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Alternatives in the treatment of abdominal aortic aneurysms
Alternatives in the Treatment of Abdominal Aortic Aneurysms
Ronald P. Savarese, MD, Philadelphia, Pennsylvania Joel C. Rosenfeld, MD, Philadelphia, Pennsylvania Dominic A. DeLaurentis, MD, Philadelphia, Pennsylvania
The overwhelming majority of patients with abdominal aortic aneurysms can be treated by aneurysmectomy with an acceptably low mortality rate. Since 1966 we have operated on 266 patients with a proven diagnosis of abdominal aortic aneurysm. Fifty-nine (22 percent) of these patients had a ruptured aneurysm at the time of initial presentation. Two hundred fifty-six patients (96 percent) underwent resection and grafting. This number includes both ruptured and elective cases. Ten patients (4 percent) had procedures other than classic resection. During this period at least 20 patients were denied surgery either because of advanced age, anatomy of the aneurysm or severe medical conditions precluding resection and graft replacement. Recent reports on the use of acute aneurysm thrombosis and axillobifemoral bypass to treat abdominal aortic aneurysms offer an alternative in poor-risk patients [I ,2]. The purpose of this report is to describe our modification of this method in the treatment of four patients who had contraindications to classic resection of abdominal aortic aneurysms. Case Reports Case I. A 68 year old white man was diagnosed as having carcinoma of the bladder in June 1979. It was also discovered at that time that he had a horseshoe kidney. He underwent a diverting ureterostomy and ileal loop and subsequently had radiation therapy to the bladder. Radiation enteritis developed with peritonitis but, he eventually recovered and was discharged from the hospital. He was rehospitalized in October 1979 and underwent total cystectomy. At operation a large abdominal aortic aneurysm was noted. He was referred to us for evaluation of the abdominal aortic aneurysm in April 1980 (Figure 1, left). We favored From the Department of Surgery, Pennsylvania Hospital and the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Ronald P. Savarese, MD, Pennsylvania Hospital, Eighth and Spruce Streets, Philadelphia, Pennsylvania 19107. Presented at the Ninth Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 8-12, 1981.
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an axillobifemoral bypass and thrombosis of the aneurysm rather than a classic aneurysm resection because of the previous irradiation, the ileostomy, and the presence of the horseshoe kidney. On April 22 we performed left axillobifemoral bypass and bilateral external iliac artery ligation. We intended to ligate each internal iliac artery as well, but because of the presence of the ileal loop, previous irradiation and the horseshoe kidney, this was not feasible. Eight days after the axillobifemoral bypass, several Gianturco-Wallace coils were inserted into each internal iliac artery through a catheter inserted into the right axillary artery. This did not successfully thrombose the aneurysm, so a series of coils were inserted at the neck of the aneurysm and then lined with Gelfoame. One of the coils broke loose and migrated up toward the renal arteries. This coil was successfully embedded into the wall of the aorta and held in place with the catheter. The aneurysm then thrombosed up to the proximal row of coils. For several days after this procedure the patient had fever and diarrhea. All blood cultures were negative, and sigmoidoscopy revealed no evidence of ischemic colitis. The diarrhea and fever eventually subsided. Translumbar arteriography, performed before discharge, confirmed that the aneurysm was completely thrombosed up to the proximal row of coils, but not up to the renal arteries (Figure 1, right). This suggested that small lumbar arteries might be keeping this segment open.
