Ruptured abdominal aortic aneurysm: impact of comorbidity and postoperative complications on outcome.

Ruptured abdominal aortic aneurysm (AAA) remains a common and highly lethal problem. This study evaluates the morbidity and mortality rates and aims to identify which clinical variables could predict the outcome. We reviewed the records of 112 patients (97 men and 15 women) operated on for ruptured infrarenal AAA within the past 12 years (April 1, 1980, to March 31, 1992). Forty-seven clinical variables were collected and correlated with outcome by univariate and multivariate analysis. Mean age was 72.4 years (range 51 to 89 years). Only 12.5% were known to have an AAA before rupture. Preoperative systolic pressure < 90 mm Hg was present in 84 patients (75%) and 11 patients (9.8%) experienced cardiac arrest before surgery. The in-hospital mortality rate was 49.1% (55/112). Two preoperative variables were associated with increased mortality: systolic pressure < 90 mm Hg and cardiac arrest (p = 0.04 and p = 0.009, respectively). Preoperative comorbidity had no impact on outcome. Massive blood loss (> or = 5000 ml) was an intraoperative factor predictive of increased mortality (p = 0.0007). After multivariate analysis, only the following five postoperative variables were associated with increased mortality: cardiac event, renal failure requiring dialysis, coagulopathy, bleeding, and multisystem organ failure (all p < 0.05). We did not identify a preoperative factor that predicts certain death and allows us to deny a patient a chance at survival. The occurrence of multisystem organ failure is associated with no survivors and raises the ethical issue of withholding treatment for these patients in the postoperative course. We favor selective screening and aggressive elective repair to improve survival by operating before rupture occurs.

Surgical treatment of achalasia in a general hospital.

The authors report their experience with 43 patients treated for achalasia of the esophagus in a general hospital between 1971 and 1986. Patients were divided into two groups according to the type of surgery performed: group 1--29 patients treated by Heller myotomy, performed by nine general surgeons between 1971 and 1983; and group 2--14 patients treated by transthoracic Heller myotomy with the addition of a Belsey Mark-IV fundoplication. Dysphagia was reduced postoperatively in 82.6% of patients in group 1 and 92.8% of patients in group 2. Three patients in group 1 and one patient in group 2 had persistent dysphagia. Ten patients in group 1 had symptoms of gastroesophageal reflux (5 of them required a second antireflux procedure). In group 2, one patient had symptoms of gastroesophageal reflux, but was treated successfully medically. There was no difference in the degree of relief of dysphagia between the abdominal and thoracic approach, or in whether the operation was performed by a general surgeon without specific experience in the treatment of achalasia. The addition of a fundoplication to a Heller myotomy appeared to lessen the problem of postoperative gastroesophageal reflux. Since the Heller myotomy is technically difficult and may lead to obstruction of the poorly emptying esophagus the authors recommend that it be used selectively and only by the experienced esophageal surgeon.

Multivariate clinical models and quantitative dipyridamole-thallium imaging to predict cardiac morbidity and death after vascular reconstruction.

Patients with peripheral vascular disease have a high prevalence of coronary artery disease and are at increased risk for cardiac morbidity and death after vascular reconstruction. The present study was undertaken to assess the value of 18 clinical parameters, of 7 clinical scoring systems, and of quantitative dipyridamole-thallium imaging for predicting the occurrence of postoperative myocardial infarction or cardiac death. Vascular surgery was performed in 125 patients. Thirteen postoperative cardiac events occurred, including 10 cardiac deaths and 3 nonfatal infarctions. Clinical parameters were not useful in predicting postoperative outcome. All 63 patients with normal scan results or fixed perfusion defects underwent surgery uneventfully, whereas 21% (13/62) of patients with reversible defects had a postoperative cardiac complication. By use of quantitative scintigraphic indexes we found that patients with reversible defects could be stratified into intermediate and high-risk subgroups with postoperative event rates of 5% (2/47) and 85% (11/13), respectively, despite intensive postoperative monitoring and antianginal medication. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically, whereas dipyridamole-thallium imaging successfully identified all patients who had a postoperative cardiac event. By use of quantification we found that patients with reversible defects can be stratified into an intermediate risk subgroup that can undergo surgery with minimal complication rate and a high-risk subgroup that requires coronary angiography.

[In situ femoro-popliteal bypass grafts. Study of 85 cases using Cartier's technique]. / Le pontage fémoro-poplité in situ. Etude de 85 cas opérés d'après la technique de Cartier.

