Ruptured abdominal aortic aneurysms: selecting patients for surgery.
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OBJECTIVES: Mortality from ruptured abdominal aortic aneurysm (RAAA) remains high. Despite this, withholding surgery on poor-prognosis patients with RAAA may create a difficult dilemma for the surgeon. Hardman et al. identified five independent, preoperative risk factors associated with mortality and proposed a model for preoperative patient selection. The aim of this study was to test the validity of the same model in an independent series of RAAA patients. METHODS: A consecutive series of patients undergoing surgery for RAAA was analysed retrospectively by case-note review. Thirty-day operative mortality and the presence of the five risk factors: age (> 76 years), creatinine (Cr) (> 190 mumol/l), haemoglobin (Hb) (< 9 g/dl), loss of consciousness and electrocardiographic (ECG) evidence of ischaemia were recorded for each patient. RESULTS: Complete data sets existed for 69 patients (mean age: 73 years, range: 38-86 years, male to female ratio: 6:1). Operative mortality was 43%. The cumulative effect of 0, 1 and 2 risk factors on mortality was 18%, 28% and 48%, respectively. All patients with three or more risk factors died (eight patients). CONCLUSIONS: These results lend support to the validity of the model. The potential to avoid surgery in patients with little or no chance of survival would spare unnecessary suffering, reduce operative mortality and enhance use of scarce resources. (+info)
Repair of ruptured thoracoabdominal aortic aneurysm is worthwhile in selected cases.
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INTRODUCTION: The risks and benefits of operating on patients with ruptured thoracoabdominal aortic aneurysm (TAAA) have not been defined. The aim of the present study is to report this unit's experience with operations performed for ruptured TAAA over a 10-year period. METHODS: Interrogation of a prospectively gathered computerised database. PATIENTS: Between 1 January 1983 and 30 June 1996, 188 consecutive patients with TAAA were operated on, of whom 23 (12%) were operated for rupture. RESULTS: There were nine survivors (40%). Patients whose preoperative systolic blood pressure remained above 100 mmHg were significantly more likely to survive (4/8 vs. 13/15, p = 0.03 by Fisher's exact test). Survival was also related to Crawford type: type I (two of three survived); II (none of six); III (two of six); and IV (five of eight). All non-type II, non-shocked patients survived operation. Survivors spent a median of 28 (range 10-66) postoperative days in hospital, of which a median of 6 (range 2-24) days were spent in the intensive care unit. Survivor morbidity comprised prolonged ventilation (> 5 days) (n = 3); tracheostomy (n = 1); and temporary haemofiltration (n = 2). No survivor developed paraplegia or required permanent dialysis. CONCLUSIONS: Patients in shock with a Crawford type II aneurysm have such a poor prognosis that intervention has to be questioned except in the most favourable of circumstances. However, patients with types I, III and IV who are not shocked on presentation can be salvaged and, where possible, should be transferred to a unit where appropriate expertise and facilities are available. (+info)
Rupture of aortic aneurysm with right-sided haemothorax.
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A 62-yr-old male with a history of high blood pressure was admitted for persistent dyspnoea and a right-sided pleural effusion, complicated by a recent episode of shock. There was no history of trauma and the patient denied any thoracic pain. A chest tube was inserted which released nonclotting bloody fluid. A thoracic computed tomographic scan of the chest revealed an aneurysm of the inferior third of the descending thoracic aorta. The patient underwent a successful prosthetic graft replacement. We emphasize that rupture of aortic aneurysms should be considered in the evaluation of spontaneous haemothorax even if it is right-sided and not associated with pain. (+info)
Frame dislocation of body middle rings in endovascular stent tube grafts.
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OBJECTIVES: To understand the cause, and propose a mechanism for frame dislocation in endovascular grafts. MATERIALS AND METHODS: Five tube grafts were explanted due to secondary distal leakage 15-21 months after operation. One bifurcated graft was removed during emergency operation after aortic rupture caused by secondary leakage. A second bifurcated graft was harvested from a patient with thrombotic occlusion of one limb, who died after transurethral prostatic resection. The inside of the grafts were examined endoscopically. The stent was inspected after removal of the fabric, broken ligatures were counted and examined by scanning electron microscopy. The fabric strength was tested by probe puncture. RESULTS: We found 17-44% of the stent ligatures of the body middle rings to be loose. The knots were intact. Degradation of the polyester textile was not observed. CONCLUSIONS: Continuous movements in the grafted aorta and blood pressure impose permanent stress to the stent frame and the polyester fabric resulting in morphological changes in the body middle ring of grafts. The clinical implications of the suture breakages are unknown although they may be related to distal secondary leakage in tube grafts. (+info)
Acute renal impairment due to a primary aortocaval fistula is normalised after a successful operation.
