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18.12 Long-term results of abdominal aortic aneurysm repair
Z3rd World Congress of the ISCVS
18.9 Tubegrafts for Ruptured Abdominal Aortic Aneurysms and Long-term Follow-up of Untreated Iliac Aneurysms A./. WITKAMP, EL. MOLL and T.J. BAST, Nieuwegein, Netherlands Introduction: There is a tendency for tubegrafts in ruptured abdominal aorta aneurysms (RAAA) for patients in a critical condition to shorten the operative procedure and minimize the dissection. However, uncorrected iliac aneurysms may be threat for postoperative rupture. Objective: Report of a 3-16 year follow-up of patients in which aneurysms of the iliac arteries were left in situ after emergency surgery for a RAAA. Design: Retrospective study Patients: From 1980 to 1993 306 patients underwent emergency surgery for a RAAA. In 144 patients a bifurcationgraft was implanted, and in 162 a tubegraft. Of the latter group 30 patients had an iliac aneurysm, which was defined as a clear local dilatation of an iliac artery diagnosed during operation or on a postoperative i.v. DSA. Results: There was a significant shorter operating time and a better short-term survival in the tubegraft group. In 30 patients an iliac aneurysm was left behind. In this group, one patient died within the first 30 postoperative days of a ruptured iliac aneurysm despite reoperation. Three patients died unrelated to iliac pathology. The other patients had a medium follow-up of 5 years. During this time for individual reasons a tubegraft was converted electively into a bifurcationgraft in two patients (2.1 cm and 2.6cm) at 1 and 6 years. Conclusion: Patients in a critical condition due to a RAAA, benefit from shortening the operating time and minimization of dissection. In such a situation iliac aneurysms might be left inside and eventually excluded for an individual indication during follow-up.
18.10 Venous Abnormalities and Abdominal Aortic Surgery: A Challenging Management G.E GZUFFRZDA, Z’.L. GZORGETTI, S. TRZMARCHZ, V. TOLVA, E CUSMAZ and R. SCORZA. Milan, Italy Unsuspected venous abnormalities can represent a formidable challenge during abdominal aortic surgery, above all in an emergency. The incidence of the double inferior vena cava is approximately 3%, the left-side inferior vena cava 0.2-0.5%, the retro-aortic left renal vena 4%. The authors refer to five cases of congenital venous anomalies, two left-side inferior vena cava and three retro-aortic left renal vein affecting three patients with abdominal aortic aneurysms and two patients with aorto-bifemoral bypass graft for aorto-iliac occlusive disease in a period of 3 years (1993-1995) among 500 patients operated on for abdominal aortic surgery. All five cases were treated in election. The postoperative course was uneventful in all the patients. Because of the fact that in three cases we occasionally detected the anomalies intraoperatively, we analyzed these particular situations in order to evaluate the diagnostic approach and the surgical implications.
94
18.11 High Prevalence of Abdominal Aortic Aneurysm in a Primary-Care Screening Programme A.P.M. BOLL, A.L.M. VERBEEK and J.A. VAN DER VLZET, Nijimegen, The Netherlands Introduction: The mortality associated with ruptured abdominal aortic aneurysm (AAA) remains high. Detection of AAA by ultrasonography is simple and accurate and effective treatment is available. A public screening programme is a method for secondary prevention of AAA related mortality. To determine the feasibility of screening for AAA a study was performed in a primary-care setting with optimal accessibility. Patients and methods: In an area with a mixed rural and industrialized population of 60, 343 inhabitants, all 23 general practioners (GPs) participated. All men of the age of 60-80 years in a condition for possible referral for surgery were selected by their GP for a single postal invitation. Ultrasonography of the aorta of all responding men was performed in or close to the GPs office. Diagnosis of AAA was established for aorticdiameter of 2 30 mm. Management of all cases was taken care of by the GP. Referral for surgery was advised for diameter 2 50 mm. Results: On 2925 invitations 2418 men responded, resulting in an attendance rate of 82.7%. A total of 2415 aortas could be measured. One hundred and ninety-six aortic aneurysms were diagnosed corresponding with a prevalence of 8.1%. In 34 men (17%) the AAA was over 50mm. Conclusion: Ultrasonographic screening for AAA in a primary-care setting is feasible, resulting in a good attendance rate. High prevalence of AAA was recorded. The impact on the population well being as well as the cost-effectiveness has to be evaluated.
