicos de los pacientes. Este estudio examina reparaciones del tipo AAA en un centro no especializado, en el que no se practican técnicas avanzadas. MÉTODOS: Se llevo a cabo un análisis retrospectivo en una cohorte de 83 pacientes que acudieron para reparación de AAA a un hospital no especializado - el Hospital Universitario de West Indies (UHWI). Los aspectos finales evaluados incluyeron la mortalidad operatoria (30 días), las complicaciones post-operatorias, la duración de la operación, la pérdida de sangre, la estadía en la unidad de cuidados intensivos, y la estadía general en el hospital. RESULTADOS: La mortalidad operatoria general fue 9.4% (23% para los aneurismas rotos y 5% para los aneurismas no rotos). El tiempo promedio de operación, la pérdida de sangre, la estadía en la UCI, y la estadía hospitalaria fueron 326 ± 98 minutos, 2420 ± 1397 mls, 3 ± 5 días y 9 ± 5 días respectivamente, sin que se observen diferencias significativas entere aneurismas rotos y no rotos. El diámetro promedio de los aneurismas fue 6.13 ± 1.59 cm. CONCLUSIÓN: Las tasas de mortalidad para la reparación abierta de aneurismas en el UHWI concuerdan con los hallazgos en la literatura corriente. Se necesita continuar los esfuerzos por lograr mejorías en cuanto a minimizar la pérdida de sangre, y reducir el tiempo de duración de la operación, especialmente en las reparaciones de aneurismas no rotos.

Aneurismas del sector aorto ilíaco: experiencia personal / Results of surgical treatment of aneurysms of the aorto iliac segment: review of 90 patients

Background: Abdominal aorta is the most common site for the formation of degenerative aneurysms. which remain asymptomatic until they rupture. Aim: To review the results of surgical treatment of aorto iliac segment aneurysms. Material and Methods: Retrospective review of medical records of 90 patients aged 48 to 88 years (60 males), operated for aneurysms of the aorto iliac segment, between 1998 and 2008. Patients were followed for a mean of 40 months. Results: Eighty six patients had infrarenal aneurysms with or without iliac extension and four had puré iliac aneurysms. Four patients had inflammatory aneurysms Eighty five were treated with open surgery. Of these, nine had ruptured or fissured aneurysms, two had lower limb ischemia, one had an extrinsic compression and one a complete thrombosis of the aneurysm. Five patients, without complications, were subjected to an endovascular repair. Overall 30 days mortality was 4.4 percent. The figures for ruptured and uncomplicated aneurysms were 11.1 and 2.7 percent respective ly. No patient subjected to endovascular repair died. One, two and three years survival rates were 90, 79 and 78 percent respectively. No patient died due to complications of the prosthetic graft. Three patients required an early re-intervention (an embolectomy in one and for a femoro-femoral bridge in two). Nine patients required a late re-intervention (an intestinal obstruction due to adherences in one and incisional hernias in eight). No patient subjected to endovascular repair required a re-intervention. Conclusions: Surgery for aorto iliac segment aneurysms is safe and avoids deaths caused by their complications.

Objetivo: Analizar la morbimortalidad precoz y alejada en la cirugía de los aneurismas del sector aorto-ilíaco. Material y Método: Revisión retrospectiva en una serie personal de pacientes operados en forma consecutiva por aneurismas del sector aorto-ilíaco desde 1998 a 2008 con seguimiento actualizado. Resultados: Se trata de 90 pacientes (60 varones), promedio de edad 72,7 años; 15,5 por ciento de 80 años o mayores; 86 casos de aneurismas de la aorta abdominal infrarrenal con o sin extensión ilíaca y 4 aneurismas ilíacos puros. Fueron sometidos a una cirugía abierta 85 pacientes y 5 tuvieron una reparación endovascular. De los 85 pacientes operados en forma abierta 13 presentaban alguna complicación: 9 rotos o Asurados, 2 con isquemia de una extremidad, una compresión extrínseca y una trombosis completa aguda del aneurisma. Hubo 4 casos de aneurisma inflamatorio. Los pacientes reparados en forma endovascular no estaban complicados. La mortalidad operatoria global a 30 días fue de 4,4 por ciento (4/90), en aneurismas rotos fue de 11,1 por ciento (1/9), en aneurismas no complicados fue un 2,7 por ciento (2/73), en casos de cirugía abierta un 4,7 por ciento (4/85) y no hubo mortalidad en la cirugía endovascular. El seguimiento medio fue de 39,63 meses (rango 1-131 meses). La supervivencia global fue de 89,7 por ciento, 79,2 por ciento y 77,8 por ciento al primer, tercer y quinto año. En el post-operatorio en relación a la cirugía clásica fueron intervenidos 12 pacientes (12/85: 14,1 por ciento), 3 precozmente (una embolectomía y dos puentes fémoro-femorales) y 9 en forma tardía (8 hernioplastías incisionales y una obstrucción intestinal por bridas). No hemos reintervenido los pacientes operados en forma endovascular. En el seguimiento alejado la mortalidad tuvo como causas principales las enfermedades cardíacas, respiratorias agudas y el cáncer avanzado, sin complicaciones o mortalidad atribuibles al injerto protésico...

