Contemporary results for open repair of suprarenal and type IV thoracoabdominal aortic aneurysms.

BACKGROUND: Endovascular and hybrid procedures are not yet widely established in the management of type IV thoracoabdominal aortic aneurysm (TAAA). Open surgery remains the treatment of choice until the long-term outcomes of these novel techniques are known. METHODS: This study reviewed a 10-year experience of open repair of non-ruptured type IV and suprarenal TAAA. All procedures were performed using a totally abdominal approach with supracoeliac clamping of the aorta. RESULTS: There were 53 patients (31 men; 58 per cent) of median age 69 (range 54-82) years. Forty-four patients had a type IV TAAA and nine a suprarenal aneurysm. Three patients (6 per cent) died within 30 days and the 12-month mortality rate for patients followed for at least 1 year was 6 per cent (three of 49). Ten patients (19 per cent) had a cardiac complication, 20 (38 percent) a respiratory complication, three (6 percent) required early reoperation, and one patient (2 percent) developed permanent paraplegia. There was one late death resulting from an aneurysm-related complication. CONCLUSION: Open repair of suprarenal aneurysms and type IV TAAA may be undertaken using a totally abdominal approach with acceptable levels of morbidity and mortality.

Significance of the early postoperative duplex result in infrainguinal vein bypass surveillance.

BACKGROUND: Duplex surveillance of infrainguinal vein grafts may not be efficient. METHODS: Consecutive patients who had received infrainguinal vein grafts were enrolled in a duplex surveillance program. A first scan at 6 weeks after surgery categorized grafts into four groups: (a) low risk grafts, (b) mild flow disturbance, (c) intermediate stenosis and (d) critical stenosis. Disease progression was assessed over time. RESULTS: Of 364 grafts followed-up for a median of 23 months, 236 (65%) had no flow abnormality at 6-weeks, and had a 40-month cumulative patency rate of 82%. The remaining 128 (35%) grafts had a flow disturbance. Of 29 critical stenoses, 15 were repaired, 11 occluded and three did not change. Of 57 intermediate lesions, 32 progressed to critical, nine occluded, two were repaired and 14 did not change or improved. Of 42 mild lesions, 16 progressed to a higher grade, four occluded and 22 did not change or improved. There was no significant difference in graft patency between grafts with repaired stenoses and those without stenoses, but grafts with untreated critical stenoses were associated with lower patency (p<0.001). CONCLUSIONS: A duplex scan 6 weeks after operation can predict those patients who require continuing duplex surveillance.

Influence of sex on expansion rate of abdominal aortic aneurysms.

BACKGROUND: The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA. METHODS: Between January 1985 and August 2005 all patients who were referred to the Royal Infirmary of Edinburgh with an AAA who were not considered for early aneurysm repair were assessed by serial abdominal ultrasonography. Maximum anteroposterior and transverse diameters of the AAAs were measured. RESULTS: A total of 1255 patients (824 men and 431 women) were followed up for a median of 30 (range 6-185) months. A median of six examinations (range 2-37) was performed for each patient. Median diameter on initial examination was 41 (range 25-83) mm. Median growth rate overall was 2.79 (range - 4.80-37.02) mm per year. Median growth rate of AAA was significantly greater in women than men (3.67 (range - 1.2-37.02) versus 2.03 (range - 4.80-21.00) mm per year; P < 0.01). Weighted linear regression analysis revealed that large initial anteroposterior AAA diameter and female sex were significant predictors of faster aneurysm growth rate (P < 0.001 and P = 0.006 respectively). CONCLUSION: The growth rate of AAA was significantly greater in women than in men. This may have implications for the frequency of follow-up and timing of repair of AAA in women.

Regional versus general anaesthesia for carotid endarterectomy: impact of change in practice.