From January 1985 to december 1989, 83 patients (69 men, 14 women) underwent an in situ femoro-popliteal bypass using a semi-closed technique and the valvulotome developed by Dr Paul Cartier. Most patients (67%) were operated for severe ischemia while 33% were for claudication. HTA was present in 31% of patients, diabetes in 38% and CAD in 57%. Mean preoperative ABI was 0.33 +/- 0.20 and mean ankle pressure was 50 +/- 30 mm of Hg. Arteriographic popliteal run-off showed three vessels in 21 cases (25%), two vessels in 17 cases (20%) and one vessel in 38 cases (45%). Nine patients (10%) presented an isolated popliteal artery. Bypass was constructed below knee in 62 patients (73%) and above knee in 23 (27%). Five mortalities (5.8%) and two major complications (2.3%) were related to surgery. Four early graft failures (4.4%) were noted but 3 were successfully reoperated. Postoperative ABI was 0.71 +/- 0.23 mm of Hg and 81% of patients had complete relief of their symptoms. With a mean follow-up 19 months, graft patency was 91% +/- 6% and 84% +/- 11% at one and two years and was not influenced by operative indication: hypertension, diabetes, preoperative ABI, arteriographic findings or distal anastomotic site. Overall survival was 80% +/- 10% and 69 +/- 13 at one and two years. The in situ technique using the Cartier valvulotomes is an excellent operation and compares favourably with other techniques.

[Arterial surgery of the upper limb]. / Chirurgie artérielle du membre supérieur.

Arterial surgery of the upper limb represents 2.5% of peripheral vascular procedures in our center. From 1976 to 1989, 58 procedures were performed in 45 patients. There were 26 men and 19 women with average age of 52 years, ranging from 6 to 92 years. These patients were grouped in three categories according to etiology: 1) trauma; 2) acute non traumatic ischemia and 3) chronic ischemia. Sixteen patients (35.5%) were operated on for arterial trauma including three false aneurysms. Blunt trauma was the cause in 9 patients, penetrating in 6 and iatrogenic in one. Angioplasty and primary end to end anastomosis were used in 6, bypass in 4, simple ligation in 3, thrombectomy in 3. The outcome was excellent in 15/16 (93%). Non traumatic acute ischemia occurred in 16 patients (35.5%) and was due to emboli of cardiac origin in 92%. All patients were treated by thromboembolectomy. This group had a high mortality (5/16, 31%) because of associated medical conditions. The third group of 13 patients (29%) underwent surgery for chronic ischemia of the upper limb localized to the subclavian artery in 92%. They were treated with carotid subclavian bypasses in 9, other types of bypass in 3 and endarterectomy in 1. Excellent results were obtained in 10/13 (78%). Overall, satisfactory results were obtained in 90% of surviving patients. Operative mortality was 11.1% and the amputation rate was 13%.

Above-knee femoropopliteal reconstruction with polytetrafluoroethylene: a good alternative to saphenous vein bypass.

Over 6 1/2 years, 64 femoropopliteal bypasses were done on 55 patients, using polytetrafluoroethylene (PTFE). The PTFE was chosen because previous surgery or small diameter prohibited the use of saphenous vein. The distal anastomoses were always placed above the knee. Patency rates were 92% at 1 month, 76% at 1 year, 72% at 2 years and 59% at 3 years, and then reached a plateau of 55% at 4 years. When autogenous vein is not available, PTFE is the material of choice for femoropopliteal reconstruction. The results compare favourably with those using saphenous vein in an above-knee situation.

Blunt diaphragmatic rupture.

Diaphragmatic injury is often a missed diagnosis in patients with multiple trauma. For this reason, mortality can be high. From 1970 to 1981, 32 patients with diaphragmatic injuries were seen at Maisonneuve-Rosemont Hospital. Twenty-four of the patients (22 men and 2 women aged 18 to 79 years) had blunt abdominal or thoracic trauma causing diaphragmatic disruption. Rupture occurred 20 times on the left side of the diaphragm, and 3 times on the right side. There was one pericardiophrenic rupture. Motor vehicle accident was the most common cause of trauma. On arrival, 21 patients had acute diaphragmatic rupture. Clinical signs and radiography permitted early diagnosis in 15 patients, whereas diagnosis was made later in 3 other patients because of deterioration of vital signs. In two patients, diagnosis was made at laparotomy for another reason. Four patients were operated on for post-traumatic chronic diaphragmatic hernia. The abdominal approach was used in 18 patients, the thoracic approach in 4, and the thoracoabdominal approach in 2. Three patients died, two of whom had a late diagnosis. Fourteen patients had no complications. Diaphragmatic trauma can be easily managed surgically when diagnosis is made early after trauma. It must always be looked for in patients with multiple trauma.

Arterial injuries.

The authors review arterial injuries in 68 patients treated at Maisonneuve-Rosemont Hospital in Montreal between 1975 and 1982. Penetrating trauma caused 54.4% of these injuries, which consisted of either laceration or intimal tear with thrombosis. Arterial injuries of the extremities were predominant (58.8%). Associated injuries were frequent. Surgical repair was effected in 60 patients. End-to-end anastomosis, angioplasty and venous or prosthetic bypass grafting were the techniques used. Postoperative complications occurred in 37% of the patients. Overall mortality was 19% and was related mainly to aortic injury. The amputation rate for arterial injuries of the extremities was 15%. Prompt recognition and treatment of arterial injuries are important in order to achieve the best results.

