R. Clement Darling

Vascular complications associated with spontaneous aortic dissection

Three hundred twenty-five cases of spontaneous aortic dissection seen at two institutions between 1965 and 1986 were reviewed to assess the incidence, morbid sequelae, and specific management of aortic branch compromise. Noncardiac vascular complications occurred in 33% of the study group, and in these patients the overall mortality rate (51%) was significantly (p less than 0.001) higher than in patients without (29%) such complications. Although aortic rupture was the strongest correlate of mortality (90%), death specifically related to vascular occlusion was common when such occlusion occurred in the carotid, mesenteric, and renal circulation. There was a strong correlation between stroke and carotid occlusion (22/26 cases), yet specific carotid revascularization was only used during the chronic phase of the disease. Similarly, peripheral operation was ineffective in reducing the mortality rate in the setting of mesenteric (87%) and renal (50%) ischemia. Fifteen patients required either fenestration or graft replacement of the abdominal aorta for acute obstruction, rupture, or chronic aneurysm development. Thirty-eight patients (12%) demonstrated some degree of lower extremity ischemia, and one third of these required a direct approach on the abdominal aorta or iliofemoral segments to restore circulation. Selected patients with acute aortic dissection may require peripheral vascular operation in accordance with a treatment strategy that directs initial attention to the immediate life-threatening complications.

Ruptured arteriosclerotic abdominal aortic aneurysms: A pathologic and clinical study☆

Abstract An autopsy study of 83 consecutive nonresected ruptured arteriosclerotic abdominal aortic aneurysms and 199 nonruptured aortic aneurysms noted at postmortem examination from 1952 to 1968 at the Massachusetts General Hospital were reviewed with regard to aneurysm size. Over 18 per cent of nonresected aneurysms under 5 cm or less had caused death by rupture. The incidence of rupture of aneurysms measuring between 5.1 and 7 cm, 7.1 and 10 cm, and over 10.1 cm in diameter was approximately 20, 60, and 95 per cent, respectively. Of patients dying with ruptured aneurysms without resection, 80 per cent survived six hours, 50 per cent for twenty-four hours, 30 per cent for six days, and 10 per cent for six weeks. There was no common anatomic site of perforation and a great majority of these aneurysms might have been easily resectable from a technical viewpoint. The clinical report consists of sixty consecutive patients with ruptured arteriosclerotic abdominal aortic aneurysms operated on by this author during the past eight years. More than half the patients were in the eighth decade of life or more. Massive blood loss and shock were present preoperatively in three quarters of the group. About 20 per cent of ruptured aneurysms were 7 cm or under in diameter. Of sixty patients, eight died of shock on the operating table, five died from one to five days, and eleven from six to sixty days postoperatively. Thirty-six or 60 per cent of patients, however, survived to leave the hospital. On the basis of this experience, I would like to emphasize the importance of some newer technical considerations. These include preoperative emergency application of an antigravity suit, intraluminal control of massive aortic hemorrhage at operation, and a method of aneurysm resection which minimizes venous injury. Particular emphasis is placed on the importance of postoperative respiratory support determined by routine arterial blood gas monitoring. A number of early deaths may be preventable, particularly those relating to pancreatitis and bowel ischemia. In my experience, since the combined operative mortality and late graft failure rate with elective aneurysmectomy is under 4 per cent, all abdominal aortic aneurysms, with rare exceptions, should be surgically treated before rupture occurs.

Durability of femoropopliteal reconstructions: Endarterectomy versus vein bypass grafts☆

Abstract Eighty-seven endarterectomies and 345 saphenous vein bypass grafts were carried out from 1955 to 1967 because of atherosclerotic femoropopliteal occlusive disease. The follow-up period ranged from three to fifteen years and accumulative patency rates were calculated by the life table method. Patency rates at three, five, and seven years for vein grafts were 74 per cent, 68 per cent, and 63 per cent, respectively. The patency rates for endarterectomy at these periods were 38 per cent, 33 per cent, and 23 per cent, respectively. In our experience once a vein bypass graft has been successfully implanted, the long-term success rate is little altered by pre-existing disease of the outflow vessels.

