Tuberculous infection of the descending thoracic and abdominal aorta: case report and literature review.

We report here a case of infrarenal aortic disruption and aortoduodenal fistula secondary to tuberculous aortitis in a 77-year-old man. From a review of experience with operative management of tuberculous infection of the descending thoracic and abdominal aorta reported in the English-language literature, including the current report, we found that operative repair was attempted in 26 patients with tuberculous aortitis of the abdominal (n = 16), thoracic (n = 8), and thoracoabdominal (n = 2) aorta. Six patients had emergent operations for massive hemoptysis (n = 2), aortoduodenal fistula (n = 2), or abdominal rupture (n = 2), with an associated 30-day mortality of 50%. Elective or semi-elective repair was undertaken in 20 patients, of whom 19 (95%) survived for at least 30 days. On the basis of limited experience with this rare entity, in situ graft replacement is an appropriate treatment of tuberculous aneurysms and pseudoaneurysms of the descending thoracic and abdominal aorta.

Ruptured visceral artery aneurysms.

Visceral artery aneurysms are uncommon lesions that are rarely identified in the absence of symptoms. Between February 1972 and April 1992, nine patients (5 men and 4 women) with rupture of visceral artery aneurysms were treated. The average age was 62 years old (range 39 to 86 years old). The arteries involved were the splenic (4), the common hepatic (2), the left hepatic (1), the celiac (1), and the superior mesenteric (SMA) (1). No ruptured renal artery aneurysm was identified. Six patients presented with abdominal distension, pain, and hemodynamic instability. Three patients had recurrent gastrointestinal bleeding with erosion into the duodenum, the common bile duct or the pancreatic duct. All three had unnecessary gastrointestinal operations despite preoperative (2 patients) or intraoperative (1 patient) identification of a visceral artery aneurysm. One patient with an SMA aneurysm had ligation and bypass. Three patients with splenic artery aneurysms had splenectomy. The remaining five patients had either ligation or resection without arterial reconstruction. No end-organ dysfunction was identified. There was one death (11%) due to the SMA aneurysm. Pathological findings in four patients were cystic medial necrosis, diffuse deficiency of the internal elastic lamina, fibromuscular dysplasia, and atherosclerosis, respectively. The remainder were thought to be due to atherosclerosis on gross examination. Rupture of visceral artery aneurysms occurs infrequently and can be treated by simple ligation in most cases. Recognition that rupture of splanchnic arterial aneurysms into adjacent viscera can cause recurrent gastrointestinal bleeding may prevent both substantial delays in diagnosis and inappropriate therapy.

Spontaneous dissection of the internal carotid artery: a nineteen-year clinical experience.

PURPOSE: This article reviews our experience with internal carotid artery dissection (ICAD), evaluates the usefulness of Duplex scanning in diagnosis, provides current recommendations for treatment, and better defines long-term prognosis. METHODS: The records from 1976 to 1995 of 24 patients who had 28 ICAD were reviewed. All diagnoses were confirmed by arteriography. Presenting symptoms, diagnostic tests, clinical management, and outcome were examined. RESULTS: Nine patients had visual symptoms or headache, 10 had transient focal neurologic symptoms (TIA), and five had stroke. Five of the 19 who had visual symptoms or TIA had a stroke before the diagnosis of ICAD. Seventeen patients who had 19 ICAD underwent a Duplex scan at the time of presentation. Duplex scan identified 18 arterial abnormalities consistent with ICAD (sensitivity, 95%). Three patients died from stroke during the initial hospitalization. Of the 21 who survived, 12 were treated with anticoagulation therapy, six with aspirin, and three with aspirin and anticoagulation therapy. None of the 21 patients had a subsequent stroke. Six patients subsequently had an operation for residual occlusive disease or aneurysm. The mean duration of follow-up was 9.3 years. Two patients developed contralateral ICAD. During follow-up, 19 arteries were studied with Duplex scan, and seven had no residual evidence of ICAD. CONCLUSIONS: Patients who have ICAD often have prodromal symptoms before stroke. If diagnosed early, treatment with anticoagulation may prevent stroke. Duplex scans are accurate for defining carotid abnormalities consistent with ICAD and for indicating the need for arteriography. Patients should undergo a follow-up Duplex scan to identify contralateral ICAD.

Treatment of recurrent femoral or popliteal artery stenosis after percutaneous transluminal angioplasty.