Case II. A 75 year old white man was in good health until March 1980, when he underwent surgery at another institution for perforated diverticulitis. Transverse colostomy and drainage of the perforation was performed. A large abdominal aortic aneurysm was discovered during the operation. The colostomy was closed in June 1980 and the patient was referred to Pennsylvania Hospital in July for treatment of his aneurysm. Translumbar arteriography on July 15 revealed an 11 cm aneurysm with very little intraluminal thrombosis. Barium enema demonstrated an area of diverticulitis in the sigmoid colon. Preoperatively, the plan was to perform exploratory laparotomy with intention to resect the aneurysm; if any infection or pus was encountered, resection of the aneurysm would be abandoned and colon resection undertaken. On July 21 the patient was operated on. While mobilizing the small bowel that was adherent to the sigmoid colon, a
The American Journal of Surgery
Abdominal Aortic Aneurysms
pericolonic abscess was entered. It was decided at that point to abandon aneurysm resection and proceed with sigmoid colectomy. The postoperative course was unremarkable. At the time of surgery the right internal iliac artery was ligated. The left internal iliac artery, which was more affected by atherosclerosis, was not ligated to preserve blood supply to the colonic anastomosis. On July 28 right axillobifemoral bypass was performed with ligation of each external iliac artery. It was thought that since the left internal iliac artery was atherosclerotic, it would spontaneously thrombose and, if not, it could be occluded by transcatheter embolization. The postoperative course was complicated by hypotension, pneumonia, confusion, diarrhea, weak distal pulses and decreased urinary output. With all of these complications, transcatheter embolization of the left internal iliac artery was repeatedly postponed. Early in the morning on August 3, the patient developed back pain and left-sided abdominal pain. Hemoglobin and urinary output were decreased. The white blood count increased to 30,000 cells/mm3. We suspected either a ruptured aneurysm, ischemic bowel or an intraabdominal abscess. The patient was again operated on and it was noted that the aneurysm had ruptured with a retroperitoneal hematoma. The infrarenal aorta was ligated with immediate thrombosis of the aneurysm. The postoperative course was uneventful. Since three of the four major outflow vessels were occluded, we may speculate that the lateral wall tension within the aneurysm was greatly increased, leading to rupt,ure. Case III. A 76 year old white man had 2 years earlier undergone total gastrectomy for carcinoma of the stomach. He later needed revision of the esophagojejunostomy because of severe reflux esophagitis. At present he is responding well to chemotherapy. When he underwent gastrectomy, the surgeon noted an abdominal aortic aneu-
Volume 142, August 1991
rysm. There was also extragastric tumor that could not be removed. Consequently, the patient was placed on chemotherapy consisting of 5fluorouracil and vincristine. A recent computed tomographic scan of the abdomen, performed to assess the amount of residual tumor, revealed that the abdominal aortic aneurysm had increased markedly in size to 7 cm. A thoracic aneurysm was also found (Figure 2, left). Because of intraabdominal malignancy and borderline pulmonary reserve, the patient was not considered a suitable candidate for resection of the abdominal aortic aneurysm. The patient then underwent right axillobifemoral bypass and ligation of each external iliac vessel on July 30, 1980. The internal iliac arteries were not ligated since they appeared markedly atherosclerotic on initial angiography and it was thought that they would thrombose spontaneously. After several days the aneurysm had not thrombosed, and it was decided to thrombose the internal iliac arteries by transcatheter embolization. This was performed through a left axillary approach on August 6. The flow through the aneurysm was slowed but not stopped completely. Further coils were positioned at the top of the aneurysm with resultant marked slowing of the flow through the aneurysm. Translumbar arteriography done several days later revealed that the aneurysm was completely thrombosed (Figure 2, right). Case IV. A 55 year old white man presented with a history of three episodes of upper gastrointestinal bleeding secondary to esophageal varices due to alcoholic cirrhosis. He also had a large abdominal aortic aneurysm. We thought that he probably could not withstand portal decompression and resection of the abdominal aortic aneurysm at the same time. Our initial plan was to perform axillobifemoral bypass first, and ligate the aneurysm at the time of splenorenal or portacaval shunt. Arteriography,
227
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et al
Figure 2. Case Ill. Left, preoperative arteriogram shows an abdominal aortlc aneurysm. Right, postoperative arteriogram shows complete thrombosis of the aneurysm. Note the coils in the iliac arteries, the aorfa and at the neck of the aneurysm.