18.12 Long-Term Results of Abdominal Aortic Aneurysm Repair M. SAKUMA, S. SASAKZ, N. SHZZYA, y. MATSUZ and K. YASUDA, Sapporo, Japan The purpose of this paper was to show long-term results of abdominal aortic aneurysm repair and to provide some aspects of surgical strategy to improve long-term survival after operation. Methods: From 1980 to 1996,312 cases of abdominal aortic aneurysms, including 38 ruptured cases, were treated in our department: 248 males and 64 females, age ranging from 42 to 88 years averaging 68.8 years. Associated complications were hypertension (SO%), coronary artery disease (28%), arteriosclerosis obliterans (18%), cerebrovascular disease (12%) and respiratory disease (10%). Preoperative evaluation was performed by CT scan, MRI and digital subtraction angiography. Since 1991, coronary artery screening using dypiridamole thalium scintigram was performed routinely in elective cases and coronary intervention underwent in 30 cases. Results: Operative mortality was 5% of elective surgery, 33% of ruptured cases. The causes of hospital death in elective surgery were myocardial infarction in two cases, respiratory failure in one, renal failure in two. Long-term complications were the following: coronary artery disease in 27 cases, thoracic aortic aneurysm or aortic dissection in 18 cases,
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
Aneurysms I ananastomotic aneurysm in eight cases including three aortoenteric fistulas. Surgical treatment was performed in 17 cases. Cumulative survival rate at 5 years, 10 years and 15 years was 74%, 51% and 17%, respectively, and the causes of late death were coronary artery disease (3O%), pneumonia (22%), cancer (20%), cerebral infarction (5%) and rupture of anastomotic aneurysm (9%). Conclusion: To improve long-term survival after aneurysm operation, coronary artery screening is important, and careful follow-up and repeated examination for coronary artery, anastomotic aneurysm and associated aneurysms are essential to prevent late cardiovascular complications.
18.13 Renovascular Imaging With Gadolinium Enhanced Magnetic Resonance Angiography (GE MRA) WD. TURNZPSEED, TM. GRIST, J.R. HOCH and C.U? ACHER, Madison, Wisconsin, USA Determining the cause for renal failure or systemic hypertension and the need for pre-and postoperative evaluation of patients with renal artery reconstructions often necessitates contrast arteriography or spiral CT scanning. These tests use large volumes of ionic contrast and increase risks for morbid complications. This study evaluates the use of GE MRA for renal artery imaging and demonstrates its utility in management of patients with suspected renal artery disease (RAD). Imaging efficacy was determined by prospectively using GE MRA to evaluate renal artery status in 28 patients requiring conventional angio (XRA) for aorto-iliac occlusive disease. A l.ST GE Signa scanner with a torso phased array coil was used. Gadolinium (a non-nephrotoxic contrast agent) was given intravenously (0.3 mmol KG) at 1.4-2.0 ml/set. Results: XRA documented > 50% stenosis in 22 of 56 arteries. GE MRA confirmed 19 lesions (86% accuracy). Three false negatives occurred (small renals). Twenty-eight additional patients with suspected RAD were studied with GE MRA. Group I (11 patients) treat. < 2.0 with HBP); Group II (nine patients treat. > 2.0 with HBP; Group III (five patients) treat. > 2.0 no HBP); Group IV (three patients) postoperative renal transplant or bypass. In Group I, GE MRA showed significant RAD in seven patients resulting in four bypasses and one PTA. In Group II; GE MRA showed significant RAD in seven patients resulting in four bypasses. There was one false positive. In Group III, GE MRA showed no RAD in four and occlusion in one. In Group IV, all reconstructions were widely patent. Surgical exploration or XRA confirmed GE MRA findings in treated patients. Conclusions: GE MRA appears useful for the diagnosis and management of RAD.