PURPOSE: This study was undertaken to compare repeat percutaneous transluminal angioplasty (rPTA), arterial reconstruction, and noninvasive therapy for treatment of patients with recurrent stenosis after PTA of the superficial femoral or popliteal artery. METHODS: From 1983 to 1993, 93 patients were treated for recurrent femoropopliteal stenosis. Indication for treatment was claudication in 72 patients, rest pain in 9, and ischemic ulcer in 12. Thirty-six patients (38%) were treated with arterial bypass, 35 (38%) with rPTA, and 22 (24%) with exercise and medication. Patients were monitored with clinical examination, ankle-brachial indexes, and duplex scanning. Follow-up ranged from 6 to 110 months (mean 42 months). RESULTS: With life-table analysis, the clinical and hemodynamic success of patients treated with rPTA was 41% at 1 year, 20% at 2 years, and 11% at 3 years. For patients treated with arterial bypass, the primary graft patency rate was 84%, 72%, and 72% at 1, 2, and 3 years, respectively. The secondary graft patency rate was 94%, 88%, and 88% at the same intervals. All patients with patent grafts were symptom free. All 22 patients treated with noninvasive therapy continued to have symptoms, but none required amputation during follow-up (range 6 to 108 months). Overall, patients with claudication did better than those treated for rest pain or an ischemic lesion after either rPTA or arterial bypass, but no other variable was statistically significant in predicting outcome. CONCLUSIONS: This study finds that arterial bypass is safe and more effective than rPTA in treating patients with recurrent stenosis. Preoperative evaluation is unable to select patients likely to benefit from rPTA. Repeat PTA should be reserved for patients with limited life expectancy or contraindications to operation.

The influence of diabetes mellitus on the risk of abdominal aortic surgery.

Risk factors and postoperative complications of 153 diabetics (DM) who underwent an abdominal aortic operation for occlusive disease or an intact aneurysm from 1964 through June, 1988 were compared with 970 nondiabetics (nonDM) who underwent similar operations during the same time period. Heart disease, hypertension, cerebrovascular disease, and renal insufficiency were more prevalent in diabetics. Postoperatively, DM had a statistically significant increase in the incidence of myocardial infarction (DM 5.2%, nonDM 2.1%, P = .0434) and wound infection (DM 2.6%, nonDM 0.6%, P = .0359). The incidence of renal failure (DM 1.3%, nonDM 1.0%), stroke (DM 2.0%, nonDM 0.6%), and death (DM 3.9%, nonDM 2.9%) was higher in diabetics, but the differences were not statistically significant (P = NS). Operative mortality was greater for patients operated on for aneurysm (DM 5.3%, nonDM 3.2%) than for patients operated for occlusive disease (DM 3.3% versus nonDM 2.7%). Diabetics treated with insulin or oral agents had a higher complication rate than diabetics treated with diet alone or nondiabetics (insulin 13.0%, oral 13.4%, diet 4.2%, nonDM 8.6%). This study finds that diabetic patients can undergo an abdominal aortic operation with operative mortality comparable to that of nondiabetics. Diabetics have more postoperative complications than nondiabetics, but only myocardial infarction and wound infection are of statistical significance. Diabetics treated with insulin or oral agents have more complications than do diabetics treated by diet alone or nondiabetics.

Hemosuccus pancreaticus from intraductal rupture of a primary splenic artery aneurysm.

Hemosuccus pancreaticus--blood entering the gastrointestinal tract through the pancreatic duct--is a rare and elusive form of gastrointestinal bleeding. The most common cause is a splenic artery pseudoaneurysm caused by acute or chronic inflammation of the pancreas. We report the case of an 86-year-old woman who had recurrent gastrointestinal bleeding from erosion of an aneurysm of the splenic artery into the pancreatic duct. The lack of associated symptoms, equivocal endoscopic findings, and the rarity of this entity resulted in a delay in diagnosis. Nonresective treatment by ligation of the splenic artery proximal and distal to the aneurysm prevented any additional bleeding. Postoperative technetium sulfur colloid scanning demonstrated normal perfusion of the spleen. Only 16 cases of hemosuccus pancreaticus from primary splenic artery disease have previously been reported in the English-language literature (15 primary aneurysms, one medial disruption without an aneurysm). In contrast to cases caused by inflammatory pseudoaneurysms, splenic artery-pancreatic duct fistulas caused by primary aneurysms of the splenic artery should be treated without pancreatic or splenic resection, either with surgery or by embolization. In elderly patients with recurrent gastrointestinal bleeding of obscure source, the differential diagnosis should include the possibility of a ruptured aneurysm communicating with a viscus.

