- Email: [email protected]
Commentary: Surgical treatment of aortic aneurysm: 50-some years later
doi:10.1016/S0967-2109(03)00083-8
Cardiovascular Surgery, Vol. 11, No. 5, pp. 413–415, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
Commentary: Surgical treatment of aortic aneurysm: 50-some years later James S. T. Yao Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, 251 East Chicago Avenue, Chicago, IL 60611-2614, USA
Since the first description of aneurysms by Galen, surgical treatment of aortic aneurysms has been of interest to surgeons. Treatment techniques range from ligation and cellophane wrapping to electrical wiring. The breakthrough came in the 1950s with open surgical repair using homograft to replace the aneurysm. The decade of the 1950s was fruitful, with many surgeons braving the new path. Charles Dubost of Paris was widely quoted as the first to perform a successful replacement of an aneurysm with a homograft. Recent reports by Leeds [1] and Thompson [2] have pointed out that two other groups performed the procedure successfully before the attempt by Dubost on March 29, 1951. Chronologically, on February 26, 1951, Norman Freeman and Frank Leeds treated a 55-year-old male with a large asymptomatic aneurysm by using a vein inlay autograft. The vein was taken from the patient’s left common iliac vein and its bifurcation. The autograft was loosely sutured into the abdominal aorta and iliac arteries. The longitudinal incision in the abdominal aorta was closed with everting sutures. In an attempt to bolster the vein graft, whole blood was then injected into the space between the aorta and the vein graft at a pressure equal to one-half of the systolic pressure [3]. The second procedure was by Paul Schafer and Creighton Hardin of the University of Kansas on March 2, 1951. They resected the aneurysm with an indwelling shunt after clamping of the aorta and replaced the aorta with a human homograft. The patient survived the operation but died 29 days later of hemorrhage from a leak in the native aortic wall [4]. In the 1950s, several well-known vascular surTel.: +1-312-695-2716; [email protected]
CARDIOVASCULAR SURGERY
fax:
+1-312-695-4955;
geons also reported successful repair with homograft replacement as outlined in chronological order in Table 1. The major advancement in surgical treatment of aortic aneurysm began with the introduction by Voorhees in 1952 of Vinyon-N cloth as a plastic arterial substitute. Prosthetic graft became a standard procedure after DeBakey and Cooley refined the design of the Dacron graft in 1954. For nearly 30 years, open repair with prosthetic graft made of knitted or woven Dacron or polyethylene graft was the standard procedure in the treatment of intact or ruptured aortic aneurysm. In 1990, surgical treatment of aortic aneurysm took a drastic change when Juan Parodi introduced the concept of endovascular graft and performed the first successful endovascular graft in Argentina [5]. The patient, a 70-year-old male who had a 6-cm aortic aneurysm, underwent successful placement of an endovascular tube graft under spinal anesthesia on September 6, 1990. From then on, surgical treatment of aortic aneurysm took a new direction. At present, there are 15 endovascular devices under investigation, three of which have received FDA Table 1 Early open repair of abdominal aortic aneurysm in the 1950s Surgeons
Date
Graft replacement
Freeman and Leeds Schafer and Hardin Dubost et al. Freeman and Leeds Julian et al. Brock DeBakey and Cooley Bahnson
Feb. 26, 1951 March 2, 1951 March 29, 1951 May 13, 1952 Oct. 25, 1952 Nov. 5, 1952 Nov. 6, 1952 Feb. 14, 1953 March 13, 1953
Vein inlay graft Homograft Homografta Splenic artery Homograft Homograft Homograft Homograft Homograft—first successful repair of ruptured aneurysm
e-mail: a
OCTOBER 2003 VOL 11 NO 5
Died on the 29th postoperative day.