Fatores de morbimortalidade na cirurgia eletiva do aneurisma da aorta abdominal infra-renal: experiência de 134 casos / Morbidity and mortality factors in the elective surgery of infrarenal abdominal aortic aneurysm: a case study with 134 patients

CONTEXTO: O tratamento cirúrgico convencional do aneurisma da aorta abdominal (AAA) infra-renal pode resultar em complicações graves. A fim de otimizar os resultados na evolução do tratamento, é importante que sejam identificados os pacientes predispostos a determinadas complicações e instituídas condutas preventivas. OBJETIVOS: Avaliar a taxa de mortalidade operatória precoce, analisar as complicações pós-operatórias e identificar os fatores de risco relacionados com a morbimortalidade. MÉTODO: Foram analisados 134 pacientes com AAA infra-renal submetidos a correção cirúrgica eletiva no período de fevereiro de 2001 a dezembro de 2005. RESULTADOS: A taxa de mortalidade foi de 5,2%, sendo secundária principalmente a infarto agudo de miocárdio (IAM) e isquemia mesentérica. As complicações cardíacas foram as mais freqüentes, seguidas das pulmonares e renais. A presença de diabetes melito (DM), insuficiência cardíaca congestiva (ICC), insuficiência coronariana (ICO) e cintilografia miocárdica positiva para isquemia estiveram associadas às complicações cardíacas. A idade avançada, a doença pulmonar obstrutiva crônica (DPOC) e a capacidade vital forçada reduzida aumentaram os riscos de atelectasia e pneumonia. História de nefropatia, tempo de pinçamento aórtico prolongado e níveis de uréia elevados aumentaram os riscos de insuficiência respiratória aguda (IRA). A isquemia dos membros inferiores esteve associada ao tabagismo e à idade avançada, e a maior taxa de mortalidade, à presença de coronariopatia, tempos prolongados de pinçamento aórtico e de cirurgia. CONCLUSÃO: A taxa de morbimortalidade esteve compatível com a literatura nacional e internacional, sendo secundária às complicações cardíacas, respiratórias e renais. Os fatores de risco identificados no pré e transoperatório estiveram relacionados com essas complicações.

BACKGROUND: Conventional surgical treatment of infrarenal abdominal aortic aneurysm (AAA) can result in serious complications. To optimize treatment outcome it is important to identify patients at risk of having complications and implement prophylaxis. OBJECTIVES: To analyze early surgical mortality rate and postsurgical complications, and to identify risk factors related to morbidity and mortality. METHOD: A total of 134 patients with infrarenal AAA submitted to elective surgical correction from February 2001 to December 2005 were analyzed. RESULTS: The mortality rate (5.2%) was secondary mainly to acute myocardial infarction and intestinal ischemia. Heart-related complications were the most frequent, followed by lung and kidney complications. Presence of diabetes mellitus, congestive heart failure, coronary artery disease, and scintigraphy suggestive of ischemia were related to cardiac complications. Advanced age, chronic obstructive lung disease and reduced forced vital capacity were related to higher risks of atelectasis and pulmonary infection. Presence of renal failure, prolonged aortic clamping and high urea rates were related to acute renal failure. Smoking and advanced age were associated with lower limb ischemia. Presence of obstructive coronary insufficiency and prolonged aortic clamping and surgery time were associated with higher mortality rate. CONCLUSION: The morbidity and mortality rate was compatible with data found in the national and international literature, secondary to cardiac, pulmonary and kidney complications. Identified risk factors before and during the surgery were related to these complications.