Tourniquet occlusion technique for tibial artery reconstruction.

PURPOSE: Vascular clamps, vessel loops, and intraluminal occluding devices used to control tibial and pedal vessels can be injurious and may fail to occlude heavily calcified arteries. In an effort to prevent injury to these small arteries, we have investigated the safety and efficacy of thigh pneumatic tourniquet occlusion for distal vascular control during infrapopliteal reconstruction. METHODS: During an 18-month period, 88 tibial or pedal arterial reconstructions were performed on 80 patients (mean age 75 years) by the tourniquet technique. Data regarding indications for operation, preoperative evaluation, intraoperative findings, surgical technique, and early outcome were recorded prospectively. RESULTS: Sixty percent of patients were diabetic: 36% insulin dependent and 24% non-insulin dependent. The indications for operation were claudication in 6 (7%), ischemic ulcer in 24 (27%), rest pain in 25 (28%), and gangrene in 33 (38%) patients. Thirty-five percent of operations followed failed ipsilateral infrainguinal reconstructions. The peroneal artery was the target vessel in 38%, anterior tibial in 26%, posterior tibial in 23%, tibioperoneal trunk in 9%, and inframalleolar vessels in 4% of cases. Preoperative analog waveforms and ankle-brachial indexes were used to classify the tibial arteries as compliant, 49%; relatively noncompressible, 30%; and absolutely noncompressible, 9%. Twelve percent had no Doppler flow at the ankle level. At operation 36 of the target arteries (41%) had mural calcification. Tourniquet pressures of 200 to 400 mm Hg (mode 250 mm Hg) were applied from 13 to 55 minutes (mean 27.1 +/- 9.1 minutes). All patients were given systemic anticoagulants. In 19 limbs (22%) the tourniquet was used to occlude a patent superficial femoral artery above the proximal (inflow) anastomosis to either the superficial femoral artery (8%), the above-knee popliteal artery (5%), or the below-knee popliteal artery (9%). Hemostasis was adequate in all cases and no alternative occlusive devices were required. There were no significant complications attributable to the use of the pneumatic tourniquet. CONCLUSION: Tourniquet occlusion simplifies the infrapopliteal dissection, lessens operating time, improves visualization of the distal anastomosis, and removes the potential for arterial injury to the target vessel. Arterial calcification and noncompressible tibial arteries do not contraindicate the use of thigh tourniquet occlusion. This technique is preferred for all patients undergoing tibial or pedal artery reconstruction.

Does routine patch angioplasty after carotid endarterectomy lessen the risk of perioperative stroke?

From 1964 through 1991 we performed primary closure of the arteriotomy in 1173 patients and patch angioplasty in 506 patients after carotid endarterectomy. The decision to patch was made at the surgeon's discretion. In general a patch was used for small arteries. In the primary closure group 32 patients (2.7%) had a perioperative stroke and in the patch angioplasty group 17 (3.4%) had a stroke. The difference (2.7% vs. 3.4%) was not significant (p < 0.5275, Fisher's exact two-tailed test). A total of 240 arteries were closed with a vein patch and 11 (4.6%) of these patients had a stroke; 266 were closed with a synthetic patch (Dacron, 211; polytetrafluoroethylene, 55) and six of the patients had a stroke (2.3%). The difference in stroke rate between the vein and synthetic patch groups (4.6% vs. 2.3%) was not significant (p < 0.2159). Patch angioplasty cannot be shown to reduce the incidence of perioperative stroke. Late carotid patency was not studied. This study supports a policy of selective patch angioplasty based on arterial size rather than patching all carotid arteries. When a patch is used, we prefer filamentous Dacron as the patch material.

Vascular complications of the intra-aortic balloon pump.