413
Commentary: Surgical treatment of aortic aneurysm: 50-some years later: James S. T. Yao
approval for clinical use. As expected, technology continues to improve; newer fixation systems, smaller deployment devices, and bifurcated grafts of unibody design or with modular limb components are now available to yield better results. Percutaneous placement of endovascular grafts is now possible in selected patients. New technology brings new problems; terminology such as “endoleak”, “endotension”, “device migration”, or “delayed rupture” not heard of in open repair are now common terms in reporting complications of endovascular graft. Despite these complications, endovascular graft has now emerged as an alternate technique in the treatment of aneurysm and certainly is of special appeal in high-risk patients. Obviously, longer follow-up study is needed to establish the role of endovascular graft in the treatment of aortic aneurysm. In addition to endovascular graft, the laparoscopyassisted abdominal aortic aneurysm repair has emerged as a minimally invasive approach to aortic aneurysm repair. Since the first report by Chen and his colleagues in 1955 [6], Dr. Yves-Marie Dion of Montreal, Canada, and Dr. John Edoga of Morristown, NJ, have reported large series of repair of aortic aneurysm by laparoscopic technique. At present, the technique has not been embraced by most vascular surgeons because it is a technically challenging and time-consuming procedure. Nevertheless, with more surgeons being trained in laparoscopic surgery and further refinement of the technology such as the autosuture device for anastomosis, laparoscopic technique may yet find a place in the treatment of aortic aneurysm. Fifty-three years after the first successful surgical repair, we are now more knowledgeable about aortic aneurysm. Pathogenesis of aneurysm is better understood with many vascular surgeons engaged in basic research of aneurysm, supported by a research initiative by NIH-NHLBI. Aneurysm formation is a chronic inflammatory condition involving complex biological processes. Matrix metalloproteinases (MMPs), hemodynamic influences on oxidative stress, and many other biologic markers have been cited to promote aneurysmal degeneration. Based on some of these studies, a group of younger vascular surgeons are now charting a pharmacological approach to retard the growth of aneurysm to prevent rupture [8]. We also know “size does matter”. Multi-center trials have found that aneurysms 5.5 cm in size seldom rupture. For small aneurysms, it is perfectly safe to use a “wait and see” approach in decision-making for surgery [14,15]. Elective surgical repair of AAA is a safe procedure with mortality rates ranging from 5% to 8% in the real world. In contrast, mortality in surgical repair of ruptured aortic aneurysm remains high. In a metaanalysis of 50 years of ruptured abdominal aortic 414
aneurysm by Bown et al. [7], a constant reduction of approximately 3.5% per decade was demonstrated but the estimated operative mortality rate remains as high as 41% for the year 2000. This figure is 5–8 times that of elective repair. It is apparent that the only way to reduce this high operative mortality from ruptured aortic aneurysm is early detection. Large-scale studies have shown screening using ultrasound to be not only life-saving but also cost-effective. For men, a single ultrasound scan at the age of 65 would demonstrate whether they are likely to develop a significant aneurysm [9– 13]. The American Association for Vascular Surgery is now promoting a screening program for aortic aneurysm in the public and it is hoped that screening of aortic aneurysm will eventually become a national program covered by Medicare and insurance carriers much as mammogram for breast cancer in women. We have come a long way in advancement of treatment of aortic aneurysm and we must not stop— there is still much to do ahead of us. Many of the population studies are on male patients and there is a need to extend the study to the female population. More research studies are needed to further define and to understand the pathogenesis of aortic aneurysm and, perhaps, to identify a better biologic marker to predict which patients are likely to develop aneurysms. Aortic aneurysm is common in the aged population and many world figures had died of ruptured aneurysm, including Albert Einstein, Joseph Pulitzer, and Charles de Gaulle. A public awareness program is needed to reduce aneurysm rupture rate. We may not be able to prevent aneurysm from developing in the aorta, but we certainly can reduce the rupture rates of aortic aneurysm.
References 1. Leeds, F. H. Letter to the Editor: Regarding “Early history of aortic surgery”. J Vasc Surg, 1999, 29, 575. 2. Thompson, J. E. Early history of aortic surgery. J Vasc Surg, 1998, 28, 746–752. 3. Freeman, N. E. and Leeds, F. H. Vein inlay graft in the treatment of aneurysms and thrombosis of the abdominal aorta. Angiology, 1951, 2, 579–587. 4. Schafer, P. W. and Hardin, C. A. The use of temporary polythene shunts to permit occlusion, resection and frozen homologous graft replacement of vital vessel segments. Surgery, 1952, 31, 186–199. 5. Parodi, J. C., Palmaz, J. C. and Barone, H. D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg, 1991, 5, 491–499. 6. Chen, M. H. M., Murphy, E. A., Halpern, V. et al. Laparoscopic assisted abdominal aortic aneurysm repair. Surg Endosc, 1955, 9, 905–907. 7. Baxter, B. T., Pearce, W. H., Waltke, E. A. et al. Prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms: report of a prospective (phase II) multicenter study. J Vasc Surg, 2002, 36, 1–12. 8. Lederle, F. A., Wilson, S. E., Johnson, G. R. et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med, 2002, 346, 1437–1444.