[Split or rupture of the infra renal abdominal aortic aneurysms: indications, treatments and results]

With increasing age of the population and improvement of diagnostic tools, the incidence of abdominal aortic aneurysm [AAA] has been rising steadily. Thus, surgical repair of fissured or ruptured AAA needs a close analysis of the indications and therapeutic strategies. The aim of this study is to define the new criteria for surgical indications. Between 2000 and 2006, 26 consecutive patients with AAA underwent open operations for ruptured AAA in 22 [84%] and fissured AAA in 4 [16%]. The mean age was 59 years [26-S2years] and the predominant aetiology was the atherosclerosis [84%]. Radiological analysis showed a mean AAA diameter of 7,3cm [4-11cm]. The AAA repair was performed with tubular or bifurcated graft in 22 patients [84%], and the AAA exclusion associated to extra-anatomical revascularisation in 4 [16%]. Operative mortality was 23%and late follow up find no recidivant AAA. The high operative mortality rate of patients with complicated AAA is related to the unstable hemodynamic status and surgical difficulties. The finite radiological images description is the best way to find new predictive elements of rupture and indicate surgery even in small AAA

Endovascular abdominal aortic aneurysm repair in high risk patients: outcomes of management.

BACKGROUND: The concomitant cardiopulmonary disease precluded the elective repair for abdominal aortic aneurysm (AAA) with acceptable risk. The endovascular abdominal aortic aneurysm repair (EVAR) has become an alternative method for the treatment of AAA with high-risk comorbidities. OBJECTIVE: Evaluate the results of EVAR in high-risk patients with large AAA. MATERIAL AND METHOD: A prospective study of high-risk patients with large AAA and suitable morphology who underwent EVAR between August 2003 and August 2005 was conducted. The long-term outcomes were observed up to December 2006. The comorbidities, size of aneurysm, types of procedures, operative time, amount of blood loss and transfusion, length of postoperative stay in intensive care unit and hospital, postoperative complications and mortality were analyzed. RESULTS: Eight patients (7 males and 1 female) with the mean age of 71.4 years (range 66-83 years) were included in the present study. The comorbidities were six of compromised cardiac status, one of severe pulmonary disease and one of morbid obesity. The average size of aneurysm was 6.2 +/- 0.64 centimetres. One patient also had large bilateral iliac artery aneurysms. Seven patients underwent EVAR with bifurcated aortic stent graft and one proceeded with aorto uni-iliac stent graft. Three patients underwent preoperative coil embolisation into internal iliac arteries when the distal landing zones at the external iliac arteries were considered. The mean estimated blood loss was 369cc and the mean blood transfusion was 0.88 units. There were no perioperative mortality, early graft occlusion, AAA rupture and open conversion in the present study. One patient had cardiac arrest due to upper airway obstruction but with successful treatment. Type II endoleak was observed in one patient and successfully treated by expectant management. One limb of bifurcated stent graft was occluded at the 5th month post EVAR and was successfully treated by artery bypass surgery at both groins. The 3-year primary graft limb patency was 87.5% (7/8). The survivals of patients at 1, 2 and 3 years were 100%, 100% and 87.5% respectively. The cause of death in one patient was not related to EVAR. CONCLUSION: EVAR may be a safe and effective alternative to open AAA repair especially in high-risk patients.

Mortalidade relacionada ao tratamento endovascular do aneurisma da aorta abdominal com o uso dos modelos revisados / Procedure-related mortality of endovascular abdominal aortic aneurysm repair using revised reporting standards