BACKGROUND: Local anaesthesia (LA) for carotid endarterectomy (CEA) may offer advantages over general anaesthesia (GA). AIM: Our aim was to compare outcome from CEA before and after changing our anaesthetic technique from GA to LA. METHODS: Sequential patients who underwent CEA between January 1997 and December 2001 were identified from a prospectively collected database. GA was used during the first two years of this period and LA was used exclusively over the last three years. Differences in the incidence of intraoperative shunting, perioperative stroke and transient ischaemic attack (TIA), cranial nerve injury, neck haematoma, perioperative death and duration of hospital stay were assessed. RESULTS: Three hundred and seventy one CEAs were carried out in 363 patients, 179 under GA and 192 under LA. Indications were TIAs (140), stroke with recovery (134), amaurosis fugax (85) and asymptomatic high-grade stenosis (12). Intraoperative shunting was used in 66 (37%) GA operations and 36 (18.8%) LA operations (p<0.01). There were nine strokes and four transient neurological events; 10 (5.5%) patients developed such problems with GA and three (1.6%) with LA (p<0.05). There were four deaths, three (1.7%) after GA and one (0.5%) after LA (p=NS). Duration of hospital stay was less in the LA group at a median (range) of three days (2-10) compared with 4.5 (3-14) days in the GA group (p<0.001). CONCLUSION: Employing LA rather than GA for CEA has been associated with a reduction in intraoperative shunting and perioperative stroke, and the duration of hospital stay. LA appears to offer clinical and possible cost advantages over GA.

Aortic trauma in Scotland--a population based study.

OBJECTIVES: This population-based study aims to determine the incidence, mechanisms and outcomes of aortic trauma in patients from Scotland between 1992-2002. METHODS: Patients with aortic trauma were identified from the Scottish Trauma Audit Group database. Demographics, mechanism of injury, initial management and outcome were analysed. RESULTS: 165 (0.3%) patients suffered trauma to the thoracic or abdominal aorta. Of these, 130 (79%) patients had an injury of the thoracic aorta, 33 (20%) an injury of the abdominal aorta and two (1%) had injuries of both. There were 123 (75%) men and 42 (25%) women with a median (range) age of 36 (14-90) years. Blunt trauma was responsible for 121 (73%) injuries, of which road traffic accidents were the most common mechanism. A further 44 (27%) aortic injuries were due to penetrating trauma, of which assault was the most common cause. The median (range) Injury Severity Score was 43 (16-75). Ninety (55%) patients died in the emergency department while 59 (32%) underwent attempted operative repair. The operative mortality was 35 (59%) of 59 patients and overall mortality 141 (86%) of 165 patients. CONCLUSIONS: The incidence of aortic trauma presenting to Scottish hospitals is low. The majority of patients do not survive to surgical repair and operative and overall mortality remain prohibitive.

Cardiac troponin I predicts outcome after ruptured abdominal aortic aneurysm repair.

BACKGROUND: Cardiac troponin I (cTnI) is a highly sensitive and specific marker for myocardial injury that predicts mortality in patients with acute coronary syndromes. This study examined the relationship between perioperative cTnI levels and clinical outcome in patients with ruptured abdominal aortic aneurysm (AAA). METHODS: Consecutive patients who underwent operative repair of a ruptured AAA over a 22-month interval and survived for more than 24 h were entered into a prospective observational cohort study. Levels of cTnI were measured immediately before, and at 24 and 48 h after surgery, and related to clinical outcome. RESULTS: Of 62 patients who underwent attempted operative repair of ruptured AAA, 50 (81 per cent) survived for more than 24 h and were included in this study. Twenty-three (46 per cent) of the 50 had a detectable cTnI level at one or more time points during the first 48 h. Of these, 11 patients had clinical or electrocardiographic evidence of an acute cardiac event and 12 did not; five patients in each of these two groups died. Of 27 patients with no increase in cTnI in the first 48 h, only three died (P = 0.031 and P = 0.043 respectively, relative to the groups with detectable cTnI). CONCLUSION: Approximately half of patients who survived repair of ruptured AAA for more than 24 h sustained a detectable myocardial injury within the first 48 h. A perioperative increase in the level of cTnI, with or without clinically apparent cardiac dysfunction, was associated with postoperative death.