The lower extremity complications of 100 consecutive patients who required the placement of an intra-aortic balloon pump (IABP) during a 3-year period were studied. Indications for the IABP included hypotension during cardiac catheterization (33%) or coronary angioplasty (13%), hemodynamic instability after open heart surgery (35%), unstable angina (5%), and cardiac arrest (14%). The incidence of IABP morbidity was 29%. Complications included ischemia (25%), bleeding (2%), lymph fistula (1%), and femoral neuropathy (1%). Twenty patients required 1 or more surgical interventions for lower extremity vascular complications. The majority of patients who underwent operation (70%) had significant pre-existing arterial occlusive disease. Local femoral artery reconstruction or repair was performed in 18 patients. Two patients had adjunctive bypasses. Continued IABP support was required in four patients after treatment of complications. One patient (1%) had an above-knee amputation. Limb ischemia was treated nonoperatively by removal of the IABP in five patients. Color-flow duplex scans were useful in distinguishing hematomas from pseudoaneurysms as well as for assessing femoral artery flow. We conclude that: (1) limb ischemia remains the primary complication of the IABP; (2) pre-insertion documentation of the severity of existing peripheral arterial disease by noninvasive studies may aid in the management of subsequent acute limb ischemia; (3) femoral artery thrombectomy or endarterectomy is usually sufficient for revascularization; and (4) noninvasive color flow studies are an important diagnostic tool in the nonoperative management of limb complications.

Early results of infrainguinal arterial reconstruction with a modified biological conduit.

We implanted 112 glutaraldehyde-fixed bovine carotid artery grafts (BioPolyMeric [BPM]) for infrainguinal reconstruction in 107 legs of 98 patients. Indications for surgery were disabling claudication in 28%, rest pain in 33% and tissue loss in 39%. In 32%, BPM bypass followed failed ipsilateral reconstruction. Autologous vein was either absent or inadequate in 60% of cases. BPM was used preferentially over vein in above-knee bypasses. The distal anastomosis was to the above-knee popliteal artery in 40%, to the below-knee popliteal artery in 35%, and to the tibial arteries in 25%. Follow-up was available from one to 25 months, with a mean of nine months. Wound complications developed after 9% of operations, including seven (6%) graft infections. Both patent grafts that became infected were salvaged. Four patients (4%) died within 60 days of surgery due to cardiac complications. Life-table primary and secondary patencies of all grafts were 64% and 65% at one year, and 48% and 62% at two years, respectively. The only factor significantly affecting graft patency was the location of the distal anastomosis (p < .01). Primary patencies at one and two years to the above-knee popliteal artery were 90% and 80%, to the below-knee popliteal artery were 56% and 37%, and to the infrapopliteal arteries were 34% and 26%. Bypass to 16% of extremities resulted in amputation, including 5% that were amputated with patent grafts. No limb loss occurred as a result of operation for claudication. In conclusion, BPM grafts provide early results comparable to saphenous vein above the knee.(ABSTRACT TRUNCATED AT 250 WORDS)

Carotid endarterectomy in the elderly.

The records of 146 patients 80 years of age or older who underwent 183 carotid endarterectomy operations from 1964 through 1990 were reviewed to determine surgical risk. The indications for operation were asymptomatic patients with carotid stenosis (n = 36); ipsilateral transient ischemic attacks (n = 46); ipsilateral stroke (n = 28); ipsilateral retinal embolus (n = 15); nonlateralizing symptoms (n = 40); and asymptomatic side in patients with contralateral symptoms (n = 18). Postoperatively, three patients (1.6% of operations) had a stroke with a residual deficit and three (1.6%) died. All deaths were from myocardial infarction. For comparison, during the same time period, the combined stroke with residual deficit and death rate for patients less than 80 operated upon for similar indications was 3.5%. Since 80-year-old patients have a life expectancy of at least five years, the authors conclude that elderly patients should be evaluated for carotid endarterectomy using criteria similar to that used for younger patients.

Late results of small untreated abdominal aortic aneurysms.

We report our experience with 73 patients who were initially selected for nonoperative management of an abdominal aortic aneurysm less than 5 cm in diameter. Size of the aneurysm was determined by ultrasound (34); arteriography (16); computerized tomography (17); plain x-ray (4); and magnetic resonance imaging (2). End points of the study were subsequent elective resection, rupture, death from cause other than rupture, or an intact aneurysm followed for a minimum of three years. Overall, 28 (38%) aneurysms were subsequently resected on an elective basis; four (5%) ruptured; 15 (21%) were intact at the time of the patient's death; and 26 (36%) remained intact during follow-up of 3 to 6.5 years. Indications for elective resection were aneurysm enlargement (21); symptoms suggesting impending rupture (3); and improvement in medical condition (4). In the 43 aneurysms initially less than 4 cm diameter, 16 (37%) had elective resection and one (2%) ruptured, and in the 30 that were 4-4.9 cm, 12 (40%) were resected and three (10%) ruptured. The four aneurysms that ruptured had enlarged to greater than 5 cm prior to rupture. We conclude that aneurysms less than 4 cm can be safely followed. Aneurysms 4-4.9 cm should be considered for operation, depending upon the size of the aneurysm, patient's life expectancy, and risk factors for surgery. Any aneurysm that enlarges should be resected, especially if the aneurysm becomes larger than 5 cm in diameter.