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Commentary: Surgical treatment of aortic aneurysm: 50-some years later: James S. T. Yao 9. The United Kingdom Small Aneurysm Trial Participants. Longterm outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med, 2002, 346, 1445–1452. 10. Bown, M. J., Sutton, A. J., Bell, P. R. F. et al. A meta-analysis of years of ruptured abdominal aortic aneurysm repair. Br J Surg, 2002, 89, 714–730. 11. Crow, P., Shaw, E., Earnshaw, J. J. et al. A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. Br J Surg, 2001, 88, 941–944. 12. Scott, R. A. P., Vardulaki, K. A., Walker, N. M. et al. The longterm benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. Eur J Vasc Endovasc Surg, 2001, 21, 535–540. 13. Greenhalgh, R. M. and Powell, J. T. Screening men for aortic
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
aneurysm: a national population screening service will be cost effective. Br Med J, 2002, 325, 1123–1124. 14. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. Br Med J, 2002, 325, 1135–1141. 15. The Multicentre Aneurysm Screening Study Group. The Multicentre Aneurysm Screen Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet, 2002, 360, 1531–1539. Paper accepted 30 April 2003
415
Cardiovascular Surgery, Vol. 11, No. 5, pp. 413–415, 2003 2003 The International Society for Cardiovascular Surgery Published by Elsevier Ltd. All rights reserved. 0967-2109/03 $30.00
www.elsevier.com/locate/cardiosur
Commentary: Surgical treatment of aortic aneurysm: 50-some years later James S. T. Yao Division of Vascular Surgery, Feinberg School of Medicine, Northwestern University, 251 East Chicago Avenue, Chicago, IL 60611-2614, USA
Since the first description of aneurysms by Galen, surgical treatment of aortic aneurysms has been of interest to surgeons. Treatment techniques range from ligation and cellophane wrapping to electrical wiring. The breakthrough came in the 1950s with open surgical repair using homograft to replace the aneurysm. The decade of the 1950s was fruitful, with many surgeons braving the new path. Charles Dubost of Paris was widely quoted as the first to perform a successful replacement of an aneurysm with a homograft. Recent reports by Leeds [1] and Thompson [2] have pointed out that two other groups performed the procedure successfully before the attempt by Dubost on March 29, 1951. Chronologically, on February 26, 1951, Norman Freeman and Frank Leeds treated a 55-year-old male with a large asymptomatic aneurysm by using a vein inlay autograft. The vein was taken from the patient’s left common iliac vein and its bifurcation. The autograft was loosely sutured into the abdominal aorta and iliac arteries. The longitudinal incision in the abdominal aorta was closed with everting sutures. In an attempt to bolster the vein graft, whole blood was then injected into the space between the aorta and the vein graft at a pressure equal to one-half of the systolic pressure [3]. The second procedure was by Paul Schafer and Creighton Hardin of the University of Kansas on March 2, 1951. They resected the aneurysm with an indwelling shunt after clamping of the aorta and replaced the aorta with a human homograft. The patient survived the operation but died 29 days later of hemorrhage from a leak in the native aortic wall [4]. In the 1950s, several well-known vascular surTel.: +1-312-695-2716; [email protected]
CARDIOVASCULAR SURGERY
fax:
+1-312-695-4955;
geons also reported successful repair with homograft replacement as outlined in chronological order in Table 1. The major advancement in surgical treatment of aortic aneurysm began with the introduction by Voorhees in 1952 of Vinyon-N cloth as a plastic arterial substitute. Prosthetic graft became a standard procedure after DeBakey and Cooley refined the design of the Dacron graft in 1954. For nearly 30 years, open repair with prosthetic graft made of knitted or woven Dacron or polyethylene graft was the standard procedure in the treatment of intact or ruptured aortic aneurysm. In 1990, surgical treatment of aortic aneurysm took a drastic change when Juan Parodi introduced the concept of endovascular graft and performed the first successful endovascular graft in Argentina [5]. The patient, a 70-year-old male who had a 6-cm aortic aneurysm, underwent successful placement of an endovascular tube graft under spinal anesthesia on September 6, 1990. From then on, surgical treatment of aortic aneurysm took a new direction. At present, there are 15 endovascular devices under investigation, three of which have received FDA Table 1 Early open repair of abdominal aortic aneurysm in the 1950s Surgeons
Date
Graft replacement
Freeman and Leeds Schafer and Hardin Dubost et al. Freeman and Leeds Julian et al. Brock DeBakey and Cooley Bahnson
Feb. 26, 1951 March 2, 1951 March 29, 1951 May 13, 1952 Oct. 25, 1952 Nov. 5, 1952 Nov. 6, 1952 Feb. 14, 1953 March 13, 1953