Lung cancer and peripheral vascular surgery.

Lung cancer, a disease of epidemic proportions, is to some extent preventable. Elimination of smoking would certainly reduce its incidence. Conventional therapy has not produced any major advance in this field, the 5-year survival of all patients with lung cancer still being very low. The disease is best managed when detected at an early stage, but on the basis of a study carried out at the Mayo Clinic, screening of the general population cannot be advocated. A few high-risk groups of patients have been identified, such as those treated surgically for laryngeal or pharyngeal tumours and those previously operated on for lung carcinoma. The authors have identified another category of high-risk patients, those who must undergo peripheral vascular surgery. Of 676 patients operated upon for peripheral vascular disease, lung cancer was found in 3.25%. The distinction is made between those whose lung cancer was detected at the time of vascular surgery (synchronous) and those whose cancer was found later (metachronous). Every patient scheduled to undergo surgery for peripheral vascular disease should be screened by chest roentgenography and cytologic examination of the sputum. These patients should be followed up closely in the postoperative period.

Extra-anatomic bypass grafting in the lower extremity.

Between January 1975 and December 1980, 104 extra-anatomic bypasses were performed on 102 patients. Of these, there were 81 femorofemoral bypasses on 80 patients and 23 axillofemoral bypasses on 22 patients. Those who underwent femorofemoral grafting were divided into three groups: group 1 - 18 patients who had undergone previous aortofemoral bypass grafting with occlusion of one limb of the graft, group 2 - 17 patients who were considered to be at high risk and group 3 - 45 patients who could have tolerated a conventional reconstructive procedure. Our results indicate that the cumulative patency rate of the femorofemoral bypass at the end of 1 year and 5 years is good and that this operation is an excellent first choice procedure in cases of unilateral iliac disease, to relieve severe ischemia or disabling claudication, whether the patient is a poor or good operative risk. On the other hand, axillofemoral grafting has a lower patency rate and should be reserved for high-risk patients and for the relief of severe ischemia only.

Cystic adventitial disease of the popliteal artery. Clinical aspects and etiology.

Cystic adventitial disease of the popliteal artery is a rare and benign disease. The appearance of claudication in a young male nonsmoker and the typical angiographic findings usually confirm the pathology. The treatment of choice is incision evacuation of the cyst. Long-term follow-up of two cases proved to be excellent with this therapy. A saphenous bypass graft provides a good alternative if incision evacuation fails to restore good peripheral pulses. The etiology of this lesion proves to be similar to a ganglion and is well demonstrated in two cases.

Blunt injury of the abdominal aorta.

This review of 27 cases of blunt injury of the abdominal aorta includes 24 cases reported in the literature and three new cases. Automobile accidents were the cause of this condition in 19 patients (70%). Clinical presentation was acute in 70% of the cases, and consisted of either acute arterial insufficiency or an acute abdomen. Intimal disruption occurred in 15 patients (55%) and was the most common anatomic lesion. Atherosclerotic involvement of the aorta was found in ten patients (37%), and in four it contributed directly to the development of this condition. The infrarenal aorta was the most affected segment (92%). The mortality rate was 29% (8/27 patients). Associated trauma occurred in 55% of the cases, but did mot increase the mortality rate. Prompt recognition and proper surgical treatment are essential in the management of this condition.

Ruptured abdominal aortic aneurysm.

Treatment of abdominal aortic aneurysms should be aggressive because less than 50% of untreated patients will be alive 3 years after diagnosis and most will die from ruptured aneurysm. In an effort to reduce the incidence of rupture, all abdominal aortic aneurysms should be excised unless the patient has a short life expectancy or very serious medical problems. In a series of 36 patients with ruptured abdominal aortic aneurysm the mortality was 42%. The main risk factors were blood loss, acute renal failure and major venous trauma. Multiple organ failure, which occurred in 8 of 15 patients often presents a therapeutic dilemma and worsens the prognosis.

Cystic adventitial disease of the popliteal artery.

Cystic degeneration of the popliteal artery is a rare vascular condition. The authors report on the third case recorded in Canada and provide a follow-up report of the first recorded case published in 1969. Observations made at operation on the anatomical relationship of the cyst give more information on the etiology of this curious entity. The clinical and roentgenologic aspects, the etiologic theories and treatment are briefly reviewed. The authors conclude that there are three principles of treatment applicable to this condition: (a) incision with evacuation of the cyst may be effective, (b) the lesion should be resected if evacuation is unsuccessful and (c) popliteal angioplasty should be avoided.

[Atherosclerotic aneurysm of the subclavian artery]. / Anévrisme athérosclérotique de l'artère sous-clavière.

An aneurysm of the right subclavian artery, a rare pathologic entity, is described. The presence of a pulsatile mass in the cervical region should always suggest the diagnosis, which is best confirmed by arteriography. Approaching the lesion by partial sternotomy extending to the third intercostal space gives excellent exposure. The aneurysm should be resected and vascular continuity re-established by the use of a synthetic prosthesis.