Validity of the Glasgow Aneurysm Score and the Hardman Index in predicting outcome after ruptured abdominal aortic aneurysm repair.

BACKGROUND: The Glasgow Aneurysm Score and the Hardman Index have been recommended as predictors of outcome after repair of ruptured abdominal aortic aneurysm (AAA). This study aimed to assess their validities. METHODS: Patients admitted to a single unit with a ruptured AAA over a 2-year interval (2000-2001) were identified from a prospectively compiled database. Hospital records of all patients undergoing attempted operative repair were reviewed. The Glasgow Aneurysm Score and the Hardman Index were calculated retrospectively and related to clinical outcome. RESULTS: One hundred patients were admitted with a ruptured AAA. Of these, 82 underwent attempted operative repair and were included in the study: 68 men and 14 women, of median age 73 (range 54-87) years. Thirty (37 per cent) patients died after the operation. The Glasgow Aneurysm Score was a poor predictor of postoperative mortality. The area under the Receiver-Operator Characteristic curve was 0.606 (P = 0.112, 95 per cent c.i. 0.483-0.729). Similarly, the Hardman Index failed to predict postoperative mortality accurately (P = 0.211, chi(2) for trend). Of nine patients in this series with three or more Hardman criteria, generally held to be fatal, six survived. CONCLUSION: Contrary to previous reports, The Glasgow Aneurysm Score and the Hardman Index were poor predictors of postoperative mortality after repair of a ruptured AAA in this study.

Does immediate operation for symptomatic non-ruptured abdominal aortic aneurysm compromise outcome?

Background. The optimum timing of surgery for acutely symptomatic abdominal aortic aneurysm (AAA) remains a clinical dilemma: should symptomatic aneurysm be operated on urgently for fear of impending rupture, or should there be a period of preoperative evaluation to optimise the patient's medical co-morbidity, with a consequent delay in surgery? Method. Ninety-five patients were diagnosed with acutely symptomatic AAA (back pain, abdominal pain or a tender aneurysmal aorta) between 1995 and 2001 and included in a retrospective case-cohort study. The in-hospital mortality rates for patients undergoing early surgery (within 24h of presentation) were compared to those of patients whose surgery had been delayed to allow further evaluation. Results. Of 95 patients with an acutely symptomatic AAA, 70 had surgery within 24h of admission. The remaining 25 underwent planned delayed surgery after a median of (range) three (2-17) days. The reasons for delay to AAA repair were primarily to allow further cardiorespiratory assessment and radiological imaging. In the early surgery group, there were six postoperative deaths (9%); in the group who were to have delayed surgery, there were three (12%) deaths (P=0.694). Conclusion. Early operation for acutely symptomatic AAA, in selected patients, is not associated with an excessive mortality rate compared to delayed operation.

Quality of life after repair of ruptured abdominal aortic aneurysm.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) continues to be associated with high operative mortality. Though survivors can expect to return to a normal life expectancy, their postoperative health related quality of life (HRQoL) remains uncertain. This review examines HRQoL following operative repair of ruptured AAA. METHODS: PreMedline, Medline and Embase databases were searched for clinical studies relating to quality of life following repair of ruptured AAA. Reference lists of relevant papers were also reviewed. RESULTS: Fourteen retrospective-observational studies of postoperative quality of life following repair of ruptured AAA were identified. Both validated and non-validated tools for generic HRQoL assessment were used. All but one study showed no significant difference in overall HRQoL following ruptured AAA repair when compared to both the normal age-adjusted population and patients undergoing elective repair of intact AAA. However, survivors of ruptured AAA did exhibit significant reductions in the isolated domains of physical function, social behaviour and general well-being. CONCLUSIONS: There are few studies of HRQoL following repair of ruptured AAA. These reports are retrospective, have small sample sizes and use generic instruments for HRQoL assessment. The findings suggest that survivors of ruptured AAA may attain a similar functional outcome to patients undergoing elective AAA repair and the age-matched healthy population. However, these results must be interpreted with caution and further prospective study is required.