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
18.14 A Single Operation for Abdominal Awtk Aneurysm Repair amidCoronary Artery Bypass DecreasesLength of Stay and Costs R.C. KZNG, P.E. PARRZNO,
J.L. HURST,
KS. SHOCKEE: C.E. TRZBBLE, and JL. KRON, Cbarichesville, Virginia, USA Controversy still exists concerning the treatment of patients with an abdominal aortic aneurysm (AAA) and clinically significant coronary artery disease (CAD). Those with surgically correctable CAD traditionally have undergone coronary artery bypass grafting (CABG) 6 weeks prior to AAA repair. We have previously shown that a delay of greater than 2 weeks following coronary artery bypass grafting (CABG) results in an increased incidence of aneurysm rupture. Our most recent experience has led us to recommend a single procedure for cardiac operation with AAA repair during the rewarming phase (CABG/AAA). Eleven patients to date have undergone a combined procedure at our institution. Ten patients underwent CABG and AAA repair, while one patient received an aortic valve replacement and aneurysm repair. No operative mortality has occurred. One patient’s hospital stay was extended due to gastric ulcer perforation on postoperative day 6 resulting in enterobacteric sepsis and renal failure necessitating long-term dialysis. There were no episodes of neurological deficit or cardiac complication following these procedures. We performed a retrospective analysis comparing the postoperative length of stay (LOS) and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. The results of the analysis are summarized below. CAAGIAAA LOS (days) Total charge Total cost Ikzct cost Indirect cost ‘P
< 0.05
7.44 $39,263 $22,941 $14,381 $8,991 CABGIAAA
* 2 t = z
AAA 0.88’ 2,957” 1,933” 1,855’ 1,176’ versus
CA H L
7.70 $25,974 $17,238 $10,216 57,021 AAA
t * -t t f
1.24 2,IOO 1,362 820 SS2
6.40 $28,756 $16,938 $10,03S $6,802
c4AA + CAABG * * 2 5 t
IO.% 2,283 2,161 1,054 1.12X
14.10 $54,730 $34,076 $20,251 $11,RZ3
* r * * s
1.4i 3,102 2.554 1.315 IJSS
+ CABG
A single operation for coronary revascularization and AAA repair has proven to be safe and effective. Simultaneous operation avoids prolonged delay in AAA repair as well as the risks of repeat anesthesia in a high risk patient popufation. Simultaneous CABG and AAA repair significantly decreases postoperative length of stay and hospital costs without increasing operative morbidity or mortality.
95
18.9 Tubegrafts for Ruptured Abdominal Aortic Aneurysms and Long-term Follow-up of Untreated Iliac Aneurysms A./. WITKAMP, EL. MOLL and T.J. BAST, Nieuwegein, Netherlands Introduction: There is a tendency for tubegrafts in ruptured abdominal aorta aneurysms (RAAA) for patients in a critical condition to shorten the operative procedure and minimize the dissection. However, uncorrected iliac aneurysms may be threat for postoperative rupture. Objective: Report of a 3-16 year follow-up of patients in which aneurysms of the iliac arteries were left in situ after emergency surgery for a RAAA. Design: Retrospective study Patients: From 1980 to 1993 306 patients underwent emergency surgery for a RAAA. In 144 patients a bifurcationgraft was implanted, and in 162 a tubegraft. Of the latter group 30 patients had an iliac aneurysm, which was defined as a clear local dilatation of an iliac artery diagnosed during operation or on a postoperative i.v. DSA. Results: There was a significant shorter operating time and a better short-term survival in the tubegraft group. In 30 patients an iliac aneurysm was left behind. In this group, one patient died within the first 30 postoperative days of a ruptured iliac aneurysm despite reoperation. Three patients died unrelated to iliac pathology. The other patients had a medium follow-up of 5 years. During this time for individual reasons a tubegraft was converted electively into a bifurcationgraft in two patients (2.1 cm and 2.6cm) at 1 and 6 years. Conclusion: Patients in a critical condition due to a RAAA, benefit from shortening the operating time and minimization of dissection. In such a situation iliac aneurysms might be left inside and eventually excluded for an individual indication during follow-up.
18.10 Venous Abnormalities and Abdominal Aortic Surgery: A Challenging Management G.E GZUFFRZDA, Z’.L. GZORGETTI, S. TRZMARCHZ, V. TOLVA, E CUSMAZ and R. SCORZA. Milan, Italy Unsuspected venous abnormalities can represent a formidable challenge during abdominal aortic surgery, above all in an emergency. The incidence of the double inferior vena cava is approximately 3%, the left-side inferior vena cava 0.2-0.5%, the retro-aortic left renal vena 4%. The authors refer to five cases of congenital venous anomalies, two left-side inferior vena cava and three retro-aortic left renal vein affecting three patients with abdominal aortic aneurysms and two patients with aorto-bifemoral bypass graft for aorto-iliac occlusive disease in a period of 3 years (1993-1995) among 500 patients operated on for abdominal aortic surgery. All five cases were treated in election. The postoperative course was uneventful in all the patients. Because of the fact that in three cases we occasionally detected the anomalies intraoperatively, we analyzed these particular situations in order to evaluate the diagnostic approach and the surgical implications.
