The epidemiology of surgically repaired aneurysms in the United States.
(17/1156)
OBJECTIVE: The purpose of this study was to determine the results of surgery for hospitalized cases of aneurysms in the United States, thereby providing a standard of comparison for new techniques proposed to treat aneurysms. METHODS: Data on hospitalized aneurysm cases were collected from the National Hospital Discharge Survey, a comprehensive database of patients hospitalized in the United States for treatment from the years 1984 to 1994. The National Hospital Discharge Survey samples non-federal, acute-care hospitals with an average length of stay of less than 30 days. All the cases had a diagnosis of or a surgical procedure for a non-cerebral aneurysm. RESULTS: In the year 1994, 51,949 non-cerebral aneurysms were repaired in the United States, and 75% of these procedures were abdominal aortic aneurysm (AAA) surgeries. The operative mortality rates for AAA were higher than previously reported from multi-institutional studies and were found to be 8.4% for elective repair and 68% for emergency AAA repair. The number of aneurysm surgeries per thousand population varied by region: surgery rates were more frequent in the Northeast and less frequent in the West. Surgical volume appeared to decrease for smaller hospitals and increase for larger hospitals for the period between 1990 and 1994. The overall mortality rates for all aneurysm surgeries diminished with hospital size. However, no significant difference was found for the rates of elective AAA repair between hospital sizes. The percentage of men with aneurysms who underwent surgery for repair was significantly higher than for women with aneurysms. In addition, the AAA repair rates increased for men from 1985 to 1994, and the number of women reported with repaired AAAs remained constant. CONCLUSION: The location of aneurysm, urgency of repair, region, sex, and hospital size are important factors related to patient treatment and outcome. These data provide a standard of comparison against which surgeons can compare their own results, and they provide a benchmark for the evaluation of interventional techniques proposed to treat aneurysms. (+info)
Tuberculous pseudoaneurysm of the descending thoracic aorta: successful treatment by surgical excision and primary repair.
(18/1156)
Tuberculous pseudoaneurysm of the aorta is a rare disease with a high mortality rate. We present the case of a 27-year-old woman who had a tuberculous pseudoaneurysm of the descending thoracic aorta. The patient underwent successful excision and primary repair of the lesion while under hypothermic circulatory arrest and partial femoral bypass. To the best of our knowledge, this is the youngest patient to be successfully treated with surgery for a tuberculous pseudoaneurysm of the descending thoracic aorta. The pathogenesis, diagnosis, and treatment of this disease are reviewed, and the need to include tuberculous pseudoaneurysm in the differential diagnosis of chest lesions is emphasized. (+info)
Elective repair of type IV thoraco-abdominal aortic aneurysms; experience of a subcostal (transabdominal) approach.
(19/1156)
OBJECTIVE: preoperative pulmonary function has been shown by univariate analysis to be an independent predictor of outcome following Crawford Type IV thoraco-abdominal aortic aneurysm repair. The aim of this study was to determine if outcome had been improved by the introduction of a subcostal approach for the elective repair of these aneurysms. METHODS: 39 patients studied (19 subcostal, 20 thoracolaparotomy) all operated on between 1993 and 1998 by a single surgeon using a standard technique. No significant difference in median age (69 years) or weight (64 kg vs. 69 kg) between the two groups. RESULTS: preoperative co-morbidities, pulmonary function and predictors of respiratory failure did not vary significantly between the two groups, despite a trend towards greater respiratory, cardiac and renal disease in the subcostal group. Preoperative median pulmonary function in both groups was 80% of that predicted for age, sex and height. The subcostal approach did not significantly reduce blood loss (3500 ml vs. 4500 ml) or anaesthetic time (255 min vs. 253 min). Overall 30 day mortality was 10.2%. The rate of re-operation was significantly higher in the subcostal group (21% vs. 0%, p=0.05). No differences were observed in intensive care unit stay, total hospital stay or respiratory complications, despite earlier extubation of the subcostal group (47% vs. 10% extubated at 12 h, p=0.01). CONCLUSION: the introduction of a subcostal approach for type IV thoraco-abdominal aneurysm repair in selected "high risk" patients has been associated with an unacceptably high rate of complications requiring early re-operation. We feel that this relates to the problems inherent in the introduction of a new technique and reduced exposure in patients of inappropriate body habitus. The predicted benefit to pulmonary function is realised in shorter intubation times, but has not translated into earlier recovery or improved outcome. Operation duration and blood loss have not been significantly reduced. Based on these outcomes, we do not currently recommend the general adoption of this approach in all type IV repairs. We will continue to evaluate this approach in patients with poor pulmonary function and a suitable body habitus. (+info)
Emergency repair of thoracoabdominal aortic aneurysms with immediate presentation.