The diminishing role of diagnostic arteriography in carotid artery disease: duplex scanning as definitive preoperative study.

In an effort to eliminate the inherent neurologic morbidity associated with arteriographic investigation, we have increasingly relied upon duplex scans of the extracranial carotid arteries prior to endarterectomy. The percentage of patients undergoing carotid endarterectomy without arteriograms has increased from 5% in 1984 to 69% during 1988-1989. Initially, carotid endarterectomy without arteriography was limited to patients with hemispheric symptoms and relative contraindications. Over the course of the study from 1984-1989, indications for operation were similar for patients having carotid endarterectomy on the basis of duplex scan alone or following arteriography. The perioperative outcome for these patients undergoing duplex scan (n = 255) and arteriography (n = 484) were similar for stroke (2.4%) versus 2.7%, p = NS) and death (0% versus 0.4%, p = NS). Stratification of groups by indication did not show any significant differences in outcome. Duplex scans were sufficiently accurate to replace preoperative arteriograms in identifying significant stenoses at the carotid bifurcation, including asymptomatic disease. Lack of information regarding intracranial arterial occlusive disease did not adversely affect perioperative outcome. Carotid arteriography can be used selectively when duplex scans are technically difficult, when physical examination or scans suggest either inflow (arch) disease or diffuse, distal internal carotid plaque, or when cerebral symptoms are not sufficiently explained by duplex findings.

Angioscopy for intraoperative management of thromboembolectomy.

Our experience with angioscopy suggests that direct visualization of the arterial lumen during thromboembolectomy procedures would provide a more reliable method of assessing luminal morphologic characteristics than angiography alone. We inspected 32 grafts (seven aortobifemoral, 18 infrainguinal bypass, and seven dialysis access fistula grafts) in 32 patients. Thirty-one patients had thrombotic events and one patient had an acute embolus. Angioscopy following standard catheter thrombectomy revealed significant amounts of retained thrombus or neointima in all thrombectomies. Angioscopic information from 18 patients with an infrainguinal bypass graft led to graft revision in six cases and placement of a new graft in 10 cases. One graft limb was replaced in seven aortobifemoral grafts, and multiple repeated thrombectomies were employed to extract debris in the remaining six cases. Repeated graft thrombectomy was also beneficial in dialysis access fistulas. Angioscopy allowed us to omit the completion angiogram and led to an improved technical result. We conclude that angioscopy is useful during thromboembolectomy procedures.

The influence of neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma.

The influence of neutralizing or not neutralizing heparin after carotid endarterectomy on postoperative stroke and wound hematoma is unknown. During the past 6 years some of the authors frequently gave protamine sulfate to neutralize heparin, whereas others did not unless a patch was used or wound hemostasis was not readily obtained. To determine the influence of protamine sulfate on stroke and wound hematoma the records of 697 patients having a carotid endarterectomy from January 1984 to September 1989 were reviewed. Protamine sulfate was given to 328 patients, and 369 did not receive protamine sulfate. The incidence of stroke in the two groups was 1.8% (n = 6) and 2.7% (n = 10), respectively, and the difference was not significant (p = 0.6019). Excluding three strokes that could not be related to neutralizing or not neutralizing heparin, the difference remained insignificant (1.5% vs 2.2%, p = 0.7290). The incidence of wound hematoma was 1.8% (n = 6) in patients given protamine sulfate and 6.5% (n = 24) in patients not given protamine sulfate, and this difference was significant (p = 0.0044). The difference remained significant when three hematomas not related to protamine sulfate were excluded (1.2% vs 6.2%, p = 0.0013). In patients not given protamine sulfate draining the wound lessened the incidence of wound hematoma (4.4% vs 8.6%), but this difference was not statistically significant (p = 0.1475). In patients given protamine sulfate the dose of protamine sulfate (15 to 45 mg vs 50 to 75 mg) had no statistically significant effect on the incidence of stroke (0.8% vs 2.0%, p = 0.6530) or wound hematoma (1.6% vs 1.0%, p = 1.000).

