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Successful Repair of Ruptured Abdominal Aortic Aneurysm Following Cardiac Transplantation
EJVES Extra 7, 64–65 (2004) doi: 10.1016/j.ejvsextra.2004.03.003, available online at http://www.sciencedirect.com on
SHORT REPORT
Successful Repair of Ruptured Abdominal Aortic Aneurysm Following Cardiac Transplantation K. Cassar* and J. R. C. Logie Department of Surgery, Raigmore Hospital, Inverness, Scotland, UK Key Words: Abdominal aortic aneurysm; Cardiac transplantation.
Introduction Life expectancy of cardiac transplant patients has improved dramatically with rates up to 94, 79 and 72% reported for 1, 5 and 10 year survival.1 The commonest indication for cardiac transplantation is end-stage cardiac failure secondary to ischaemic cardiomyopathy. With improved survival this group of patients is likely to develop symptoms from extracardiac vascular disease, such as abdominal aortic aneurysms and peripheral arterial occlusive disease. Routine ultrasonographic screening for abdominal aortic aneurysm has been recommended for male cardiac transplant patients.2 We report the successful repair of a ruptured infrarenal abdominal aortic aneurysm in a patient who had undergone cardiac transplantation 11 years before. To our knowledge this is only the second such case reported in the literature.
Case Report A 67-year-old gentleman underwent orthotopic cardiac transplantation in 1988 for end stage cardiac failure secondary to ischaemic cardiomyopathy. He developed critical ischaemia of the left lower limb secondary to left common iliac occlusion, for which he underwent a femoro-femoral crossover graft in 1995. In 1998, he was treated with radiotherapy for lowgrade non-Hodgkin’s lymphoma. He was admitted to hospital in 1999 after ‘collapsing’ at home with severe back pain. A tender pulsatile *Corresponding author. K Cassar, Ward 36, Vacular Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK.
mass was palpable on examination and he was transferred to the operating theatre. At laparotomy a ruptured infrarenal abdominal aortic aneurysm with a large retroperitoneal haematoma was found. The abdominal aortic aneurysm was repaired using a straight graft. Postoperatively the patient required inotropic support and two haemodialysis sessions for acute renal failure. He made a good recovery and was discharged home 3 weeks later. He remained well for several months but was unfortunately diagnosed as having renal cell carcinoma.
Discussion Over 20 cases of successful elective aortic aneurysm repair following cardiac transplantation have been reported in the literature. One case of successful repair of a ruptured infrarenal3 and one of suprarenal aortic aneurysm4 after cardiac transplantation have been reported. The true incidence of abdominal aortic aneurysms in patients undergoing cardiac transplantation is not known, as there has been no prospective study conducted. However, since the majority of these patients have atherosclerotic disease, they are at a higher risk than the general population of having aneurysmal disease. More importantly, the rate of expansion of abdominal aortic aneurysms in patients after cardiac transplantation is up to five times faster than in other patients (0.74 –1.75 cm/year vs 0.2 – 0.5 cm/year).2 This may be due to a number of factors. Hyperlipidaemia and hypertriglyceridaemia are classic features of cyclosporin therapy and contribute to progression of atherosclerotic changes. Systemic
1533–3167/050064 + 02 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
Successful Repair of Ruptured Abdominal Aortic Aneurysm Following Cardiac Transplantation
hypertension, which is reported in a significant number of patients on cyclosporin and responds poorly to treatment, may also be responsible for progression of atherosclerosis. Furthermore corticosteroids used in these patients increases the risk of hypertension. Besides, steroids have a detrimental effect on collagen synthesis and healing5 and may contribute to the rapid expansion and eventual rupture of aortic aneurysms in these patients. Systemic hypertension as well as the increased aortic haemodynamic stress subsequent to the rise in cardiac ejection fraction after transplantation may also contribute to the rapid expansion seen in the aneurysms of these patients. Patients undergoing cardiac transplantation are more likely to have abdominal aortic aneurysms and these tend to expand rapidly and are hence more likely to rupture. It is, therefore, important to identify the aneurysm and monitor its expansion closely and more regularly than in other patients. Elective repair is safe as these patients have normal cardiac function and the
65
reported mortality for elective repair is similar to that in other patients.2
References 1 Kriett JM, Kaye MP. The registry of the International Society for Heart Transplantation: seventh official report—1990. J Heart Transplant 1990; 9:323–330. 2 Ammori BJ, Madan M, Bodenham AR, Gough MJ. A review of the management of abdominal aortic aneurysms in patients following cardiac transplantation. Eur J Vasc Endovasc Surg 1997; 14:185–190. 3 Chandrasekar R, Nott DM, Enabi L, Harris PL, Dakran A. Successful repair of a ruptured abdominal aortic aneurysm in a cardiac transplant patient. Eur J Vasc Surg 1994; 8:750–751. 4 Benvenisty AI, Todd GJ, Argenziano M, Buda JA, Reemstsma K, Smith CR, Rose EA. Management of peripheral vascular problems in recipients of cardiac allografts. J Vasc Surg 1992; 16: 895–902. 5 Reilly JM, Savage EB, Brophy CM, Tilson MD. Hydrocortisone rapidly induces aortic rupture in a genetically susceptible mouse. Arch Surg 1990; 125:707–709. Accepted 10 March 2004
EJVES Extra, 2004
SHORT REPORT
Successful Repair of Ruptured Abdominal Aortic Aneurysm Following Cardiac Transplantation K. Cassar* and J. R. C. Logie Department of Surgery, Raigmore Hospital, Inverness, Scotland, UK Key Words: Abdominal aortic aneurysm; Cardiac transplantation.