94
18.11 High Prevalence of Abdominal Aortic Aneurysm in a Primary-Care Screening Programme A.P.M. BOLL, A.L.M. VERBEEK and J.A. VAN DER VLZET, Nijimegen, The Netherlands Introduction: The mortality associated with ruptured abdominal aortic aneurysm (AAA) remains high. Detection of AAA by ultrasonography is simple and accurate and effective treatment is available. A public screening programme is a method for secondary prevention of AAA related mortality. To determine the feasibility of screening for AAA a study was performed in a primary-care setting with optimal accessibility. Patients and methods: In an area with a mixed rural and industrialized population of 60, 343 inhabitants, all 23 general practioners (GPs) participated. All men of the age of 60-80 years in a condition for possible referral for surgery were selected by their GP for a single postal invitation. Ultrasonography of the aorta of all responding men was performed in or close to the GPs office. Diagnosis of AAA was established for aorticdiameter of 2 30 mm. Management of all cases was taken care of by the GP. Referral for surgery was advised for diameter 2 50 mm. Results: On 2925 invitations 2418 men responded, resulting in an attendance rate of 82.7%. A total of 2415 aortas could be measured. One hundred and ninety-six aortic aneurysms were diagnosed corresponding with a prevalence of 8.1%. In 34 men (17%) the AAA was over 50mm. Conclusion: Ultrasonographic screening for AAA in a primary-care setting is feasible, resulting in a good attendance rate. High prevalence of AAA was recorded. The impact on the population well being as well as the cost-effectiveness has to be evaluated.
18.12 Long-Term Results of Abdominal Aortic Aneurysm Repair M. SAKUMA, S. SASAKZ, N. SHZZYA, y. MATSUZ and K. YASUDA, Sapporo, Japan The purpose of this paper was to show long-term results of abdominal aortic aneurysm repair and to provide some aspects of surgical strategy to improve long-term survival after operation. Methods: From 1980 to 1996,312 cases of abdominal aortic aneurysms, including 38 ruptured cases, were treated in our department: 248 males and 64 females, age ranging from 42 to 88 years averaging 68.8 years. Associated complications were hypertension (SO%), coronary artery disease (28%), arteriosclerosis obliterans (18%), cerebrovascular disease (12%) and respiratory disease (10%). Preoperative evaluation was performed by CT scan, MRI and digital subtraction angiography. Since 1991, coronary artery screening using dypiridamole thalium scintigram was performed routinely in elective cases and coronary intervention underwent in 30 cases. Results: Operative mortality was 5% of elective surgery, 33% of ruptured cases. The causes of hospital death in elective surgery were myocardial infarction in two cases, respiratory failure in one, renal failure in two. Long-term complications were the following: coronary artery disease in 27 cases, thoracic aortic aneurysm or aortic dissection in 18 cases,
CARDIOVASCULAR SURGERY
SEPTEMBER 1997
Aneurysms I ananastomotic aneurysm in eight cases including three aortoenteric fistulas. Surgical treatment was performed in 17 cases. Cumulative survival rate at 5 years, 10 years and 15 years was 74%, 51% and 17%, respectively, and the causes of late death were coronary artery disease (3O%), pneumonia (22%), cancer (20%), cerebral infarction (5%) and rupture of anastomotic aneurysm (9%). Conclusion: To improve long-term survival after aneurysm operation, coronary artery screening is important, and careful follow-up and repeated examination for coronary artery, anastomotic aneurysm and associated aneurysms are essential to prevent late cardiovascular complications.
