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Abdominal aortic aneurysm: Suitability for endovascular repair using MRI
AAA II 21.13
Aortic Aneurysm Disease: Incidence and Mortality in Our Community V. MARTIN-PAREDERO, A. ESPINOSA, V. SANCHEZ, C. BERGA, J. DIAZ andJ.R. G O M E Z andJ. VADILLO Tarragona, Spain This paper will be presented at the meeting. 21.14
Ruptured Abdominal Aneurysms S. LOTINA, L. DA VIDO VIC, D. KOSTIC, D. VELIMIROVIC, P. STOJANOV, P. DJUKIC, M. VRANES, P. PETROVIC, I. CINARA and N. ZIVANO VIC, Belgrade, Yugoslavia Two hundred and thirty patients with an abdominal aortic aneurysm were operated on between January 1st 1988 and October 31st 1994. Eighty-two patients experienced a rupture. Seventy-two patients were male (88%), and 10 were female (12%); the average age was 71.3 years (range 52-87 years). The first symptoms appeared within 6-36 h before operation (mean 22 h). On admission, 64 patients (78%) were in hemorrhagic shock. An emergency ultrasound examination was carried out in 55 (67%), a CT scan in 3 (4%), angiography in 5 (6%), physical examination only in 13 (17%) and abdominal exploration in another hospital in 6 (6%) cases. lntraperitoneal hemorrhage was found in 15 patients (17.5%), aortoduodenal fistula in 2 (2.19%) and an aortocaval fistula in 1 (1.1%) case. Partial aneurysma[ resection with tubular graft interposition was performed in 27 (32%), and a bifurcated graft was used in 43 (60%) cases. Axil[o bifemoral bypass (after aneurysmal resection and aneurysmal neck suture) was performed in 3 (3%) cases. An abdominal exploration was carried out in 9 (5%). Eleven (13%) patients died during the operation (3 before and 6 after cross-clamping, and 2 following the reconstruction). Thirty (36%) died in the postoperative period (1-45 days). The total mortality rate for ruptured aneurysms was 50% (41 patients), and 3.5% (5 patients) in 142 elective operations. The main causes of death in our patients included respiratory failure (8; 26.6%), myocardial infarction (5; 17%), renal failure (3; 10%), gastrointestinal hemorrhage (2; 6.6%), colon infarction (1; 3.3 %) and pulmonary immobilization ( 1 3.3 %). In our experience, variables such as: age exceeding 70 years, hemorrhagic shock on admission, symptoms present more then 24 h, intra-abdominal hemorrhage rupture, and suprarenal aortic cross clamping were significantly associated with a high mortality. In contrast, a history of pectoral angina, myocardial infarction, chronic renal failure and respiratory failure were not significantly associated with the mortality rate. 21.15
Ruptured Aortic Aneurysm: Prediction of Outcome I.E. LORENTZEN, T. V. SCHR OEDER and L.P. JENSEN, Copenhagen, Denmark The mortality rate following ruptured abdominal aortic aneurysm (AAA) continues to be high, in spite of improved resuscitation, surgical techniques and critical care manage-
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ment. Criteria are needed to identify those patients with a poor prognosis, so that treatment and resources may be directed to those with a better prognosis. In this study, based on a prospective vascular database registration, we reviewed a number of perioperative variables, outcome and length of intensive care unit (ICU) stay for 161 consecutive patients with ruptured AAA between 1989 and 1993. The perioperative 30-day mortality rate was 33%, which remained unchanged throughout the period of the study. Among the preoperative risk factors, only age exceeding 70 years had a significant impact on mortality (P < 0.02). Among the intraoperative variables, long-lasting surgery (> 3 h) and blood loss exceeding 8 I were significant (P < 0.005). Occurrence of postoperative organ dysfunction (cardiac, pulmonary or renal) increased the mortality rate significantly in each instance. However, an assessment of the most severe complication and risk factors combined failed to enable identification of patients in whom the survival rate was 0%. Twenty percent of patients with multiorgan failure survived for 6 months or more. These data justify an aggressive therapeutic approach, including ICU therapy following AAA surgery, in spite of failure of one or more organ systems. 21.16
Abdominal Aortic Aneurysm: Suitability for Endovascular Repair Using M R I A. FOX, M.S. WHITELEY, P. MURPHY, J.S. BUDD and M. HORROCKS, Bath, United Kingdom Computerized tomography (CT), angiography and ultrasound are currently being used to determine patient suitability for endovascular repair of abdominal aortic aneurysm. We have performed MR1 scans in 20 patients (14 men and 6 women, mean age 73 years) with infrarenal abdominal aortic aneurysms. Neck diameter and length, aneurysm length, distal aortic involvement and common iliac artery length and tortuosity were assessed according to current endovascular graft selection criteria. We have compared the results with those of duplex sonography and the gold standard intraoperative measurements. No significant difference (P > 0.05; Mann Whitney U Test) was demonstrated between the two imaging modalities and the gold standard during assessment of both the diameter and length of the infrarenal neck and aneurysm. Although ultrasound correctly determined aortic neck diameter, MRI was found to be more reliable in determining the relationship of the aneurysm neck to the renal arteries. Both renal arteries were visualized in all cases except two, one patient with agenesis of the right kidney and one with a renal artery occlusion and atrophic kidney. MRI accurately determined the distal aortic involvement and tortuosity, length and diameter of the common iliac arteries in all cases, using its direct multiplanar imaging facility. Bilateral internal iliac occlusions were identified in one patient and confirmed at operation. Only two patients met the criteria for endoluminal straight grafting. MRI is noninvasive, uses no ionizing radiation and is not affected by bowel gas. When available, it provides comprehensive details for patient selection and should be the imaging modality of choice when contemplating an endovascular repair.