Are familial abdominal aortic aneurysms different

A 9-year prospective study of 542 consecutive patients undergoing operation by one of the authors for abdominal aortic aneurysms was undertaken to define the incidence, clinical behavior, and anatomic characteristics of familial abdominal aortic aneurysms. Eighty-two (15.1%) patients having surgery for abdominal aortic aneurysms were found to have a first-degree relative with an aneurysm, as compared to nine (1.8%) of a control group of 500 patients of similar age and sex without aneurysmal disease (p less than 0.001). Detailed analysis was next performed of the pedigree charts of patients with a positive family history of aneurysm who underwent repair of abdominal aortic aneurysms by all authors over the 9-year study period. This review identified a total study population of 86 families with 209 first-degree relatives with abdominal aortic aneurysms. Clinical and anatomic features of this familial group were compared to those of 460 patients operated on for abdominal aortic aneurysms who had no family history of abdominal aortic aneurysms. Patients with familial abdominal aortic aneurysms were more likely to be women (35% vs 14%), and men with familial abdominal aortic aneurysms tended to be about 5 years younger than the women. There was no significant difference between the patients with nonfamilial and familial abdominal aortic aneurysms in anatomic extent of aneurysmal disease, multiplicity of aneurysms, associated occlusive disease, or blood type. There was a history of aneurysm rupture in 35 of 86 (40.7%) families with familial abdominal aortic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortocaval and iliac arteriovenous fistulas: Recognition and treatment

Despite the well characterized physiologic effects of aortocaval or iliac arteriovenous fistulas, patients with such uncommon lesions may manifest a diverse array of symptoms, and diagnosis is often delayed or overlooked. To examine clinical features that facilitate recognition and allow successful repair, a 30-year experience with 20 such fistulas was reviewed. Fourteen fistulas were caused by aneurysm erosion, four followed iatrogenic injury during lumbar disk surgery, and two developed from abdominal gunshot wounds. The interval from presumed occurrence to diagnosis ranged from 3 hours to 8 years. The diagnosis was not recognized before surgery in five (25%) patients. Back pain (70%) was the most common symptom. The presence of a typical abdominal bruit (80%) was the most reliable physical finding, but its significance was occasionally overlooked or misinterpreted. Congestive heart failure was prominent in only seven (35%) patients. Severe lower extremity edema and mottling was the primary manifestation in eight cases, often causing initial confusion with venous thrombosis. Hematuria (5 patients) and oliguric renal failure (4 patients), both fully reversible after fistula repair, also caused diagnostic uncertainty. The mean preoperative cardiac output was 12.2 L/min, falling to 5.4 L/min with fistula repair. Mean blood loss was 5960 ml, supporting use of intraoperative autotransfusion. Two operative deaths (10%) occurred, both in patients not correctly diagnosed before surgery. Despite varied modes of presentation, prompt recognition and use of appropriate operative techniques should achieve successful repair.

Angiography in the Management of Aneurysms of the Abdominal Aorta: Its Value and Safety

The course of 190 patients with aneurysm of the abdominal aorta who underwent preoperative aortography was reviewed to determine the safety and usefulness of that procedure. There were no serious complications; minor problems occurred in only four patients and did not affect operative therapy. In 21 patients, the clinical impression of aneurysm was found to be incorrect. Surgically important findings included suprarenal extension of the aneurysm in nine patients, and demonstration of stenotic lesions in the renal arteries (37 patients) or superior mesenteric artery/celiac axis (17 patients). Helpful findings were associated aneurysms (26 patients), multiple renal arteries (28 patients), and occlusive lesions in the lower extremities or aortocranial system in 82 and eight patients respectively. Such information was found useful in planning operative procedures and minimizing operative time and blood loss. In our experience, angiography in patients with aneurysm of the abdominal aorta is both safe and informative.