18.13 Renovascular Imaging With Gadolinium Enhanced Magnetic Resonance Angiography (GE MRA) WD. TURNZPSEED, TM. GRIST, J.R. HOCH and C.U? ACHER, Madison, Wisconsin, USA Determining the cause for renal failure or systemic hypertension and the need for pre-and postoperative evaluation of patients with renal artery reconstructions often necessitates contrast arteriography or spiral CT scanning. These tests use large volumes of ionic contrast and increase risks for morbid complications. This study evaluates the use of GE MRA for renal artery imaging and demonstrates its utility in management of patients with suspected renal artery disease (RAD). Imaging efficacy was determined by prospectively using GE MRA to evaluate renal artery status in 28 patients requiring conventional angio (XRA) for aorto-iliac occlusive disease. A l.ST GE Signa scanner with a torso phased array coil was used. Gadolinium (a non-nephrotoxic contrast agent) was given intravenously (0.3 mmol KG) at 1.4-2.0 ml/set. Results: XRA documented > 50% stenosis in 22 of 56 arteries. GE MRA confirmed 19 lesions (86% accuracy). Three false negatives occurred (small renals). Twenty-eight additional patients with suspected RAD were studied with GE MRA. Group I (11 patients) treat. < 2.0 with HBP); Group II (nine patients treat. > 2.0 with HBP; Group III (five patients) treat. > 2.0 no HBP); Group IV (three patients) postoperative renal transplant or bypass. In Group I, GE MRA showed significant RAD in seven patients resulting in four bypasses and one PTA. In Group II; GE MRA showed significant RAD in seven patients resulting in four bypasses. There was one false positive. In Group III, GE MRA showed no RAD in four and occlusion in one. In Group IV, all reconstructions were widely patent. Surgical exploration or XRA confirmed GE MRA findings in treated patients. Conclusions: GE MRA appears useful for the diagnosis and management of RAD.
CARDIOVASCULAR
SURGERY
SEPTEMBER
1997
18.14 A Single Operation for Abdominal Awtk Aneurysm Repair amidCoronary Artery Bypass DecreasesLength of Stay and Costs R.C. KZNG, P.E. PARRZNO,
J.L. HURST,
KS. SHOCKEE: C.E. TRZBBLE, and JL. KRON, Cbarichesville, Virginia, USA Controversy still exists concerning the treatment of patients with an abdominal aortic aneurysm (AAA) and clinically significant coronary artery disease (CAD). Those with surgically correctable CAD traditionally have undergone coronary artery bypass grafting (CABG) 6 weeks prior to AAA repair. We have previously shown that a delay of greater than 2 weeks following coronary artery bypass grafting (CABG) results in an increased incidence of aneurysm rupture. Our most recent experience has led us to recommend a single procedure for cardiac operation with AAA repair during the rewarming phase (CABG/AAA). Eleven patients to date have undergone a combined procedure at our institution. Ten patients underwent CABG and AAA repair, while one patient received an aortic valve replacement and aneurysm repair. No operative mortality has occurred. One patient’s hospital stay was extended due to gastric ulcer perforation on postoperative day 6 resulting in enterobacteric sepsis and renal failure necessitating long-term dialysis. There were no episodes of neurological deficit or cardiac complication following these procedures. We performed a retrospective analysis comparing the postoperative length of stay (LOS) and hospital costs for this single procedure to a combined cohort of 20 randomly selected patients who either received AAA repair (n = 10) or standard CABG (n = 10) during the same time period. The results of the analysis are summarized below. CAAGIAAA LOS (days) Total charge Total cost Ikzct cost Indirect cost ‘P
< 0.05
7.44 $39,263 $22,941 $14,381 $8,991 CABGIAAA
* 2 t = z
AAA 0.88’ 2,957” 1,933” 1,855’ 1,176’ versus
CA H L
7.70 $25,974 $17,238 $10,216 57,021 AAA
t * -t t f
1.24 2,IOO 1,362 820 SS2
6.40 $28,756 $16,938 $10,03S $6,802
c4AA + CAABG * * 2 5 t
IO.% 2,283 2,161 1,054 1.12X
14.10 $54,730 $34,076 $20,251 $11,RZ3
* r * * s
1.4i 3,102 2.554 1.315 IJSS
+ CABG
A single operation for coronary revascularization and AAA repair has proven to be safe and effective. Simultaneous operation avoids prolonged delay in AAA repair as well as the risks of repeat anesthesia in a high risk patient popufation. Simultaneous CABG and AAA repair significantly decreases postoperative length of stay and hospital costs without increasing operative morbidity or mortality.
95