however, demonstrated the possibility of a mycotic aneurysm (Figure 3, left). Therefore, it was decided to attempt a portosystemic shunt and resection of the aneurysm at the same time. On October 17,1980, the patient successfully underwent a Warren splenorenal shunt, after which the retroperitoneum over the aneurysm was opened and mobilization was attemnted. Because of marked Dortosvstemic toirential collateral vessels &in the retroperitoneum,
bleeding was encountered. We decided to terminate the procedure and deal with the aneurysm later. Therefore, both internal iliac arteries were ligated and the abdomen was closed. The patient did well postoperatively, and on October 22 he was returned to the operating room and right axillobifemoral bvpass and ligation of both external iliac arteries were performed. Even-with both internal and external iliac
Figure 3. Case IV. Preoperative arterlogram demonstrates a large saccular aneurysm. Right, postoperative arteriogram demonstrates marked slowing of flow through the aneurysm. 228
The American Journal of Surgery
Abdominal Aortic Aneurysms
arteries ligated, there was not complete thrombosis of the aneurysm and, on October 25, the patient underwent embolization of the aneurysm through a left transaxillary approach. Multiple coils and Gelfoam were embolized into the common iliac arteries, the distal aorta and the aneurysm. There was a great deal of turbulence within the aneurysm, making complete thrombosis difficult. Repeat arteriography on November 18, 1980, revealed markedly reduced flow through the aneurysm (Figure 3, right). Comments The ultimate fate of patients with large abdominal aortic aneurysms is well known. Sixty-eight percent of these patients will have a rupture of the aneurysm within 2 years if resection is not performed [3]. Dubost et al [4] initiated the era of surgery for abdominal aortic aneurysm when, in 1952, they reported a case of aneurysm resection and homograft replacement. At present, elective aneurysmectomy carries an acceptable mortality rate, variously reported between 4 and 10 percent. Our own mortality rate in elective cases is 7 percent over a period of 15 years. Serious cardiac, pulmonary and renal disease drastically increases the mortality rate of elective resections. In these patients, the risks of surgery must be weighed against the risk of rupture of the aneurysm. Patients with acute myocardial infarction, intractable congestive heart failure, chronic renal failure, associated terminal disease, crippling pulmonary insufficiency and intraabdominal infection represent absolute contraindications to aneurysm resection [5]. Blaisdell et al [6] were the first to describe the management of a poor-risk patient with an abdominal aortic aneurysm by axillobifemoral bypass and ligation of the neck of the aneurysm. Berguer et al [I] reported a technique of balloon occlusion of the common iliac arteries and thrombosis of the aneurysm by instillation of thrombin into the aneurysm through a transaxillary catheter. Leather et al [2] treated 15 poor-risk patients by acute thrombosis of the aneurysm induced by retroperitoneal ligation of the iliac arteries. Both of these groups restored flow to the legs through an axillobifemoral bypass, as described originally by Blaisdell et al [6]. Our four patients presented with either absolute or relative contraindications for resection of abdominal aortic aneurysm. Our technique is a modification of the aforementioned methods. Thrombosis in our patients was achieved by a combination of ligation of t.he external iliac arteries and transcatheter embolization of the internal iliac arteries and the aneurysm itself (Figure 4). Briefly, the procedure as described by Leather et al [2] involves a standard axillobifemoral bypass. The common iliac arteries are examined through a retroperitoneal approach. If they are not aneurysmal or calcified, they can be ligated. If they cannot be ligated, the internal and external iliac arteries are ligated. Our modification involves ligation of the external iliac arteries above the circumflex iliac and deep epigastric arteries through the Volume
142,
August
1981
Figure 4. Our modified technique involves ligation of the external iliac arteries above the circumflex iliac and deep eplgastrlc arteries through the femoral incision during axiltobtfemoral bypass. Thrombosis is induced by embolixatlon of coils into the internal iliac arteries and the aneurysm.