OBJETIVO: O objetivo do estudo foi avaliar a definição da mortalidade relacionada ao procedimento após tratamento endovascular do aneurisma de aorta abdominal (EVAR) como definido pelo Committee for Standardized Reporting Practices in Vascular Surgery. MÉTODO: Dados de pacientes com aneurisma de aorta abdominal foram analisados do banco de dados EUROSTAR. Os pacientes foram submetidos ao EVAR entre junho de 1996 a fevereiro de 2004 e foram estudados retrospectivamente. A probabilidade explicita da causa de morte foi registrada. O intervalo entre a operação, alta hospitalar ou intervenção secundária até a morte foi registrado. RESULTADOS: De um total de 5612 pacientes, 589 (10,5 por cento) faleceram após o EVAR em acompanhamento total e qualquer causa de morte foi inclusa. Cento e quarenta e um pacientes (12,5 por cento) morreram devido a causa relacionada ao aneurisma, sendo que 28 (4,8 por cento) foram rupturas, 25 (4,2 por cento) infecções do implante e 88 (14,9 por cento) foram pacientes que morreram num prazo de 30 dias após o procedimento inicial (definição atualmente utilizada, também conhecido como resultado clínico a curto prazo). Além disso, 25 pacientes faleceram após 30 dias, mas continuavam ainda hospitalizados (ou transferidos a home-care para reavaliação posterior, ou necessitaram intervenção secundária). Levando em conta a duração da admissão ao hospital e a mortalidade imediata após o procedimento relacionada a intervenções secundárias, 49 mortes tardias também podem ser relacionadas ao EVAR. CONCLUSÃO: Morte tardia compõe uma proporção considerável da mortalidade relacionada ao EVAR dentro do tempo de análise revisado.

OBJECTIVE: The aim of this study was to evaluate the definition of Procedure-related mortality after endovascular aneurysm repair (EVAR) as defined by the Committee for Standardized Reporting Practices in Vascular Surgery. METHODS: Data on patients with an AAA were taken from the EUROSTAR database. The patients underwent EVAR between June 1996 and February 2004 and were analyzed retrospectively. Explicit probability of cause of death was recorded. The time interval from operation, hospital discharge or second interventions till death was recorded. RESULTS: A total of 589 out of 5612 patients (10.5 percent) died after EVAR in total follow up and all causes of death were included. 141 (2.5 percent) patients died due to aneurysms reported after the EVAR procedure of which 28 (4.8 percent) were ruptures, 25 (4.2 percent) graft-infections and 88 (14.9 percent) patients who died within 30 days after the initial procedure (present definition, also known as short term clinical outcome). In addition 25 patients died after 30 days, but were then (at moment of death) still in the hospital, or were transferred to a nursing home for further re-evaluation, or needed second interventions. Taking into account the duration of hospitalization and mortality immediately after procedure-related second interventions, 49 delayed deaths might also be regarded as being EVAR procedure-related. CONCLUSION: Delayed deaths are a considerable proportion of procedure-related deaths after EVAR within the revised time frame.

Detección temprana de aneurismas de la aorta abdominal mediante escáner dúplex a color / Use of duplex scan color for the early detection of abdominal aortic aneurysms

Los métodos no invasivos, en especial el escáner dúplex a color, ocupan un lugar de gran importancia en el armamento diagnóstico del cirujano vascular. Su empleo, cada vez más frecuente, permite realizar diagnósticos más precoces, especialmente en patologías arteriales, disminuyendo riesgos, costos y tiempo. Debido a que la ruptura de aneurismas de la aorta abdominal continúa siendo una entidad de alta mortalidad, en especial en pacientes mayores de 65 años, resulta particularmente útil contar con un método que permita detectar esos aneurismas en forma temprana y realizar su manejo antes de que ocurra esta catástrofe vascular. Al respecto, presentamos nuestra experiencia en un estudio piloto realizado en veteranos de las Fuerzas Militares de Colombia, durante el mes de mayo de 2006 y en el cual se demostró la utilidad del escáner dúplex a color para la detección, en forma temprana, de aneurismas de la aorta abdominal con ausencia de síntomas y signos clínicos y sus ventajas respecto a su aplicación masiva por el tiempo requerido por examen, costos, sensibilidad y baja morbimortalidad

Outcome after surgical repair of sealed rupture abdominal aortic aneurysms: a case-control study