(20/1156)
OBJECTIVE: The objective of this report was the study of the clinical outcome of emergently repaired thoracoabdominal aortic aneurysms (TAAAs). METHODS: We retrospectively reviewed our experience with TAAA repairs from 1990 to 1998. During this interval, 110 TAAA procedures were performed, 33 (30%) of which were for immediate presentations. The chi(2) test and regression analysis were used for the analysis of mortality, paraplegia, and renal failure (hemodialysis) rates and of factors that predict these complications, respectively. RESULTS: There were no significant differences between the elective and immediate presentations with respect to the use of adjunctive procedures (lumbar drain, hypothermia, and bypass grafting). The overall mortality rate was 13%. There were no statistically significant differences between the 30-day mortality rates or the complication rates in elective versus immediate presentations. Subgroup analysis results showed a significantly higher in-hospital mortality rate in type II TAAA with immediate presentation and free rupture presentation as compared with the overall mortality rate (50% vs 13%, P <.05, and 67% vs 13%, P <.01, respectively). Multiple regression analysis results identified the use of bypass grafting (atrial-femoral or cardiopulmonary) and lumbar drain and shorter bypass grafting time as significant predictors of decreased overall mortality (P <.05). The mortality rates were not significantly different among aneurysm types and were not significantly decreased with the use of hypothermia. Paraplegia (5%) and renal failure (9%) rates were not predicted with aneurysm type, immediate versus elective presentation, or the adjunctive use of hypothermia, lumbar drain, or bypass grafting. CONCLUSION: The emergency repair of TAAA with immediate presentation can be performed with mortality and morbidity rates that approach those of elective presentations, except in the setting of free rupture or symptomatic type II TAAA. Adjunctive circulatory management techniques and lumbar drains may reduce mortality in TAAA repair. (+info)
Aortoesophageal fistula caused by aneurysm of the thoracic aorta: successful surgical treatment, case report, and literature review.
(21/1156)
Aortoesophageal fistula induced by atherosclerotic thoracic aortic aneurysm is rare, but is usually a fatal disorder, with few survivors reported. We report the case of a 72-year-old man with aortoesophageal fistula successfully treated in a two-stage operation. In the first stage, we performed resection and replacement of the aortic aneurysm with a prosthetic graft in situ, esophagectomy, cervical esophagostomy, and jejunostomy. After the patient recovered well postoperatively, a transmediastinal retrosternal interposition of the stomach was performed, with esophagogastroanastomosis in the cervical area, to re-establish the gastrointestinal tract. We include a discussion of the causes, diagnostic approach, management of the aorta and esophagus, and review of the literature. (+info)
Hyperbaric oxygenation treatment of acute paraplegia after resection of a thoracoabdominal aortic aneurysm.
(22/1156)
Acute spinal cord ischemic injury after resection of thoracoabdominal aneurysm remains a relatively common and potentially devastating complication. The complete resolution of postoperative paraplegia after resection of a type II thoracoabdominal aneurysm, after treatment with hyperbaric oxygenation, is reported. (+info)
Late aneurysm of the distal aortic arch after repair of aortic interruption. A case report.
(23/1156)
Aneurysm formation after aortic coarctation repair is not a rare complication of post-coarctation of aorta repair. We describe the case of a 43-year-old woman who had undergone repair of an isolated interruption of the aortic arch 30 years earlier, who came to our hospital with progressive chest pain, cough and dyspnea. A giant aortic aneurysm was revealed in the distal aortic arch by CT study. The patient underwent aneurysmectomy with total aortic arch replacement using a Dacron graft through redo median sternotomy. An embryologic explanation of this patient's anomaly and the previous surgical procedure are discussed for defining this rare clinical condition. (+info)
Comparison of transcranial motor evoked potentials and somatosensory evoked potentials during thoracoabdominal aortic aneurysm repair.
(24/1156)
OBJECTIVE: To compare transcranial motor evoked potentials (tc-MEPs) and somatosensory evoked potentials (SSEPs) as indicators of spinal cord function during thoracoabdominal aortic aneurysm repair. SUMMARY BACKGROUND DATA: Somatosensory evoked potentials reflect conduction in dorsal columns. tc-MEPs represent anterior horn motor neuron function. This is the first study to compare the techniques directly during thoracoabdominal aortic aneurysm repair. METHODS: In 38 patients, thoracoabdominal aortic aneurysm repair (type I, n = 10, type II, n = 14, type III, n = 6, type IV, n = 8) was performed using left heart bypass and segmental artery reimplantation. tc-MEP amplitudes <25% and SSEP amplitudes <50% and/or latencies >110% were considered indicators of cord ischemia. The authors compared the response of both methods to interventions and correlated the responses at the end of surgery to neurologic outcomes. RESULTS: Ischemic tc-MEP changes occurred in 18/38 patients and could be restored by segmental artery reperfusion (n = 12) or by increasing blood pressure (n = 6). Significant SSEP changes accompanied these tc-MEP events in only 5/18 patients, with a delay of 2 to 34 minutes. SSEPs recovered in only two patients. In another 11 patients, SSEP amplitudes fell progressively to <50% of control without parallel tc-MEP changes or association with cross-clamp events or pressure decreases. At the end of the procedure, tc-MEP amplitudes were 84 +/- 46% of control. In contrast, SSEP amplitudes were <50% of control in 15 patients (39%). No paraplegia occurred. CONCLUSION: In all patients, tc-MEP events could be corrected by applying protective strategies. No patient awoke paraplegic. SSEPs showed delayed ischemia detection and a high rate of false-positive results. (+info)