Abdominal aortic aneurysm--a plea for early elective excision (aneurysmectomy).

Though peripheral arterial disease is not as common as in the Western countries, abdominal aorit aneurysm (AAA) is the most frequent arterial problem in Malaysia. A prospective study was made of 100 consecutive patients who presented with AAA to the author between January 1986 to September 1988 (31 months' period). There were 88 males and 12 females. The age range was 47-90 years, mean = 68.7. All the major ethnic rates were equally affected. The sizes of the AAA were documented by ultrasonography and the diameters ranged from 3-10 centimetres, mean = 5.8. Aneurysmectomy was performed on 58 patients, 17 of which were emergencies for ruptured AAA. The operative mortality for elective surgery was 2 percent, but that for emergency surgery was 47 percent. Ten patients refused surgery and 28 were not offered an operation. The true incidence of AAA is likely to be much higher than the number of patients referred for treatment. Many cases are not diagnosed or referred for treatment. Many cases of ruptured AAA died at home or in peripheral hospitals without a diagnosis being made. It is estimated that an AAA is present in 17,000 persons in Peninsular Malaysia. The risk of elective surgery is significantly lower than that of emergency. The overall mortality for ruptured AAA is even higher at about 99 percent. Furthermore, AAA is a benign disease and after surgery the patients return to their normal life expectancy. It is recommended that patients with AAA of five centimetres or more should be advised surgery if premature death is to be avoided.

Noninvasive cardiac risk evaluation before elective abdominal aortic aneurysm surgery--clinical value of the Goldman index and echocardiography.

Cardiac complications comprise as much as 50% of perioperative vascular surgical morbidity and mortality. Using the Goldman multifactorial index for evaluating cardiac risk pre-operatively, 53 consecutive patients who underwent abdominal aortic aneurysm surgery were prospectively studied. Forty patients (75.5%) were also evaluated with echocardiography for assessment of left ventricular function. There were 14 (23.7%) peri-operative events, of which nine (17.0%) were acute myocardial infarctions--two of whom died (3.8%). The minor complications included three with hypovolaemic renal failure, and one each with acute respiratory failure and cerebrovascular accident. Patients with Goldman cardiac risk index (CRI) classes III and IV were associated with significantly higher risks of peri-operative complications (p less than 0.001), i.e. 77.8% and 66.7% respectively, compared with class II (22.7%) and class I (nil). Echocardiographic left ventricular shortening fraction (LVFS) of less than 28% helped identify high risk groups in all classes, although its positive predictive value was low (42.3%). Combining LVFS less than 28% with Goldman CRI categories II to IV improved the sensitivity to 91.7% and the positive predictive value to 61.1%. Careful pre-operative assessment using the simple Goldman index and echocardiography is helpful in identifying higher risk patients who would benefit from pre-operative stabilisation and more rigorous perioperative hemodynamic monitoring preferably including intensive care (ICU) management, so as to reduce cardiac complications.

Peripheral arterial embolism: a prospective study of 40 consecutive cases.

A prospective study was made of 40 consecutive patients who presented with peripheral arterial embolism to the Vascular Surgical Service in UKM. Atrial fibrillation was the most common source of the embolus. Twelve patients did not present until the affected limb(s) were in established gangrene. Thirty-two embolectomies were performed on 25 patients. Only 10 of these patients were discharged well with their limbs intact. Four patients required amputation because embolectomy did not restore viability of the limbs. Eleven patients died following embolectomy. The overall mortality for arterial embolism was 50%. Among the survival (n = 20), only 11 patients were discharged with their limbs intact. The cause of the poor result was related to the delay in definitive treatment and the poor general state of the patients. It was concluded that the prognosis for arterial embolism was very poor. This result needs to be improved and recommendations are made to achieve this.