OBJETIVO: Estabelecer, através de um estudo caso-controle, a mortalidade precoce e sobrevida a longo prazo após o tratamento cirúrgico do aneurisma da aorta abdominal roto contido crônico comparada aos respectivos controles, submetidos ao reparo do aneurisma da aorta abdominal não roto, operado eletivamente. PACIENTES E MÉTODO: De Janeiro de 1992 a Dezembro de 2002, 465 pacientes foram submetidos ao reparo de aneurismas da aorta abdominal. Destes, 13 eram aneurisma da aorta abdominal roto contido crônico (2,8%), que foram comparados a 26 controles nos quais a correção eletiva do aneurisma ocorreu imediatamente antes e após a correção do aneurisma da aorta abdominal roto contido crônico.RESULTADO: Não houve diferença entre os grupos com relação a idade, sexo, fatores de risco para aterosclerose, doenças associadas e cardiopatia isquêmica. Pacientes com aneurisma da aorta abdominal roto contido crônico apresentaram maior incidência de dor lombar (92,3% versus 3,9%; p<0,001); febre e perda ponderal foram detectados em cinco (38,5%) dos pacientes com aneurisma da aorta abdominal roto contido crônico e em nenhum dos controles (p=0,0022). A média de transfusão de hemácias também maior no aneurisma da aorta abdominal roto contido crônico (1516±697 vs. 773±463 ml (p=0,0003). As complicações pós-operatórias foram semelhantes entre os grupos. A mortalidade precoce foi de 7,7% nos pacientes com aneurisma da aorta abdominal roto contido crônico e 0% nos controles. A sobrevida em cinco anos foi significativamente menor nos portadores de aneurisma da aorta abdominal roto contido crônico (68.4%) do que no grupo controle (84,4%, p=0,04). CONCLUSÃO: Concluímos que o aneurisma da aorta abdominal roto contido crônico representa um desafio diagnóstico e terapêutico, que pode ser adequadamente conduzido com mortalidade precoce e taxas de complicações semelhantes ao aneurisma da aorta abdominal eletivo; entretanto, a mortalidade tardia do aneurisma da aorta abdominal roto contido crônico é maior.

Estudo prospectivo da morbi-mortalidade precoce e tardia da cirurgia do aneurisma da aorta abdominal / Prospective study of early and late morbidity and mortality in the abdominal aortic aneurysm surgical repair

OBJETIVO: Avaliar, prospectivamente, a morbidade e mortalidade precoce e tardia de pacientes submetidos a correção cirúrgica eletiva de aneurisma de aorta abdominal infra-renal e determinar os preditores independentes de eventos cardiológicos. MÉTODOS: Estudados 130 pacientes durante seis anos consecutivos, submetidos a rotina de avaliação pré-operatória padronizada e cirúrgica, sempre pela mesma equipe clínica, cirúrgica e anestesiológica. RESULTADOS: A mortalidade hospitalar foi de 3,1 por cento (4 pacientes), sendo a principal causa de óbito isquemia mesentérica, ocorrida em três pacientes. Houve 48 (37 por cento) complicações não-operatórias, 8,5 por cento consistiram em complicações cardíacas e 28,5 por cento em complicações não cardíacas. As complicações pulmonares foram as mais comuns, ocorridas em 14 (10,8 por cento) pacientes. A sobrevida no 1°, 3° e 6° ano pós-operatório foi, respectivamente, de 95 por cento, 87 por cento e 76 por cento. As variáveis que se correlacionaram significativamente com a morbimortalidade foram preditor clínico, idade média de 70,5 anos, presença de insuficiência cardíaca e insuficiência renal crônica. Não foi identificado nenhum preditor de morbimortalidade tardia. CONCLUSÃO: Apesar de ser uma cirurgia considerada de alta complexidade, a mortalidade é baixa, as complicações cardíacas são de pequena monta e os pacientes apresentam boa evolução a longo prazo.

Ruptured abdominal aortic aneurysm: prognostic factors

OBJETIVO: Analisar fatores prognósticos relacionados com a letalidade dos doentes com aneurisma de aorta abdominal roto. MÉTODO: Foram analisados, retrospectivamente, 72 doentes portadores de aneurisma de aorta abdominal roto, operados no período de 1976 a 2000 pela disciplina de Cirurgia Vascular da Santa Casa de São Paulo. RESULTADOS: A análise descritiva dos dados mostra média de idade de 67,93 anos, com desvio padrão de 11,58 anos, sendo 32% do sexo feminino e 68% do sexo masculino. Do total, 28% tinham história prévia de aneurisma e 72% desconheciam a doença. A pressão arterial sistólica na admissão foi de 96,53 mmHg. A dor esteve presente em 100% dos doentes, assim como massa abdominal pulsátil. O local de rompimento do aneurisma foi em 93% dos casos para o retroperitônio, 4% para o duodeno e 2% para peritônio livre. CONCLUSÃO: Os fatores prognósticos relacionados à letalidade que se mostraram com significância estatística foram: idade, pressão arterial admissional, diurese intra-operatória, volume infundido e creatinina admissional.