Surgical management of mycotic aneurysms and the complications of infection in vascular reconstructive surgery

Abstract A series of seventeen mycotic aneurysms treated over the past fifteen years at this institution has been reported. Thirteen of these involved the abdominal aorta and four involved peripheral vessels. Rupture of the aneurysm occurred in ten. There were no survivors in the seven patients with ruptured aneurysms that involved the aorta, four of whom underwent emergency surgery. There were two survivors among the three patients with peripheral ruptured mycotic aneurysms. There were five survivors of the seven with nonruptured aneurysms treated surgically. Four of the six patients with mycotic nonruptured aneurysms of the aorta treated surgically survived and are well at periods of nineteen months to nine years. Three additional successfully managed cases of infection complicating vascular reconstructive procedures have been presented, emphasizing the technics of management. The following factors appear to be of importance to the successful management of mycotic aneurysms or infection complicating vascular reconstructive surgery: (1) early diagnosis and prompt surgery; (2) appropriate pre- and intraoperative antibiotic therapy and postoperative intravenous antibiotic therapy for a period of at least six weeks; (3) resection of infected tissue, foreign material, and adequate drainage; (4) placement of the new graft reconstruction through clean tissue planes; (5) use of wide drainage and local antibiotic irrigation in addition to systemic antibiotics in rare situations in which resection and reconstruction does not seem possible; (6) careful long-term follow-up study.

Carotid endarterectomy in awake patients: Its safety, acceptability, and outcome

PURPOSE The purpose of this study was to determine the safety and efficacy of performing carotid endarterectomy procedures with the patient receiving cervical block anesthetic. METHODS Over the last 14 years, 654 carotid endarterectomy procedures were performed with patients receiving regional anesthetic. Intraluminal shunts were placed on demand, if neurologic changes with clamping of the carotid artery developed in the patient. During the same period, 419 cases were done with the patients receiving general anesthetic. Choice of anesthetic was based on surgeon and patient preference. RESULTS In the regional anesthetic group the indications for operation included transient ischemic attack (311), asymptomatic hemodynamically significant stenosis (146), amaurosis fugax (106), stroke (86), restenosis (3), and aneurysm (2). Shunts were used in 46 of 654 cases (7%). Conversion from regional to general anesthetic was required in seven patients (1.1%). The operative mortality rate was 0.76% (5 of 654). Permanent nonfatal neurologic deficits occurred in 0.76% (5 of 654), and temporary neurologic deficits occurred in 1.07% (7 of 654). CONCLUSIONS On the basis of these results, we believe regional cervical block anesthetic is an acceptable option to the routine use of shunts performed with the patient receiving general anesthetic during carotid endarterectomy. In addition, the ability to continuously assess the awake patient receiving cervical block may contribute to a decrease in perioperative stroke and mortality rates while simplifying functional cerebral monitoring during carotid endarterectomy.

The current surgical management of carotid body paragangliomas

To determine if recent trends in evaluation and therapy have contributed to the successful surgical management of carotid body paragangliomas, we reviewed our experience over the past decade. Nineteen carotid body paragangliomas were identified in 17 patients. Eleven patients underwent complete, preoperative embolization of their afferent arteries with one complication. Calculated carotid body paragangliomas surface areas did not differ between the embolized 64.6 +/- 43.3 cm2 and nonembolized 63.0 +/- 57.9 cm2 lesions. Intraoperative blood loss was lower (p = 0.02) in the patients treated with embolization (372 +/- 213 ml) compared with their cohorts (609 +/- 564 ml). However, the operative times were equivalent 4.1 hours versus 4.5 hours in both groups. Intraoperative electroencephalographic (EEG) monitoring was used in 10 patients; in one patient the EEG indicated intraoperative thrombosis of the carotid artery, which was successfully treated by thrombectomy without complications. Two patients required carotid bifurcation resection and vascular reconstruction to remove the entire tumor; a late stroke manifested by contralateral hand weakness developed in one of these patients. The incidence of cranial nerve injury was low at 16%, with one transient ramus mandibularis paresis and two instances of vocal cord dysfunction. Two additional patients had a postoperative Horners syndrome. We conclude that by diminishing intraoperative blood loss through complete and careful preoperative embolization and use of intraoperative EEG monitoring along with careful surgical technique, the complications associated with this challenging operation are facilitated and diminished.

Fate of the excluded abdominal aortic aneurysm sac: Long-term follow-up of 831 patients

PURPOSE Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed. METHODS From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed. RESULTS The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 +/- 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted. CONCLUSION Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention.