Progress in the management of type I thoracoabdominal and descending thoracic aortic aneurysms.

We reviewed our categorization of patients at high risk for neurologic complications in the repair of descending thoracic and thoracoabdominal aortic aneurysm in which we used cerebrospinal fluid drainage and distal aortic perfusion (adjuncts). A total of 409 patients were operated on by one surgeon for descending thoracic or thoracoabdominal aortic aneurysm between 1992 and 1997. Of these patients, 232 had total descending thoracic or type I thoracoabdominal aortic aneurysm, 131 (56%) of whom were operated on with adjuncts. These patients were compared to 101 nonadjunct patients for demographic variables, intraoperative variables, blood product consumption, and neurologic status. In 131 consecutive patients with adjuncts, all but one awoke from anesthesia without neurologic deficit. In nonadjunct patients, however, neurologic deficit occurred in 6 of 101 (6%) (p < 0.003). The adjunct group had more preoperative renal insufficiency (p < 0.05), an established risk factor for neurologic deficit (odds ratio = 2.2 in published studies). All other risk factors for neurologic deficit occurred with comparable frequency in both groups. We conclude that the introduction of adjuncts has dramatically reduced the neurologic risk associated with type I thoracoabdominal or total descending thoracic aortic repair. Previously considered high risk for neurologic complications, these aneurysms can now be reclassified as low risk in surgery accompanied by adjuncts. Future investigations will focus on type II thoracoabdominal aortic aneurysm as the major source of neurologic morbidity.

Hypothermic circulatory arrest for thoracic aneurysmectomy through left-sided thoracotomy.

PURPOSE: In an attempt to clarify the role of hypothermic circulatory arrest (HCA) in the management of complex aortic aneurysms operated on through the left thoracotomy, our technique of HCA and outcome were reviewed. METHODS: During a 21-month period, 15 (17%) of 87 aneurysms of the descending thoracic or thoracoabdominal aorta were operated on by HCA. Eleven patients had chronic aortic dissections (four type A and seven type B), two patients had atherosclerotic aneurysms, and one each had congenital or infected postoperative aneurysms. The use of HCA was planned before surgery in 14 patients. Indications included proximal aortic disease in 12 patients, making either clamping of the transverse aortic arch unsafe (eight patients) or necessitating replacement of the arch with a graft (four patients). Preoperative decision to use HCA was made in two additional patients, one with a ruptured aneurysm and another patient for spinal cord and visceral protection because of anticipated prolonged ischemia as a result of reoperation. Intraoperative technical difficulties prompted the use of HCA in only one patient. Deep hypothermia (15 degrees to 24 degrees C) was induced through partial cardiopulmonary bypass. Left-sided heart venting was necessary in five patients. Aortic replacement was limited to the descending thoracic aorta in five patients, whereas it involved the thoracoabdominal aorta in 10 patients. Four patients had associated replacement of the aortic arch. RESULTS: Three patients died (one of a ruptured aneurysm) during surgery or early after surgery (two of bleeding and one of left ventricular failure). All other patients awoke neurologically intact, but one patient had delayed onset of paraplegia. Another patient died 4 days after surgery of rupture of the ascending aorta. Eleven patients were perioperative survivors without significant morbidity. CONCLUSIONS: Hypothermic circulatory arrest is a valuable adjunct in the management of complex aortic aneurysms through left-sided thoracotomy. Its results warrant consideration of its selective use for spinal cord/visceral protection.

In situ allograft replacement of infected infrarenal aortic prosthetic grafts: results in forty-three patients.

PURPOSE: Dissatisfaction with conventional methods of treatment of infected infrarenal aortic prosthetic grafts and excellent long-term results reported by heart surgeons after allograft replacement for management of infections involving the ascending aorta have prompted us to investigate allograft replacement in the management of arterial infections. METHODS: From October 1988 to April 1992, 43 consecutive patients with infected infrarenal aortic prosthetic grafts underwent in situ replacement with preserved allografts obtained from cadavers as part of a program to retrieve multiorgan transplant tissue. Thirty-four patients had isolated prosthetic infections, whereas nine had aortoenteric fistulas. One patient had a concomitant below-knee amputation for septic arthritis of the ankle as a result of septic emboli. Nineteen patients had nonvascular-associated procedures, including 17 intestinal procedures. RESULTS: Five patients (12%) died after operation: four of general causes and one of rupture of the native aorta as a result of persistent infection. Three patients successfully underwent repeat operation for allograft-related complications (one case each of occlusion, septic rupture, and graft-enteric fistula). All surviving patients were discharged after control angiography showed patent allografts. Two patients were unavailable for follow-up. The other 36 patients have been monitored with serial duplex and computed tomography scanning for a mean follow-up of 13.8 months (range 1 to 42 months). There were four late deaths: three were unrelated to the vascular operation, and one may have been caused by late persistent or recurrent infection. Nine patients (26%) have had pathologic changes in the allograft, with three (9%) requiring repeat operation. There were no early or late postoperative amputations in the entire series. CONCLUSIONS: Although complete protection against persistent or recurrent infection has not been achieved and late deterioration may be expected, in situ allograft replacement seems to be a major advance in the management of infected infrarenal aortic prosthetic grafts.