Aneurisma toracoabdominal roto: relato de caso com uso de anel rígido sulcado de Delrin intraluminal na anastomose proximal / Thoracoabdominal aneurysm rupture: case report of the use of a intraluminal rigid Delrin sulcate ring in anastomosis of the proximal aorta

A rotura do aneurisma de aorta toracoabdominal possui altas taxas de mortalidade e morbidades graves como paraplegia, falência renal e cardíaca, sendo de difícil resolução cirúrgica. Paciente de 51 anos, sexo masculino, tem aneurisma de aorta toracoabdominal roto,tipo III, no qual foi utilizado anel rígido proximalmente, sendo queuma anastomose única, biselada, incluindo os ramos viscerais, foi realizada distalmente. O uso do anel e a anastomose distal única, com substituição completa da porção aneurismática, permitiram um tempo cirúrgico e de clampeamento reduzidos, além de baixa morbidadeconstatada. A técnica cirúrgica adotada possibilitou boa evolução pós-operatória.(AU)#S#a

Tratamento cirúrgico dos aneurismas da aorta abdominal em octogenários: resultados a longo prazo / Surgical treatment of abdominal aortic aneurysms in octogenarians: long-term results

Objetivo: avaliar os resultados do tratamento cirúrgico deaneurisma da aorta abdominal não-roto em pacientes octogenários,analisando os desfechos a curto e longo prazos nos pacientes com ou sem sintomas relacionados ao aneurisma da aorta abdominal.Pacientes e método: entre março de 1982 e março de 2004,41 pacientes, com idade média de 82,7 anos (variação de 80-89 anos),foram submetidos ao tratamento cirúrgico do aneutisma da aorta abdominal,infra-renal, sendo divididos em dois, grupos, de acordo com os seus sintomas: grupo A (n = 21): asslntomaticos; grupo S (n = 20):sintomáticos. Os resultados foram avaliados pelo teste do X2 , testeexato de Fisher ou teste t quando necessário. A análise da curva de sobrevida foi feita pelo método de Kaplan-Meier. Um valor de P < 0,05 foi considerado estatisticamente significativo.Resultados: a presença de hipertensão arterial, cardiopatia isquêmica e insuficiência renal não diferiu entre os grupos. Sexo mas-culino e tabagismo foram significativamente mais freqüentes no grupo A (P < 0,05). A mortalidade operatória total foi de 9,75 por cento, sendo maior no grupo S (15 versus 4,76 por cento; P = 0,343). A taxa de sobrevida global em 1, 3, 5 e 7 anos foi de 94,2, 67,8, 47,2 e 33 por cento, respectivamente, não sendo estatisticamente diferente entre os grupos.Conclusão: a taxa de mortalidade operatória obtida nos pacientesoctogenários submetidos à cirurgia de aneurisma da aorta abdominal parece ser segura e está de acordo com a literatura. A presença de sintomas aumentou, embora sem força estatística, a mortalidade perioperatória, mas os resultados a longo prazo são semelhantes entre esses dois grupos.

Aneurisma aórtico abdominal en pacientes mayores de 80 años: tratamiento quirúrgico convencional en 80 casos consecutivos / Abdominal aortic aneurysms in patients over 80 years of age: conventional surgical treatment in 80 consecutive cases

BACKGROUND: Abdominal aortic aneurysms (AAA) may be lethal unless appropriately and timely treated. Since age is a surgical risk, octogenarians are usually not considered as candidates for surgical intervention. AIM: To asses surgical complications and mortality in octogenarians treated for AAA. SUBJECTS AND METHODS: Patients aged 80 years older, treated consecutively between 1984-2001 were retrospectively analyzed. RESULTS: Sixty one patients were male, and their age ranged from 80 to 95 years. All were treated with open surgery. The operation was elective in 58 and as an emergency in 22 patients (symptomatic or ruptured AAA). Aortic diameter was 6.8 +/- 1.4 cm in asymptomatic patients and 7.7 +/- 1.8 cm in emergency cases (p = 0.024). Thirty days postoperative mortality was 5.1% in elective surgery compared to 40.6% in emergency operations (p < 0.01). Five years survival rate was 44.7% in asymptomatic patients compared to 10.4% in the emergency cases (p < 0.023). CONCLUSIONS: Elective surgery for asymptomatic AAA can be performed with low operative mortality in octogenarians. However, surgery in emergency cases has an 8 fold increase in risk. Accordingly, octogenarian patients should be considered for elective AAA repair in a selective basis.