femoral incision during axillobifemoral bypass. Thrombosis of the aneurysm in our cases was induced by embolization of Gianturco-Wallace coils and Gelfoam into the internal iliac arteries and the aneurysm through a catheter inserted into the opposite axillary artery. Two potential complications of this procedure, mentioned by Berguer et al [I], have caused us concern. The first is the possibility of proximal extension of the thrombus to involve the renal and visceral arteries. The second is the possibility of rectosigmoid ischemia after acute interruption of flow in the internal iliac arteries and the inferior mesenteric artery. To date, we have not had these problems, although our first patient did have fever and diarrhea after thrombosis. Our experience with axillobifemoral bypass as a substitute for conventional aortofemoral reconstruction when the latter is contraindicated was reported earlier [7]. We believe it is an acceptable operation with good immediate results because it carries minimal surgical morbidity and mortality. Despite advances in surgical technique and postoperative care, the mortality rate for patients undergoing resection of ruptured abdominal aortic aneurysms remains approximately 50 percent. Our own mortality rate over a 15 year period with 59 such patients is 47 percent. Perhaps if poor-risk patients can be offered an alternative to classic resection, their already-limited life expectancy can be restored. 229
Savarese et al
Summary Most patients with abdominal aortic aneurysm can safely undergo aneurysmectomy. In poor-risk patients the mortality rate is greatly increased. A procedure which is a safe alternative for patients who might otherwise be denied an elective procedure is described. However, this technique for the management of abdominal aortic aneurysm is not a substitute for the classic surgical treatment. References 1. Berguer R, Schneider J, Wilner HI. Induced thrombosis of inoperable abdominal aortic aneurysm. Surgery 1978;83:4259.
230
2. Leather RP, Shah D, Goldman M, Rosenberg M, Karmody AM. Nonresective treatment of abdominal aortic aneurysms. Arch Surg 1979;114:1402-8. 3. Szilagyi EE, Smith RF, Elliott JE, et al. Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 1966;164:678-99. 4. Dubost C, Allory M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: re-establishment of the continuity by a preserved human graft with the result after five months. Arch Surg 1952;64:405. 5. Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysms. Surg Clin North Am 1974;54: 175-93. 6. Blaisdell FW, Hall AD, Thomas AN. Ligation treatment of an abdominal aortic aneurysm. Am J Surg 1965:109:560-4. 7. DeLaurentis DA, Sala LE, Russell E, McCombs PR. A twelve year experience with axillofemoral and femorofemoral bypass operations. Surg Gynecol Obstet 1978;147:881-7.
The American Journal of Surgery
Ronald P. Savarese, MD, Philadelphia, Pennsylvania Joel C. Rosenfeld, MD, Philadelphia, Pennsylvania Dominic A. DeLaurentis, MD, Philadelphia, Pennsylvania
The overwhelming majority of patients with abdominal aortic aneurysms can be treated by aneurysmectomy with an acceptably low mortality rate. Since 1966 we have operated on 266 patients with a proven diagnosis of abdominal aortic aneurysm. Fifty-nine (22 percent) of these patients had a ruptured aneurysm at the time of initial presentation. Two hundred fifty-six patients (96 percent) underwent resection and grafting. This number includes both ruptured and elective cases. Ten patients (4 percent) had procedures other than classic resection. During this period at least 20 patients were denied surgery either because of advanced age, anatomy of the aneurysm or severe medical conditions precluding resection and graft replacement. Recent reports on the use of acute aneurysm thrombosis and axillobifemoral bypass to treat abdominal aortic aneurysms offer an alternative in poor-risk patients [I ,2]. The purpose of this report is to describe our modification of this method in the treatment of four patients who had contraindications to classic resection of abdominal aortic aneurysms. Case Reports Case I. A 68 year old white man was diagnosed as having carcinoma of the bladder in June 1979. It was also discovered at that time that he had a horseshoe kidney. He underwent a diverting ureterostomy and ileal loop and subsequently had radiation therapy to the bladder. Radiation enteritis developed with peritonitis but, he eventually recovered and was discharged from the hospital. He was rehospitalized in October 1979 and underwent total cystectomy. At operation a large abdominal aortic aneurysm was noted. He was referred to us for evaluation of the abdominal aortic aneurysm in April 1980 (Figure 1, left). We favored From the Department of Surgery, Pennsylvania Hospital and the University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania. Requests for reprints should be addressed to Ronald P. Savarese, MD, Pennsylvania Hospital, Eighth and Spruce Streets, Philadelphia, Pennsylvania 19107. Presented at the Ninth Annual Meeting of the Society for Clinical Vascular Surgery, Palm Springs, California, April 8-12, 1981.
226
an axillobifemoral bypass and thrombosis of the aneurysm rather than a classic aneurysm resection because of the previous irradiation, the ileostomy, and the presence of the horseshoe kidney. On April 22 we performed left axillobifemoral bypass and bilateral external iliac artery ligation. We intended to ligate each internal iliac artery as well, but because of the presence of the ileal loop, previous irradiation and the horseshoe kidney, this was not feasible. Eight days after the axillobifemoral bypass, several Gianturco-Wallace coils were inserted into each internal iliac artery through a catheter inserted into the right axillary artery. This did not successfully thrombose the aneurysm, so a series of coils were inserted at the neck of the aneurysm and then lined with Gelfoame. One of the coils broke loose and migrated up toward the renal arteries. This coil was successfully embedded into the wall of the aorta and held in place with the catheter. The aneurysm then thrombosed up to the proximal row of coils. For several days after this procedure the patient had fever and diarrhea. All blood cultures were negative, and sigmoidoscopy revealed no evidence of ischemic colitis. The diarrhea and fever eventually subsided. Translumbar arteriography, performed before discharge, confirmed that the aneurysm was completely thrombosed up to the proximal row of coils, but not up to the renal arteries (Figure 1, right). This suggested that small lumbar arteries might be keeping this segment open.
Case II. A 75 year old white man was in good health until March 1980, when he underwent surgery at another institution for perforated diverticulitis. Transverse colostomy and drainage of the perforation was performed. A large abdominal aortic aneurysm was discovered during the operation. The colostomy was closed in June 1980 and the patient was referred to Pennsylvania Hospital in July for treatment of his aneurysm. Translumbar arteriography on July 15 revealed an 11 cm aneurysm with very little intraluminal thrombosis. Barium enema demonstrated an area of diverticulitis in the sigmoid colon. Preoperatively, the plan was to perform exploratory laparotomy with intention to resect the aneurysm; if any infection or pus was encountered, resection of the aneurysm would be abandoned and colon resection undertaken. On July 21 the patient was operated on. While mobilizing the small bowel that was adherent to the sigmoid colon, a
The American Journal of Surgery
Abdominal Aortic Aneurysms
pericolonic abscess was entered. It was decided at that point to abandon aneurysm resection and proceed with sigmoid colectomy. The postoperative course was unremarkable. At the time of surgery the right internal iliac artery was ligated. The left internal iliac artery, which was more affected by atherosclerosis, was not ligated to preserve blood supply to the colonic anastomosis. On July 28 right axillobifemoral bypass was performed with ligation of each external iliac artery. It was thought that since the left internal iliac artery was atherosclerotic, it would spontaneously thrombose and, if not, it could be occluded by transcatheter embolization. The postoperative course was complicated by hypotension, pneumonia, confusion, diarrhea, weak distal pulses and decreased urinary output. With all of these complications, transcatheter embolization of the left internal iliac artery was repeatedly postponed. Early in the morning on August 3, the patient developed back pain and left-sided abdominal pain. Hemoglobin and urinary output were decreased. The white blood count increased to 30,000 cells/mm3. We suspected either a ruptured aneurysm, ischemic bowel or an intraabdominal abscess. The patient was again operated on and it was noted that the aneurysm had ruptured with a retroperitoneal hematoma. The infrarenal aorta was ligated with immediate thrombosis of the aneurysm. The postoperative course was uneventful. Since three of the four major outflow vessels were occluded, we may speculate that the lateral wall tension within the aneurysm was greatly increased, leading to rupt,ure. Case III. A 76 year old white man had 2 years earlier undergone total gastrectomy for carcinoma of the stomach. He later needed revision of the esophagojejunostomy because of severe reflux esophagitis. At present he is responding well to chemotherapy. When he underwent gastrectomy, the surgeon noted an abdominal aortic aneu-
Volume 142, August 1991
