William Loan

Role of the Hardman Index in Predicting Mortality for Open and Endovascular Repair of Ruptured Abdominal Aortic Aneurysm

Purpose: To correlate the Hardman prognostic index with perioperative mortality in patients undergoing open and endovascular repair of ruptured abdominal aortic aneurysm (rAAA). Methods: Over a 5-year period, 126 patients (109 men; mean age 74 years, range 51–91) underwent open (n=74) or endovascular (n=52) repair of rAAA in a single unit. Five Hardman factors (age >76 years, history of loss of consciousness, ECG evidence of ischemia, hemoglobin <9.0 g/dL, and serum creatinine >0.19 mmol/L) were assessed, and their association with in-hospital or 30-day mortality was evaluated retrospectively by chi-square or logistic regression analysis. Results: The mortality for open repair was 51.4% (38/74) in comparison to 32.7% (17/52) for the endovascular group (p=0.05). On multivariate analysis, loss of consciousness (p=0.03, OR 2.9, 95% CI 1.1 to 7.5) was the only significant predictor of mortality in both groups. The mortality rates for open repair patients with Hardman scores <2 were 43.5% (20/46) in comparison to 22.9% (8/35) for the endovascular group (p=0.06), whereas mortality rates for patients with scores ≥2 were 64.3% (18/28) and 52.9% (9/17) for the respective groups (p=0.54). Conclusion: The Hardman index correlates well with mortality in both the open and endovascular groups. Those with a score <2 have a trend toward better survival following endovascular repair compared to open repair, while this benefit is not obvious in patients with a score ≥2.

The effects of abdominal compartment hypertension after open and endovascular repair of a ruptured abdominal aortic aneurysm

OBJECTIVE This study assessed if emergency endovascular repair (eEVR) reduces the increase in intra-abdominal compartment pressure and host inflammatory response in patients with ruptured abdominal aortic aneurysm (AAA). METHODS Thirty patients with ruptured AAA were prospectively recruited. Patients were offered eEVR or emergency conventional open repair (eOR) depending on anatomic suitability. Intra-abdominal pressure was measured postoperatively, at 2 and 6 hours, and then daily for 5 days. Organ dysfunction was assessed preoperatively by calculating the Hardman score. Multiple organ dysfunction syndrome, systemic inflammatory response syndrome, and lung injury scores were calculated regularly postoperatively. Hematologic analyses included serum urea and electrolytes, liver function indices, and C-reactive protein. Urine was analyzed for the albumin-creatinine ratio. RESULTS Fourteen patients (12 men; mean age, 72.2 +/- 6.2 years) underwent eEVR, and 16 (14 men; mean age, 71.4 +/- 7.0 years) had eOR. Intra-abdominal pressure was significantly higher in the eOR cohort compared with the eEVR group. The eEVR patients had significantly less blood loss (P < .001) and transfused (P < .001) and total intraoperative intravenous fluid infusion (P = .001). The eOR group demonstrated a greater risk of organ dysfunction, with a higher systemic inflammatory response syndrome score at day 5 (P = .005) and higher lung injury scores at days 1 and 3 (P = .02 and P = .02) compared with eEVR. A significant correlation was observed between intra-abdominal pressure and the volume of blood lost and transfused, amount of fluid given, systemic inflammatory response syndrome score, multiple organ dysfunction score, lung injury score, and the length of stay in the intensive care unit and hospital. CONCLUSION These results suggest that eEVR of ruptured AAA is less stressful and is associated with less intra-abdominal hypertension and host inflammatory response compared with eOR.

Change in Aneurysm Diameter after Stent-Graft Repair of Ruptured Abdominal Aortic Aneurysms

Purpose: To compare the changes in aneurysm size following endovascular aneurysm repair (EVAR) for ruptured versus elective abdominal aortic aneurysms (AAA). Methods: Aneurysm sac diameter was measured from computed tomographic (CT) scans in 14 hemodynamically stable patients (14 men; mean age 74±7 years, range 60 to 83) prior to emergent stent-graft repair for ruptured AAA. The aneurysm diameter change was followed postprocedurally with serial CT and the outcomes compared to 74 AAA patients (58 men; mean age 74± 7 years, range 56 to 87) having elective EVAR in the same time period. The mean rate of sac decrease (mm/month) was calculated for each group. Results: There were 3 postoperative deaths in the ruptured AAA cohort, leaving 11 patients available for follow-up analysis (mean 16 months, range 2–49). Eight (73%) patients with ruptured AAA demonstrated significantly decreased (>5 mm) aneurysm diameters compared with 32 (43%) elective cases (p=0.07) followed a mean 20 months (range 3–51). The mean rate of sac diameter decrease was 1.50± 1.03 mm/month in the rupture group versus 0.73±0.86 mm/month in the elective group (p=0.04). Conclusions: This study suggests that ruptured AAAs treated with stent-graft experience sac regression at a higher rate compared with electively treated AAA. The reasons for these findings remain unclear.

