John A. Murie

Influence of sex on expansion rate of abdominal aortic aneurysms.

The UK Small Aneurysm Trial suggested that female sex is an independent risk factor for rupture of abdominal aortic aneurysm (AAA). This study assessed the effect of sex on the growth rate of AAA.

Vascular trauma of the upper limb and associated nerve injuries

In an analysis of vascular audit data on upper limb vascular trauma over a 10 year period in a major UK injury centre it was found that 15 patients required operation for subclavian or axillary artery injuries. Eleven cases were the result of blunt injury. Twelve patients had an ischaemic arm on presentation, all of whom had an associated brachial plexus lesion. Subclavian or axillary artery transections, irrespective of limb viability, also were found to have associated plexus trauma. Twenty-eight patients had brachial artery injuries repaired, 46 per cent of whom had an associated nerve injury. A good functional result was achieved in only half of the patients who underwent repair of a peripheral nerve injured in association with the brachial artery. Vascular reconstruction was successful in all cases. The long-term outcome of brachial plexus lesions was very poor and the role of exploratory surgery is discussed. The long-term outcome of upper limb injury is not dependent on the vascular injury which can be successfully managed, but upon the recognition, treatment, and outcome of the associated nerve injuries.

The value of computed tomography in the assessment of suspected ruptured abdominal aortic aneurysm

OBJECTIVE The objective of this study was to determine the diagnostic value of computed tomography (CT) in patients with suspected ruptured abdominal aortic aneurysm. STUDY DESIGN The study was an interrogation of a prospectively gathered computerized database. SETTING The study was performed at a regional vascular surgery unit. SUBJECTS Six hundred fifty-two consecutive patients were admitted to this unit with suspected ruptured abdominal aortic aneurysm between January 1, 1989, and December 31, 1996. Seventy-four patients (11.3%) in whom the diagnosis was in doubt on clinical grounds alone underwent urgent CT. A total of 47 men and 27 women with a median age of 73 years (range, 52 to 86 years) were evaluated. MAIN OUTCOME MEASURES CT and operative findings were compared. RESULTS CT correctly diagnosed rupture in 22 of 28 patients who underwent operation and correctly excluded rupture in 30 of 39 patients who underwent operation. The sensitivity and specificity of CT when compared with operative findings were therefore 79% and 77%, respectively. CONCLUSIONS These data indicate that CT has little additional diagnostic value. If in the opinion of an experienced vascular surgeon rupture cannot be excluded on clinical grounds alone, and the patient has no medical contraindications to abdominal aortic aneurysm repair, then the patient should be taken directly to the operating department.

Contemporary results for open repair of suprarenal and type IV thoracoabdominal aortic aneurysms

Endovascular and hybrid procedures are not yet widely established in the management of type IV thoracoabdominal aortic aneurysm (TAAA). Open surgery remains the treatment of choice until the long‐term outcomes of these novel techniques are known.

Randomized controlled trial of dual antiplatelet therapy in patients undergoing surgery for critical limb ischemia

Background and Objective:Patients with critical limb ischemia have a perioperative cardiovascular morbidity comparable to patients with acute coronary syndromes. We hypothesized that perioperative dual antiplatelet therapy would improve biomarkers of atherothrombosis without causing unacceptable bleeding in patients undergoing surgery for critical limb ischemia. Methods:In a double-blind randomized controlled trial, 108 patients undergoing infrainguinal revascularization or amputation for critical limb ischemia were maintained on aspirin (75 mg daily) and randomized to clopidogrel (600 mg prior to surgery, and 75 mg daily for 3 days; n = 50) or matched placebo (n = 58). Platelet activation and myocardial injury were assessed by flow cytometry and plasma troponin concentrations, respectively. Results:Clopidogrel reduced platelet-monocyte aggregation before surgery (38%–30%; P = 0.007). This was sustained in the postoperative period (P = 0.0019). There were 18 troponin-positive events (8 [16.0%] clopidogrel vs. 10 [17.2%] placebo; relative risk [RR]: 0.93, 95% confidence interval [CI]: 0.39–2.17; P = 0.86). Half of troponin-positive events occurred preoperatively with clopidogrel causing a greater decline in troponin concentrations (P < 0.001). There was no increase in major life-threatening bleeding (7 [14%] vs. 6 [10%]; RR: 1.4, 95% CI: 0.49–3.76; P = 0.56) or minor bleeding (17 [34%] vs. 12 [21%]; RR 1.64, 95% CI: 0.87–3.1; P = 0.12), although blood transfusions were increased (28% vs. 12.6%, RR: 2.3, 95% CI: 1.0–5.29; P = 0.037). Conclusions:In patients with critical limb ischemia, perioperative dual antiplatelet therapy reduces biomarkers of atherothrombosis without causing unacceptable bleeding. Large-scale randomized controlled trials are needed to establish whether dual antiplatelet therapy improves clinical outcome in high-risk patients undergoing vascular surgery.