rysm. There was also extragastric tumor that could not be removed. Consequently, the patient was placed on chemotherapy consisting of 5fluorouracil and vincristine. A recent computed tomographic scan of the abdomen, performed to assess the amount of residual tumor, revealed that the abdominal aortic aneurysm had increased markedly in size to 7 cm. A thoracic aneurysm was also found (Figure 2, left). Because of intraabdominal malignancy and borderline pulmonary reserve, the patient was not considered a suitable candidate for resection of the abdominal aortic aneurysm. The patient then underwent right axillobifemoral bypass and ligation of each external iliac vessel on July 30, 1980. The internal iliac arteries were not ligated since they appeared markedly atherosclerotic on initial angiography and it was thought that they would thrombose spontaneously. After several days the aneurysm had not thrombosed, and it was decided to thrombose the internal iliac arteries by transcatheter embolization. This was performed through a left axillary approach on August 6. The flow through the aneurysm was slowed but not stopped completely. Further coils were positioned at the top of the aneurysm with resultant marked slowing of the flow through the aneurysm. Translumbar arteriography done several days later revealed that the aneurysm was completely thrombosed (Figure 2, right). Case IV. A 55 year old white man presented with a history of three episodes of upper gastrointestinal bleeding secondary to esophageal varices due to alcoholic cirrhosis. He also had a large abdominal aortic aneurysm. We thought that he probably could not withstand portal decompression and resection of the abdominal aortic aneurysm at the same time. Our initial plan was to perform axillobifemoral bypass first, and ligate the aneurysm at the time of splenorenal or portacaval shunt. Arteriography,
227
Savarese
et al
Figure 2. Case Ill. Left, preoperative arteriogram shows an abdominal aortlc aneurysm. Right, postoperative arteriogram shows complete thrombosis of the aneurysm. Note the coils in the iliac arteries, the aorfa and at the neck of the aneurysm.
however, demonstrated the possibility of a mycotic aneurysm (Figure 3, left). Therefore, it was decided to attempt a portosystemic shunt and resection of the aneurysm at the same time. On October 17,1980, the patient successfully underwent a Warren splenorenal shunt, after which the retroperitoneum over the aneurysm was opened and mobilization was attemnted. Because of marked Dortosvstemic toirential collateral vessels &in the retroperitoneum,
bleeding was encountered. We decided to terminate the procedure and deal with the aneurysm later. Therefore, both internal iliac arteries were ligated and the abdomen was closed. The patient did well postoperatively, and on October 22 he was returned to the operating room and right axillobifemoral bvpass and ligation of both external iliac arteries were performed. Even-with both internal and external iliac
Figure 3. Case IV. Preoperative arterlogram demonstrates a large saccular aneurysm. Right, postoperative arteriogram demonstrates marked slowing of flow through the aneurysm. 228
The American Journal of Surgery
Abdominal Aortic Aneurysms
arteries ligated, there was not complete thrombosis of the aneurysm and, on October 25, the patient underwent embolization of the aneurysm through a left transaxillary approach. Multiple coils and Gelfoam were embolized into the common iliac arteries, the distal aorta and the aneurysm. There was a great deal of turbulence within the aneurysm, making complete thrombosis difficult. Repeat arteriography on November 18, 1980, revealed markedly reduced flow through the aneurysm (Figure 3, right). Comments The ultimate fate of patients with large abdominal aortic aneurysms is well known. Sixty-eight percent of these patients will have a rupture of the aneurysm within 2 years if resection is not performed [3]. Dubost et al [4] initiated the era of surgery for abdominal aortic aneurysm when, in 1952, they reported a case of aneurysm resection and homograft replacement. At present, elective aneurysmectomy carries an acceptable mortality rate, variously reported between 4 and 10 percent. Our own mortality rate in elective cases is 7 percent over a period of 15 years. Serious cardiac, pulmonary and renal disease drastically increases the mortality rate of elective resections. In these patients, the risks of surgery must be weighed against the risk of rupture of the aneurysm. Patients with acute myocardial infarction, intractable congestive heart failure, chronic renal failure, associated terminal disease, crippling pulmonary insufficiency and intraabdominal infection represent absolute contraindications to aneurysm resection [5]. Blaisdell et al [6] were the first to describe the management of a poor-risk