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Aortic Aneurysm Disease: Incidence and Mortality in Our Community V. MARTIN-PAREDERO, A. ESPINOSA, V. SANCHEZ, C. BERGA, J. DIAZ andJ.R. G O M E Z andJ. VADILLO Tarragona, Spain This paper will be presented at the meeting. 21.14
Ruptured Abdominal Aneurysms S. LOTINA, L. DA VIDO VIC, D. KOSTIC, D. VELIMIROVIC, P. STOJANOV, P. DJUKIC, M. VRANES, P. PETROVIC, I. CINARA and N. ZIVANO VIC, Belgrade, Yugoslavia Two hundred and thirty patients with an abdominal aortic aneurysm were operated on between January 1st 1988 and October 31st 1994. Eighty-two patients experienced a rupture. Seventy-two patients were male (88%), and 10 were female (12%); the average age was 71.3 years (range 52-87 years). The first symptoms appeared within 6-36 h before operation (mean 22 h). On admission, 64 patients (78%) were in hemorrhagic shock. An emergency ultrasound examination was carried out in 55 (67%), a CT scan in 3 (4%), angiography in 5 (6%), physical examination only in 13 (17%) and abdominal exploration in another hospital in 6 (6%) cases. lntraperitoneal hemorrhage was found in 15 patients (17.5%), aortoduodenal fistula in 2 (2.19%) and an aortocaval fistula in 1 (1.1%) case. Partial aneurysma[ resection with tubular graft interposition was performed in 27 (32%), and a bifurcated graft was used in 43 (60%) cases. Axil[o bifemoral bypass (after aneurysmal resection and aneurysmal neck suture) was performed in 3 (3%) cases. An abdominal exploration was carried out in 9 (5%). Eleven (13%) patients died during the operation (3 before and 6 after cross-clamping, and 2 following the reconstruction). Thirty (36%) died in the postoperative period (1-45 days). The total mortality rate for ruptured aneurysms was 50% (41 patients), and 3.5% (5 patients) in 142 elective operations. The main causes of death in our patients included respiratory failure (8; 26.6%), myocardial infarction (5; 17%), renal failure (3; 10%), gastrointestinal hemorrhage (2; 6.6%), colon infarction (1; 3.3 %) and pulmonary immobilization ( 1 3.3 %). In our experience, variables such as: age exceeding 70 years, hemorrhagic shock on admission, symptoms present more then 24 h, intra-abdominal hemorrhage rupture, and suprarenal aortic cross clamping were significantly associated with a high mortality. In contrast, a history of pectoral angina, myocardial infarction, chronic renal failure and respiratory failure were not significantly associated with the mortality rate. 21.15
Ruptured Aortic Aneurysm: Prediction of Outcome I.E. LORENTZEN, T. V. SCHR OEDER and L.P. JENSEN, Copenhagen, Denmark The mortality rate following ruptured abdominal aortic aneurysm (AAA) continues to be high, in spite of improved resuscitation, surgical techniques and critical care manage-
CARDIOVASCULAR SURGERY SEPTEMBER 1995
ment. Criteria are needed to identify those patients with a poor prognosis, so that treatment and resources may be directed to those with a better prognosis. In this study, based on a prospective vascular database registration, we reviewed a number of perioperative variables, outcome and length of intensive care unit (ICU) stay for 161 consecutive patients with ruptured AAA between 1989 and 1993. The perioperative 30-day mortality rate was 33%, which remained unchanged throughout the period of the study. Among the preoperative risk factors, only age exceeding 70 years had a significant impact on mortality (P < 0.02). Among the intraoperative variables, long-lasting surgery (> 3 h) and blood loss exceeding 8 I were significant (P < 0.005). Occurrence of postoperative organ dysfunction (cardiac, pulmonary or renal) increased the mortality rate significantly in each instance. However, an assessment of the most severe complication and risk factors combined failed to enable identification of patients in whom the survival rate was 0%. Twenty percent of patients with multiorgan failure survived for 6 months or more. These data justify an aggressive therapeutic approach, including ICU therapy following AAA surgery, in spite of failure of one or more organ systems. 21.16
Abdominal Aortic Aneurysm: Suitability for Endovascular Repair Using M R I A. FOX, M.S. WHITELEY, P. MURPHY, J.S. BUDD and M. HORROCKS, Bath, United Kingdom Computerized tomography (CT), angiography and ultrasound are currently being used to determine patient suitability for endovascular repair of abdominal aortic aneurysm. We have performed MR1 scans in 20 patients (14 men and 6 women, mean age 73 years) with infrarenal abdominal aortic aneurysms. Neck diameter and length, aneurysm length, distal aortic involvement and common iliac artery length and tortuosity were assessed according to current endovascular graft selection criteria. We have compared the results with those of duplex sonography and the gold standard intraoperative measurements. No significant difference (P > 0.05; Mann Whitney U Test) was demonstrated between the two imaging modalities and the gold standard during assessment of both the diameter and length of the infrarenal neck and aneurysm. Although ultrasound correctly determined aortic neck diameter, MRI was found to be more reliable in determining the relationship of the aneurysm neck to the renal arteries. Both renal arteries were visualized in all cases except two, one patient with agenesis of the right kidney and one with a renal artery occlusion and atrophic kidney. MRI accurately determined the distal aortic involvement and tortuosity, length and diameter of the common iliac arteries in all cases, using its direct multiplanar imaging facility. Bilateral internal iliac occlusions were identified in one patient and confirmed at operation. Only two patients met the criteria for endoluminal straight grafting. MRI is noninvasive, uses no ionizing radiation and is not affected by bowel gas. When available, it provides comprehensive details for patient selection and should be the imaging modality of choice when contemplating an endovascular repair.
111