[Rupture of abdominal aorta aneurysms. Study of 92 cases operated on over a ten year period (1980-1989)]. / Rupture des anévrysmes de l'aorte abdominale. Etude de 92 cas opérés en dix ans (1980-1989).

From January 1980 to December 1989, 92 ruptured abdominal aortic aneurysms (AAA) were operated upon in emergency at our institution. During the same period, 747 AAA were operated in election or in the absence of rupture. The mean age of patients was 72.8 +/- 9.1 (52-95). There were 81 men and 11 women. Etiology of the AAA was common degenerative in all cases except in one case of aortic dissection and one case of infectious aneurysm. 27 (29.3%) patients presented antecedents of bronchopathy, 31 (33.7%) antecedents of hypertension and 36 (39.1%) antecedents of coronary heart disease. All patients were operated upon under general anesthesia, in two (2.1%) cases through a thoraco-abdominal exposure, in one case through a lombotomy, in one case, using exclusion and an extra anatomic bypass and through a midline transperitoneal laparotomy in all 88 (96.9%) other cases. The mean diameter of the AAA was 9 +/- 3.9 (4-25) cm. The rupture was intra-peritoneal in 26 (28.3%) cases, intra caval in 5 (5.4%) cases, intra duodenal in 2 (2.2%) cases and retro peritoneal in all the other 59 (64.1%) cases. The aorta was cross clamped above the renal arteries in 15 (16.3%) cases, under the renal arteries in 48 (52.2%) cases and at both levels in 29 (31.5%) cases. Surgical treatment consisted in an aorto-aortic tubular graft in 45 (48.9%) cases, a bifurcated aortic graft in 32 (34.8%) cases, an exclusion with extra anatomic bypass in one (1%) case and could not be completed before the death of the patient in 14 (15.3%) cases. There were 56 (60.9%) deaths, 27 (29.4%) in the per operative and 29 (31.5%) in the post operative periods after a mean time of 5.7 +/- 9.2 (0-36) days. The cause of the death was hemorrhage in 25 (44.4) cases, cardiac complications in 28 (50%) cases, renal insufficiency in 1 (2%) case, pulmonary complications in 1 (2%) case and septic complications in one (2%) case. During the period of the present study, rupture of an AAA remained, in our institution as in other institutions an often fatal condition. This condition could probably be avoided with a policy of early detection and surgical treatment.

[Long term results of surgery of aortic aneurysms]. / Résultats tardifs de la chirurgie des anévrysmes de l'aorte.

During 10 years, between 01.01.80 and 01.12.89, 838 patients have been operated on consequently for a A.A.A. in the vascular surgery department of the Hospital Pitié-Salpêtrière (Paris). Post-operative death was 7.3% (51 patients) among 692 operated on without emergency and 41.7% (60 patients) among 146 patients operated on emergency. The study was undertaken with the 727 surviving patients (86.8%) for the long term follow-up. Only 25 patients (3.4%) were lost out, so 702 patients (96.6%) had complete recalls even to their late death until the fourth trimester 1990. Total deaths, were 172 patients, (24.5%) out of the 702 patients in the follow-up. 60 patients (34.9%) died from cancer, 52 patients (30.2%) from heart disease, 21 patients (12.2%) from C.V.A. (cerebro-vascular-accident), 8 (4.6%) from rupture of aneurysm, 6 (3.6%) from renal insufficiency, 5 (2.9%) from prosthesis infection, 10 (5.8%) died from known reasons, 10 (5.8%) from unknown reasons. All these results were studied according to the "actuarial method" and the conclusions were as follow. The actual survival rate at 5 years was 72.1% +/- 5.6% and the average annual death rate was 5.8%. The factors which have influenced the late death are: a) Patients age: survival rate at 5 years and average annual death rate were significantly different whether the patients were less or more than 70 at the time of surgery. b) Surgical circonstances: late survival was significatively less with patients operated on emergency. c) Cerebro-vascular insufficiency. The average annual rates from cardio-vascular and cerebro-vascular accident were significatively more important in patients which previously had cerebro-vascular insufficiency. This work shows out that cardiac death are slightly overcame by cancer, but these two factors represent almost 2/3 (65.1%) of late death. So it should be important for prevention of late death to screen for lung and E.N.T. cancers. Some authors have proposed for prevention of coronarian accidents extensive use of coronarography and myocardial revascularisation. We prefer more acute screening than aggressive methods for patients with coronary problem who had surgery for A.A.A. and specially when they are less than 70 at surgical time.