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OBJECTIVES: To study renal function in patients with aortocaval fistula, before and after surgery. DESIGN: Retrospective study. MATERIAL AND METHODS: During the last 22 years nine male patients (median age 67, age range 50-72) with spontaneous aortocaval fistula in combination with AAA were operated upon. This constitutes 4% of the patients with ruptured AAA and 1.5% of all patients with AAA. RESULTS: A preoperative diagnosis of aortocaval fistula was established in three of the nine cases. The medium duration of symptoms prior to surgery was 5 days (range 4 h-14 days). The fistula was combined with an extravasating ruptured AAA in only three patients. Seven of the patients had acute renal insufficiency, with creatinine levels of in median 292 mumol (IQR 218-342). Creatinine declined to 172 mumol/l (IQR 170-313) on the fifth postoperative day in uncomplicated cases and to 86 mumol at discharge. One patient died due to multi-organ failure, whereas the other left hospital well and alive with normal renal function. CONCLUSION: Acute preoperative renal insufficiency due to an aortocaval fistula in patients with AAA is often due to venous congestion, and is normalised after successful surgery. (+info)
Mortality in ruptured abdominal aortic aneurysms. The Finnvasc Study Group.
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OBJECTIVE: To assess mortality related to rupture of abdominal aortic aneurysm (RAAA). DESIGN: A 4-year cross-sectional study based on a nationwide vascular registry Finnvasc and national cause-of-death registry (Statistics Finland). MATERIALS AND METHODS: A total of 454 operations for RAAA among 11,747 surgical vascular reconstructions recorded in the Finnvasc registry and 1004 deaths due to RAAA during the same period based on Statistics Finland. RESULTS: The operative mortality rate was 49% based on the Finnvasc registry and 54% based on Statistics Finland. With all RAAA deaths at hospitals included, total hospital mortality was 68%. No association existed between hospital volume of RAAA operations and surgical mortality, although an inverse association did exist between hospital volume of RAAA operations and all RAAA deaths in the hospital (p = 0.01). The case fatality for RAAA in Finland was 80%. CONCLUSIONS: RAAA surgical mortality calculations for RAAA, based on a vascular registry, underestimate the true rate because some cases with fatal outcome tend to escape registration. Because surgical mortality rates may also be skewed by patient selection, total hospital RAAA mortality thus represents the results of RAAA treatment more accurately. (+info)
Chronic aneurysm of the descending thoracic aorta presenting with right pleural effusion and left phrenic paralysis.
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A 62-year-old man was admitted to the emergency department with chronic dysphagia and lower back pain. Chest radiography revealed a wide mediastinal shadow and an elevated left diaphragm, which proved to be secondary to left phrenic paralysis. The patient was diagnosed with an aneurysm of the descending thoracic aorta and was admitted to the hospital. After the patient was admitted, the aneurysm ruptured into the right chest. The patient underwent an emergency operation to replace the ruptured segment with a synthetic graft. Postoperative recovery and follow-up were uneventful. This report describes an unusual presentation of a thoracic aortic aneurysm. Hemidiaphragmatic paralysis caused by compression of the phrenic nerve is an unusual complication that, to our knowledge, has not been previously reported. (+info)
Ruptured abdominal aortic aneurysm in the Huntingdon district: a 10-year experience.
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A study was undertaken to establish the true incidence of ruptured abdominal aortic aneurysms (RAAA) in the Huntingdon districts. RAAAs in the Huntingdon district between 1986 and 1995 were studied retrospectively. Data were collected from hospital records and hospital and community autopsies. There was a total of 139 cases of RAAA; 119 were males and 20 females, giving a M:F ratio of 6:1. The incidence of RAAAs was 17.8/100,000 person years (py) in males and 3.0/100,000 py in females. Mean age at rupture was 75.5 years in men (95% confidence intervals (CI) 74-78 years) and 80.2 in women (95% CI 78.8-83 years). There was an age-specific increase in incidence after the age of 65 years in men and after 80 years in women, although 12.6% of all RAAAs occurred in men under 65 years. In all, 100 patients were confirmed to have died of RAAA during the 10-year period. This represents 79% of all ruptures discovered. Almost three-quarters of patients did not reach the operating theatre. Of the 61 patients operated on, 29 survived (48%). The size of the aneurysm at rupture was recorded in 68 cases (49%). The mean size was 8.14 cm (SD 2.0 cm). In five cases (7.4%), rupture occurred in AAAs smaller than 6 cm. The overall mortality from RAAA in Huntingdon health district is approximately 80% and three-quarters of all deaths occurred without an operation. (+info)