Introduction Life expectancy of cardiac transplant patients has improved dramatically with rates up to 94, 79 and 72% reported for 1, 5 and 10 year survival.1 The commonest indication for cardiac transplantation is end-stage cardiac failure secondary to ischaemic cardiomyopathy. With improved survival this group of patients is likely to develop symptoms from extracardiac vascular disease, such as abdominal aortic aneurysms and peripheral arterial occlusive disease. Routine ultrasonographic screening for abdominal aortic aneurysm has been recommended for male cardiac transplant patients.2 We report the successful repair of a ruptured infrarenal abdominal aortic aneurysm in a patient who had undergone cardiac transplantation 11 years before. To our knowledge this is only the second such case reported in the literature.
Case Report A 67-year-old gentleman underwent orthotopic cardiac transplantation in 1988 for end stage cardiac failure secondary to ischaemic cardiomyopathy. He developed critical ischaemia of the left lower limb secondary to left common iliac occlusion, for which he underwent a femoro-femoral crossover graft in 1995. In 1998, he was treated with radiotherapy for lowgrade non-Hodgkin’s lymphoma. He was admitted to hospital in 1999 after ‘collapsing’ at home with severe back pain. A tender pulsatile *Corresponding author. K Cassar, Ward 36, Vacular Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen AB25 2ZN, UK.
mass was palpable on examination and he was transferred to the operating theatre. At laparotomy a ruptured infrarenal abdominal aortic aneurysm with a large retroperitoneal haematoma was found. The abdominal aortic aneurysm was repaired using a straight graft. Postoperatively the patient required inotropic support and two haemodialysis sessions for acute renal failure. He made a good recovery and was discharged home 3 weeks later. He remained well for several months but was unfortunately diagnosed as having renal cell carcinoma.
Discussion Over 20 cases of successful elective aortic aneurysm repair following cardiac transplantation have been reported in the literature. One case of successful repair of a ruptured infrarenal3 and one of suprarenal aortic aneurysm4 after cardiac transplantation have been reported. The true incidence of abdominal aortic aneurysms in patients undergoing cardiac transplantation is not known, as there has been no prospective study conducted. However, since the majority of these patients have atherosclerotic disease, they are at a higher risk than the general population of having aneurysmal disease. More importantly, the rate of expansion of abdominal aortic aneurysms in patients after cardiac transplantation is up to five times faster than in other patients (0.74 –1.75 cm/year vs 0.2 – 0.5 cm/year).2 This may be due to a number of factors. Hyperlipidaemia and hypertriglyceridaemia are classic features of cyclosporin therapy and contribute to progression of atherosclerotic changes. Systemic
1533–3167/050064 + 02 $35.00/0 q 2004 Elsevier Ltd. All rights reserved.
Successful Repair of Ruptured Abdominal Aortic Aneurysm Following Cardiac Transplantation
hypertension, which is reported in a significant number of patients on cyclosporin and responds poorly to treatment, may also be responsible for progression of atherosclerosis. Furthermore corticosteroids used in these patients increases the risk of hypertension. Besides, steroids have a detrimental effect on collagen synthesis and healing5 and may contribute to the rapid expansion and eventual rupture of aortic aneurysms in these patients. Systemic hypertension as well as the increased aortic haemodynamic stress subsequent to the rise in cardiac ejection fraction after transplantation may also contribute to the rapid expansion seen in the aneurysms of these patients. Patients undergoing cardiac transplantation are more likely to have abdominal aortic aneurysms and these tend to expand rapidly and are hence more likely to rupture. It is, therefore, important to identify the aneurysm and monitor its expansion closely and more regularly than in other patients. Elective repair is safe as these patients have normal cardiac function and the
65
reported mortality for elective repair is similar to that in other patients.2
References 1 Kriett JM, Kaye MP. The registry of the International Society for Heart Transplantation: seventh official report—1990. J Heart Transplant 1990; 9:323–330. 2 Ammori BJ, Madan M, Bodenham AR, Gough MJ. A review of the management of abdominal aortic aneurysms in patients following cardiac transplantation. Eur J Vasc Endovasc Surg 1997; 14:185–190. 3 Chandrasekar R, Nott DM, Enabi L, Harris PL, Dakran A. Successful repair of a ruptured abdominal aortic aneurysm in a cardiac transplant patient. Eur J Vasc Surg 1994; 8:750–751. 4 Benvenisty AI, Todd GJ, Argenziano M, Buda JA, Reemstsma K, Smith CR, Rose EA. Management of peripheral vascular problems in recipients of cardiac allografts. J Vasc Surg 1992; 16: 895–902. 5 Reilly JM, Savage EB, Brophy CM, Tilson MD. Hydrocortisone rapidly induces aortic rupture in a genetically susceptible mouse. Arch Surg 1990; 125:707–709. Accepted 10 March 2004
EJVES Extra, 2004