patient with an abdominal aortic aneurysm by axillobifemoral bypass and ligation of the neck of the aneurysm. Berguer et al [I] reported a technique of balloon occlusion of the common iliac arteries and thrombosis of the aneurysm by instillation of thrombin into the aneurysm through a transaxillary catheter. Leather et al [2] treated 15 poor-risk patients by acute thrombosis of the aneurysm induced by retroperitoneal ligation of the iliac arteries. Both of these groups restored flow to the legs through an axillobifemoral bypass, as described originally by Blaisdell et al [6]. Our four patients presented with either absolute or relative contraindications for resection of abdominal aortic aneurysm. Our technique is a modification of the aforementioned methods. Thrombosis in our patients was achieved by a combination of ligation of t.he external iliac arteries and transcatheter embolization of the internal iliac arteries and the aneurysm itself (Figure 4). Briefly, the procedure as described by Leather et al [2] involves a standard axillobifemoral bypass. The common iliac arteries are examined through a retroperitoneal approach. If they are not aneurysmal or calcified, they can be ligated. If they cannot be ligated, the internal and external iliac arteries are ligated. Our modification involves ligation of the external iliac arteries above the circumflex iliac and deep epigastric arteries through the Volume
142,
August
1981
Figure 4. Our modified technique involves ligation of the external iliac arteries above the circumflex iliac and deep eplgastrlc arteries through the femoral incision during axiltobtfemoral bypass. Thrombosis is induced by embolixatlon of coils into the internal iliac arteries and the aneurysm.
femoral incision during axillobifemoral bypass. Thrombosis of the aneurysm in our cases was induced by embolization of Gianturco-Wallace coils and Gelfoam into the internal iliac arteries and the aneurysm through a catheter inserted into the opposite axillary artery. Two potential complications of this procedure, mentioned by Berguer et al [I], have caused us concern. The first is the possibility of proximal extension of the thrombus to involve the renal and visceral arteries. The second is the possibility of rectosigmoid ischemia after acute interruption of flow in the internal iliac arteries and the inferior mesenteric artery. To date, we have not had these problems, although our first patient did have fever and diarrhea after thrombosis. Our experience with axillobifemoral bypass as a substitute for conventional aortofemoral reconstruction when the latter is contraindicated was reported earlier [7]. We believe it is an acceptable operation with good immediate results because it carries minimal surgical morbidity and mortality. Despite advances in surgical technique and postoperative care, the mortality rate for patients undergoing resection of ruptured abdominal aortic aneurysms remains approximately 50 percent. Our own mortality rate over a 15 year period with 59 such patients is 47 percent. Perhaps if poor-risk patients can be offered an alternative to classic resection, their already-limited life expectancy can be restored. 229
Savarese et al
Summary Most patients with abdominal aortic aneurysm can safely undergo aneurysmectomy. In poor-risk patients the mortality rate is greatly increased. A procedure which is a safe alternative for patients who might otherwise be denied an elective procedure is described. However, this technique for the management of abdominal aortic aneurysm is not a substitute for the classic surgical treatment. References 1. Berguer R, Schneider J, Wilner HI. Induced thrombosis of inoperable abdominal aortic aneurysm. Surgery 1978;83:4259.
230
2. Leather RP, Shah D, Goldman M, Rosenberg M, Karmody AM. Nonresective treatment of abdominal aortic aneurysms. Arch Surg 1979;114:1402-8. 3. Szilagyi EE, Smith RF, Elliott JE, et al. Contribution of abdominal aortic aneurysmectomy to prolongation of life. Ann Surg 1966;164:678-99. 4. Dubost C, Allory M, Oeconomos N. Resection of an aneurysm of the abdominal aorta: re-establishment of the continuity by a preserved human graft with the result after five months. Arch Surg 1952;64:405. 5. Bergan JJ, Yao JST. Modern management of abdominal aortic aneurysms. Surg Clin North Am 1974;54: 175-93. 6. Blaisdell FW, Hall AD, Thomas AN. Ligation treatment of an abdominal aortic aneurysm. Am J Surg 1965:109:560-4. 7. DeLaurentis DA, Sala LE, Russell E, McCombs PR. A twelve year experience with axillofemoral and femorofemoral bypass operations. Surg Gynecol Obstet 1978;147:881-7.
The American Journal of Surgery