Vein inlay graft Homograft Homografta Splenic artery Homograft Homograft Homograft Homograft Homograft—first successful repair of ruptured aneurysm
e-mail: a
OCTOBER 2003 VOL 11 NO 5
Died on the 29th postoperative day.
413
Commentary: Surgical treatment of aortic aneurysm: 50-some years later: James S. T. Yao
approval for clinical use. As expected, technology continues to improve; newer fixation systems, smaller deployment devices, and bifurcated grafts of unibody design or with modular limb components are now available to yield better results. Percutaneous placement of endovascular grafts is now possible in selected patients. New technology brings new problems; terminology such as “endoleak”, “endotension”, “device migration”, or “delayed rupture” not heard of in open repair are now common terms in reporting complications of endovascular graft. Despite these complications, endovascular graft has now emerged as an alternate technique in the treatment of aneurysm and certainly is of special appeal in high-risk patients. Obviously, longer follow-up study is needed to establish the role of endovascular graft in the treatment of aortic aneurysm. In addition to endovascular graft, the laparoscopyassisted abdominal aortic aneurysm repair has emerged as a minimally invasive approach to aortic aneurysm repair. Since the first report by Chen and his colleagues in 1955 [6], Dr. Yves-Marie Dion of Montreal, Canada, and Dr. John Edoga of Morristown, NJ, have reported large series of repair of aortic aneurysm by laparoscopic technique. At present, the technique has not been embraced by most vascular surgeons because it is a technically challenging and time-consuming procedure. Nevertheless, with more surgeons being trained in laparoscopic surgery and further refinement of the technology such as the autosuture device for anastomosis, laparoscopic technique may yet find a place in the treatment of aortic aneurysm. Fifty-three years after the first successful surgical repair, we are now more knowledgeable about aortic aneurysm. Pathogenesis of aneurysm is better understood with many vascular surgeons engaged in basic research of aneurysm, supported by a research initiative by NIH-NHLBI. Aneurysm formation is a chronic inflammatory condition involving complex biological processes. Matrix metalloproteinases (MMPs), hemodynamic influences on oxidative stress, and many other biologic markers have been cited to promote aneurysmal degeneration. Based on some of these studies, a group of younger vascular surgeons are now charting a pharmacological approach to retard the growth of aneurysm to prevent rupture [8]. We also know “size does matter”. Multi-center trials have found that aneurysms 5.5 cm in size seldom rupture. For small aneurysms, it is perfectly safe to use a “wait and see” approach in decision-making for surgery [14,15]. Elective surgical repair of AAA is a safe procedure with mortality rates ranging from 5% to 8% in the real world. In contrast, mortality in surgical repair of ruptured aortic aneurysm remains high. In a metaanalysis of 50 years of ruptured abdominal aortic 414
aneurysm by Bown et al. [7], a constant reduction of approximately 3.5% per decade was demonstrated but the estimated operative mortality rate remains as high as 41% for the year 2000. This figure is 5–8 times that of elective repair. It is apparent that the only way to reduce this high operative mortality from ruptured aortic aneurysm is early detection. Large-scale studies have shown screening using ultrasound to be not only life-saving but also cost-effective. For men, a single ultrasound scan at the age of 65 would demonstrate whether they are likely to develop a significant aneurysm [9– 13]. The American Association for Vascular Surgery is now promoting a screening program for aortic aneurysm in the public and it is hoped that screening of aortic aneurysm will eventually become a national program covered by Medicare and insurance carriers much as mammogram for breast cancer in women. We have come a long way in advancement of treatment of aortic aneurysm and we must not stop— there is still much to do ahead of us. Many of the population studies are on male patients and there is a need to extend the study to the female population. More research studies are needed to further define and to understand the pathogenesis of aortic aneurysm and, perhaps, to identify a better biologic marker to predict which patients are likely to develop aneurysms. Aortic aneurysm is common in the aged population and many world figures had died of ruptured aneurysm, including Albert Einstein, Joseph Pulitzer, and Charles de Gaulle. A public awareness program is needed to reduce aneurysm rupture rate. We may not be able to prevent aneurysm from developing in the aorta, but we certainly can reduce the rupture rates of aortic aneurysm.