Acute thrombosis of the non-aneurysmal abdominal aorta

Fourteen patients admitted over a 9 year period with acute thrombotic occlusion of the non-aneurysmal abdominal aorta have been reviewed. Twelve patients underwent aortic bifurcation graft reconstruction, one thromboendarterectomy alone, and one a re-entry operation for dissection. Two patients (14%) died in the perioperative period. The mean postoperative survival of the remaining patients is to date 55 (range 4-93) months with a mean follow-up period of 69 (range 18-100) months. The results indicate these patients should be treated aggressively by early reconstructive surgery in the expectation that the majority will survive their operation and gain a useful extension to their lives.

Non-operative Management of High-Risk Patients with Abdominal Aortic Aneurysm

OBJECTIVES to determine the risk of rupture in patients with large non-operated abdominal aortic aneurysms (AAAs). METHODS in 128 patients admitted over a 5-year period with an intact AAA, and who did not have a surgical repair were included, initial maximum antero-posterior AAA diameter was related to survival and cause of death. RESULTS at the end of follow-up 27/52 (52%) patients with AAA <55 mm were alive compared to 17/62 (27%) patients with AAA > or =55 mm. Six (12%) in the former and 18 (29%) in the latter group had an AAA-related death. However, non-AAA-related death was commoner in both groups. CONCLUSION these findings support a role for non-operative management in high-risk patients with large AAAs.

Systemic Inflammation and Repair of Abdominal Aortic Aneurysm

BackgroundInflammation is integral to the pathogenesis of abdominal aortic aneurysm (AAA). This study examines preoperative biomarkers of systemic inflammation in patients undergoing open repair of intact and ruptured AAA.MethodsOne-hundred twelve patients were entered into a prospective observational study. Preoperative POSSUM physiology score, C-reactive protein (CRP), white blood count (WBC), platelet count, fibrinogen, and albumin were recorded and related to clinical variables using univariate analysis.ResultsSixty-one patients with a ruptured AAA, 39 with an asymptomatic intact AAA, and 12 with an acutely symptomatic intact AAA underwent attempted repair. There were two inflammatory asymptomatic aneurysms and one inflammatory ruptured aneurysm. No patient had clinical evidence of coexistent inflammatory disease. Patients with a symptomatic intact AAA had a significantly greater level of CRP and fibrinogen, higher WBC, and lower serum albumin, than those with an asymptomatic intact AAA. Patients with a ruptured aneurysm had a significantly greater level of CRP, higher WBC, and lower serum albumin than those with an asymptomatic intact aneurysm. Patients with a symptomatic intact AAA had a significantly higher CRP level, but lower WBC, than those with a ruptured AAA. There was no difference in CRP level, WBC, or serum albumin between survivors and non-survivors of attempted repair of asymptomatic, symptomatic and ruptured AAA.ConclusionsAcutely symptomatic and ruptured AAAs are associated with an early elevation in systemic inflammatory biomarkers. This early activation of the inflammatory response might influence perioperative outcome.

Outcome and Survival of Patients Aged 65 Years and Younger after Abdominal Aortic Aneurysm Rupture

Advanced age (> 80 years) confers a survival disadvantage after operative repair of a ruptured abdominal aortic aneurysm (AAA). This study aimed to determine if young age (≤65 years) confers a survival benefit. Consecutive patients undergoing attempted repair of a ruptured AAA between 1995 and 2001 were included in the study. Demographic, clinical, and operative factors were analyzed together with in-hospital mortality, duration of postoperative hospital stay, and long-term survival. Of 378 patients admitted with a ruptured AAA, 52 (14%) were ≤ 65 years of age and 326 (86%) were > 65 years. There were 4 (8%) women in the younger cohort compared to 74 (23%) women in the older group (p = 0.015). Four (8%) patients in the younger group were thought to be unsuitable for surgical repair compared to 77 (24%) patients in the older cohort (p = 0.009). Of the 48 younger patients who underwent attempted operative repair, 22 (46%) died in hospital, compared to 108 (43%) of 249 patients > 65 years (p = 0.753). The median (range) postoperative hospital stay of survivors was 11 days (6–59 days) in the younger cohort and 15 days (6–121 days) in the older group (p = 0.005). Patients ≤ 65 years of age undergoing operative repair of ruptured AAA have no survival advantage over older patients. These data support AAA screening for the “at risk” and age-defined population.