The risk of carotid endarterectomy for the asymptomatic patient: an argument for prophylactic operation.

We reviewed the records of 291 asymptomatic patients who underwent 377 carotid endarterectomy operations. The study excludes endarterectomies performed simultaneously with other operations that influence morbidity as well as endarterectomies on patients with symptoms caused by contralateral carotid stenosis. Postoperatively, nine patients had a stroke but two of the nine recovered completely after reoperation. Seven patients (2% of operations) were discharged with a neurologic deficit. One patient died of a myocardial infarction. Combined strokes with residual deficit and deaths totaled eight patients (2.2% of operations). During the time of the study the indication for operation changed from greater than 60% stenosis of the carotid artery to greater than 80% stenosis. This paper argues that, based on information currently available, a surgical morbidity rate of less than 3% justifies prophylactic endarterectomy. Surgeons must audit their results to demonstrate they can perform the operation with low risk to the patient.

Comparison of contrast arteriography to arterial mapping with color-flow duplex imaging in the lower extremities.

Color flow duplex scanning was used to "map" the iliofemoral and femoral popliteal segments in 61 patients (84 extremities) undergoing evaluation for excimer laser angioplasty. Eight locations, iliac, common femoral, profunda femoris, proximal and distal superficial femoral artery, proximal and distal popliteal, and tibioperoneal trunk were scored as normal versus abnormal, greater than 50% stenosis, or occluded, and occlusions were measured in centimeters. Specificity, sensitivity, and accuracy were calculated with the arteriogram as the gold standard (83% and 96%, respectively, for normal vs abnormal, 87% and 99% for 50% stenosis, and 81% and 99% for occlusions). Color flow accurately identified the presence and extent of occlusions in 48 of 51 extremities (94%) when compared to arteriography plus operative findings, since arteriography alone tended to overestimate occlusion length. It is concluded that color flow Doppler alone may be used to screen patients with peripheral vascular disease to assess candidacy for endovascular procedures without antecedent arteriography, and that arteriography alone would exclude some patients from consideration by falsely overestimating occlusion lengths.

Anastomotic false aneurysms of the abdominal aorta and the iliac arteries.

Anastomotic false aneurysm (AFA) of the aorta or iliac artery is a potentially lethal complication of prosthetic grafts. To study this complication, the records of 18 patients with 22 noninfected AFAs (15 aortic and seven iliac) were reviewed. Patients with an intact AFA had a pulsatile abdominal mass, abdominal pain, an occluded graft, peripheral emboli, or a femoral anastomotic false aneurysm. All patients with a ruptured AFA were in shock, but 67% (four of six) had symptoms before hemorrhage. For diagnosis, single-plane angiography was 69% accurate (11 of 16), computed tomography was 100% accurate (six of six), and ultrasound was used once and suggested an AFA. Three patients with an AFA less than 5 cm diameter were initially observed; however, all three aneurysms rapidly enlarged and one ruptured. The operative mortality rate was 8% (1 of 12) for patients with an intact aneurysm and 67% (four of six) for patients with a ruptured aneurysm. Treatment was resection of the AFA and replacement with a new graft. Retroperitoneal AFAs often appear years after the initial operation, and life-long follow-up is required for patients with an aortic or iliac graft. All retroperitoneal AFAs should be resected since the outcome of patients with a ruptured AFA is poor.

Aneurysmectomy in the octogenarian. A study of morbidity and quality of survival.

The records of 52 octogenarians who underwent resection of an abdominal aortic aneurysm were reviewed. Thirty-five elective operations were performed with an operative mortality of 8.6 percent, which was twice that of the group less than 80 years of age. Seventeen emergency operations were performed for rupture with an operative mortality of 58.8 percent. Postoperative follow-up in the elective group found that by 6 months 93 percent of surviving patients had returned to their preoperative status. Survival rates by life table analysis were 67 percent at 1 year, 52 percent at 3 years, and 14 percent at 5 years. In the ruptured group, all patients at risk were alive at 1, 3, and 5 years. We advise elective resection of an abdominal aortic aneurysm in the octogenarian with good functional capacity using the same criteria that we use for younger patients. Most octogenarians can anticipate a prompt return to their usual environment and a meaningful postoperative life-style.