References 1. Leeds, F. H. Letter to the Editor: Regarding “Early history of aortic surgery”. J Vasc Surg, 1999, 29, 575. 2. Thompson, J. E. Early history of aortic surgery. J Vasc Surg, 1998, 28, 746–752. 3. Freeman, N. E. and Leeds, F. H. Vein inlay graft in the treatment of aneurysms and thrombosis of the abdominal aorta. Angiology, 1951, 2, 579–587. 4. Schafer, P. W. and Hardin, C. A. The use of temporary polythene shunts to permit occlusion, resection and frozen homologous graft replacement of vital vessel segments. Surgery, 1952, 31, 186–199. 5. Parodi, J. C., Palmaz, J. C. and Barone, H. D. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg, 1991, 5, 491–499. 6. Chen, M. H. M., Murphy, E. A., Halpern, V. et al. Laparoscopic assisted abdominal aortic aneurysm repair. Surg Endosc, 1955, 9, 905–907. 7. Baxter, B. T., Pearce, W. H., Waltke, E. A. et al. Prolonged administration of doxycycline in patients with small asymptomatic abdominal aortic aneurysms: report of a prospective (phase II) multicenter study. J Vasc Surg, 2002, 36, 1–12. 8. Lederle, F. A., Wilson, S. E., Johnson, G. R. et al. Immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med, 2002, 346, 1437–1444.
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
Commentary: Surgical treatment of aortic aneurysm: 50-some years later: James S. T. Yao 9. The United Kingdom Small Aneurysm Trial Participants. Longterm outcomes of immediate repair compared with surveillance of small abdominal aortic aneurysms. N Engl J Med, 2002, 346, 1445–1452. 10. Bown, M. J., Sutton, A. J., Bell, P. R. F. et al. A meta-analysis of years of ruptured abdominal aortic aneurysm repair. Br J Surg, 2002, 89, 714–730. 11. Crow, P., Shaw, E., Earnshaw, J. J. et al. A single normal ultrasonographic scan at age 65 years rules out significant aneurysm disease for life in men. Br J Surg, 2001, 88, 941–944. 12. Scott, R. A. P., Vardulaki, K. A., Walker, N. M. et al. The longterm benefits of a single scan for abdominal aortic aneurysm (AAA) at age 65. Eur J Vasc Endovasc Surg, 2001, 21, 535–540. 13. Greenhalgh, R. M. and Powell, J. T. Screening men for aortic
CARDIOVASCULAR SURGERY
OCTOBER 2003 VOL 11 NO 5
aneurysm: a national population screening service will be cost effective. Br Med J, 2002, 325, 1123–1124. 14. Multicentre Aneurysm Screening Study Group. Multicentre aneurysm screening study (MASS): cost effectiveness analysis of screening for abdominal aortic aneurysms based on four year results from randomised controlled trial. Br Med J, 2002, 325, 1135–1141. 15. The Multicentre Aneurysm Screening Study Group. The Multicentre Aneurysm Screen Study (MASS) into the effect of abdominal aortic aneurysm screening on mortality in men: a randomised controlled trial. Lancet, 2002, 360, 1531–1539. Paper accepted 30 April 2003
415