No Difference in Medium-Term Outcome Between Zenith and Talent Stent-Grafts in Endovascular Aneurysm Repair

Background Many devices are available for endovascular aneurysm repair (EVAR). Our aim was to analyze morphological effects of the Zenith and Talent systems. Methods Patients included underwent EVAR from June 1999 to June 2005 using a Zenith or Talent stent-graft, with computed tomography follow-up. Aortic dimensions over time and clinical outcome were analyzed. Results Twenty-nine patients with Zenith stent-grafts and 33 with Talent devices were included. Mean preoperative age was similar (75.5 ± 6.0 years vs 74.2 ± 6.7 years; P = .29). Preoperative neck length was longer in the Zenith group (29.9 ± 15.2 mm vs 25.5 ± 10.8 mm; P = .10), and stent-graft oversizing was greater in the Talent patients (20.2% ± 7.9% vs 23.0% ± 11.3%). There was proximal aortic dilatation and aneurysm sac shrinkage in each group. Complication rates were comparable, with 83% of both groups free from 10-mm migration. Conclusion Although device designs differ, there is no difference in clinical outcome between Zenith and Talent stent-grafts. Migration rates were not influenced by suprarenal fixation.

Endovascular repair of abdominal aortic aneurysm in a patient with renal transplant.

Patients with functioning renal transplant who develop abdominal aortic aneurysm can safely be treated with endovascular repair. Endovascular repair of aneurysm avoids renal ischemia associated with cross-clamping of aorta.

A 6.5-cm pseudoaneurysm of the superior mesenteric artery managed by primary surgical repair.

Superior mesenteric artery (SMA) aneurysms are rare but associated with significant mortality (25–40%) when complicated by rupture or thrombosis. Symptomatic SMA aneurysms, asymptomatic aneurysms of ≥2 cm size and pseudoaneurysms need intervention. We report a case of a 6.5-cm symptomatic SMA aneurysm managed by open surgical repair. At intraoperative exploration, the aneurysm was recognized to be a pseudoaneurysm with a narrow neck (1 mm defect in the native vessel) and was dealt by primary repair. Clinical presentation, the role of radiological investigations and management are discussed. Detailed preoperative assessment of the anatomical characters is essential in planning the intervention for SMA aneurysms. The required information can be obtained by selective interventional angiogram or computed tomographic angiogram with three-dimensional reconstruction. Multi-institutional prospective databases might provide better evidence regarding the timing of intervention, treatment modality, postinterventional follow-up and surveillance of patients with mesenteric aneurysms.

Setting the standards for reporting ruptured abdominal aortic aneurysm.

Introduction: Reported mortality rates for endovascular repair (EVR) of ruptured abdominal aortic aneurysm (rAAA) vary from 0% to 50%. Selection bias, inaccurate reporting, and lack of uniform reporting standards are responsible for this significant discrepancy. Material and Methods: Existing literature about the classification/reporting systems of rAAA is reviewed. A standard way of reporting rAAA based on the physiological, radiological, and operative findings is proposed. Conclusion: The proposed system attempts to provide a universal language of communicating the severity of rupture, address the reporting bias, and allow comparing the outcomes of rAAA.

Late aneurysm rupture after delayed secondary open conversion with partial explantation for failed endovascular repair

A delayed secondary open conversion (SOC) after endovascular aneurysm repair may be necessary due to a failing graft. Many surgical techniques can be performed, and one such approach is partial explantation of the graft with resuturing of a new graft to the retained components of the endograft. No guidelines exist with regards to the follow-up of retained endovascular components after a delayed SOC. The theoretical risk of endoleaks remains with retained components, and this case demonstrates the development of a type Ib endoleak after SOC leading to free flow of blood into a partially resected aneurysm sac and causing a symptomatic aneurysm rupture.

Complex biventricular pacing - a case series.

It is established that cardiac resynchronisation therapy (CRT) reduces mortality and hospitalisation and improves functional class in patients with NYHA class 3-4 heart failure, an ejection fraction of ≤ 35% and a QRS duration of ≥ 120ms. Recent updates in the American guidelines have expanded the demographic of patients in whom CRT may be appropriate. Here we present two cases of complex CRT; one with a conventional indication but occluded central veins and the second with a novel indication for CRT post cardiac transplant.