Non-operative management of high-risk patients with abdominal aortic aneurysm.

OBJECTIVES: to determine the risk of rupture in patients with large non-operated abdominal aortic aneurysms (AAAs). METHODS: in 128 patients admitted over a 5-year period with an intact AAA, and who did not have a surgical repair were included, initial maximum antero-posterior AAA diameter was related to survival and cause of death. RESULTS: at the end of follow-up 27/52 (52%) patients with AAA <55 mm were alive compared to 17/62 (27%) patients with AAA > or =55 mm. Six (12%) in the former and 18 (29%) in the latter group had an AAA-related death. However, non-AAA-related death was commoner in both groups. CONCLUSION: these findings support a role for non-operative management in high-risk patients with large AAAs.

Antiplatelet and anticoagulant therapy to prevent bypass graft thrombosis in patients with lower extremity arterial occlusive disease.

The incidence of graft failure for above knee femoropopliteal grafts is described by the European Consensus Document on Critical Limb Ischaemia. It occurs in approximately 15% of patients when vein is used for the grafting procedure and in 20% of patients when PTFA (polytetrafluoroethylene) or other prosthetic material is used. Femorodistal grafts have a much poorer outcome with 45% and 75% failure rates for vein and prosthetic grafts, respectively. Prevention of primary graft failure and thus the need for surgical reintervention is of major clinical and economic importance. Early failure, occurring within one month of operation, is usually due to technical error such as poor patient selection or operative technique. Approximately 10% of graft failures will fall into this time period. When grafts thrombose after two years, progression of native atherosclerosis either proximally or distally is the usual cause. This accounts for 2-3% of all graft failures each year. The most common time for grafts to fail is between one month and two years (80% of all failures) and this is the same period in which graft stenoses are now known to develop. There are few evidence-based recommendations for the use of pharmacological agents in maintaining graft patency following peripheral vascular surgery. This article reviews the evidence for or against the use of anticoagulant and antiplatelet therapy for the prevention of bypass graft thrombosis in patients with peripheral arterial occlusive disease.

Training in infrainguinal bypass surgery for severe leg ischaemia.

BACKGROUND: Recent changes in surgical training in the UK mean that operative experience must be gained more efficiently. However, it is important to demonstrate that improved training opportunities are not associated with inferior patient outcomes. The aim was to examine changes in training in infrainguinal bypass surgery and to compare the outcomes of operations performed by consultants and trainees. METHODS: A prospectively gathered, computerized database of 1077 consecutive infrainguinal bypasses performed on 1003 patients for chronic severe leg ischaemia between 1 January 1983 and 31 December 1998 was analysed. RESULTS: Consultants performed 733 (68 per cent) infrainguinal bypasses to the following distal sites: 347 (47 per cent) above-knee popliteal artery, 257 (35 per cent) below-knee popliteal artery, 121 (17 per cent) to a crural artery and eight (1 per cent) other. Trainees performed 344 operations: 170 (49 per cent) were to the above-knee popliteal artery, 122 (35 per cent) to the below-knee popliteal artery, 48 (14 per cent) crural and four (1 per cent) other. The operative mortality rate was 27 (4 per cent) of 733 for consultants and 11 (3 per cent) of 344 for trainees (P > 0.05, chi2 test). There were no significant differences in patency or limb salvage at 36 months after operation between consultants and trainees, regardless of the site of distal anastomosis and the type of conduit used. CONCLUSION: With appropriate case selection and supervision, training in infrainguinal bypass grafting does not compromise early or long-term patient outcomes.