Symptomatic aortic aneurysm is an extremely acute condition with manifest or threatening aortic rupture. The mortality is high and urgent surgery is essential and often life-saving. A correct diagnosis needs to be made without delay, a fact which places great demands on the doctor--often not a surgeon--who is first consulted by the patient. The differential diagnosis and emergency management are discussed here against the background of the course of events in four patients with aortic aneurysm who were referred erroneously for admission to a coronary intensive care unit during a 12-month period. Two of the patients died. The ultrasonographic findings were decisive for the outcome in the two surviving patients and yielded a rapid diagnosis in one further case. Ultrasonography is recommended as the method of first choice for verifying or excluding this condition when it is suspected on clinical grounds.
Department of Surgical Sciences, Section of Vascular Surgery, Uppsala University, Uppsala, Sweden; Department of Surgery, Falun County Hospital, Falun, Sweden. Electronic address: firstname.lastname@example.org.
Acquiring contemporary data on prevalence and natural history of abdominal aortic aneurysms (AAA) is essential in the effort to optimise modern screening programmes. The primary aim of this study was to determine the fate of a 65-year-old male population 5 years following an invitation to an aortic ultrasound (US) examination.
In this population-based cohort-study, men were invited to US examination at age 65, and were re-invited at age 70. Mortality, AAA repair, and risk factors were recorded. An AAA was defined as a diameter =30 mm, and a sub-aneurysmal aorta as 25-29 mm.
In 2006-2007, 3,268 65-year-old men were invited, and 2,736 (83.7%) were examined. After 5 years, 24 had completed AAA repair (6 died within 0-4 years), an additional 239 had died, and 194 had moved. Thus, 2,811 70-year-old men were re-invited, and 2,247 (79.9%) were examined. The AAA prevalence increased from 1.5% at 65 to 2.4% (95% CI: 1.8 to 3.0) at 70, and of sub-aneurysmal aortas from 1.7% at 65 to 2.6% (2.0 to 3.3), at 70. Of 2,041 with
To report an initial experience with endovascular stent-graft implantation for diseases of the descending thoracic aorta in high-risk patients.
Forty-three patients (28 men; mean age 67 years, range 17-82) with 16 descending thoracic aortic dissections, 14 aneurysms, 7 contained ruptures, 3 mycotic aneurysms, 2 posttraumatic pseudoaneurysms, and an aneurysm of an anomalous right subclavian artery were treated between June 1999 and July 2001. Twenty-three (53%) patients were treated emergently.
There were no conversions to open repair, but 3 (7%) patients died during the first 30 days (pneumonia, multiorgan failure, and acute bowel ischemia). Thirteen (30%) patients suffered 18 major complications (8 strokes, paraplegia in 3, respiratory insufficiency in 6, and 1 renal failure). Of 7 (16%) endoleaks detected in the early postoperative period, 3 required additional stents, while the other 4 were treated conservatively. Follow-up, which averaged 19 +/- 6 months (median: 13; range 0-34), was 100% complete. Five (12%) patients died: 3 of aortic rupture at 34, 47, and 139 days, respectively, and 2 from heart failure at 3 and 15 months, respectively. No late migration or endoleaks have been detected in the remaining 35 patients; however, 1 (2%) patient showed progressive aortic dissection proximal to the stent-graft. In all other cases, the size of the aneurysm or the false lumen was unchanged or diminished.
Treatment of descending thoracic aortic diseases with an endovascular approach has acceptable early mortality and morbidity in high-risk patients. In selected cases, stent-grafts may afford the best therapy.
The aim of this study was to report the five-year incidence of incisional hernia after vascular repair of abdominal aortic occlusive (AOD) and aneurysmal disease (AAA), and to determine the factors associated with the development of this complication. Consecutive patients who underwent AAA and AOD at the University of Manitoba, Canada, between January 1999 and December 2002, were recruited and evaluated by clinical examination one week, one month and six months after the surgery, and through medical records review thereafter. The development of postoperative incisional hernia was recorded and analyzed. Two-hundred four patients, with a mean age of 70.1 years, provided consent for the study. The overall five-year incidence of incisional hernia was 69.1% and the overall median failure time was 48 months. The median failure time was 48 months for AOD and 36 months for AAA (P
The goal of the present study was to investigate the number of operations for abdominal aortic aneurysm (AAA) including time-trends in treatment during a 20-year period. Operating time and anesthesia time were also studied.
During the period 1983-2002, a total of 1,041 patients with AAA were treated with open surgery (905) or EVAR (136). Number of operations, type of graft, anesthesia time, and operating time were the variables investigated. Data were collected retrospectively from the patients' medical records.
There was an increase in the number of operations both for ruptured and non-ruptured AAA in men during the study period. Among women, an increase was observed only for ruptured aneurysm. Operating time and anesthesia time increased significantly during the 20-year period. The number of patients treated by EVAR increased significantly, beginning in 1995.
In conclusion, there has been an increase in the number of AAA operations, and the proportion of patients treated with EVAR is increasing. Furthermore, we found an increase in both anesthesia time and operating time. These trends may be important for allocation of resources needed for the treatment of patients with AAA.
Hybrid operations combining open and endovascular surgeries are used in cardio-vascular surgery for the last 10-15 years. It leads to decrease complications frequency and mortality in case of pronounced comorbidities and severe heart, aorta and its branches disease. Authors have experience in performing of 10 hybrid surgeries and 7 aneurysms endoprosthesis of abdominal aorta. All operated patients had severe comorbidities which significantly increase risk of open surgery. These comorbidities were contraindication for open surgery in patients with abdominal aorta aneurysm. Thanks to introduction into practice hybrid operations and aorta aneurysms endoprosthesis the authors decreased complications frequency and avoided deaths in operated patients.
Worldwide, increasing proportions of aortic aneurysms are repaired electively via the endovascular route. The purpose of this study was to report the recent utilization of endovascular repair in Canada by reviewing a national administrative database.
The Canadian Institute for Health Information database (a collection of all acute care hospitalizations) was reviewed to identify patients who received nonemergent repair of an abdominal aortic aneurysm (AAA) between April 1, 2003 and March 31, 2004. During this 1-year period, differentiation between endovascular (EVAR) and open repair was possible using ICD-10-CA procedural codes in eight of ten provinces. Case volumes, patient age, length of hospitalization, and mortality were stratified by method of repair, province, and size and teaching status of hospitals.
In this 1-year period, 1996 patients in eight provinces (representing 72% of Canada's population) underwent open repair (n = 1818, 91.1%) or EVAR (n = 178, 8.9%) of a nonruptured AAA. National utilization rates were 8.4 and 0.8 per 100,000 population for open repair and EVAR. These rates were more constant for EVAR (0 to 1.3) then for open repair (4 to 18.3) when analyzed on a provincial basis. Mean patient age did not differ between EVAR and open repair (73.7 vs 71.9 years, P = 0.4) while mean length of stay (5.8 vs 11.9 days, P = 0.03) and in-hospital mortality (0.6% vs 4.6%, P = .025) were significantly lower for EVAR than for open repair. Most EVAR (96%) and more than half of open repairs (56%) were performed in academic teaching centers.
Although EVAR results in significant reductions in length of hospitalization and early mortality, it continues to be underutilized in Canada compared with other national reports involving administrative databases.
Community screening to guide preventive interventions for acute aortic disease has been recommended in high-risk individuals. We sought to prospectively assess risk factors in the general population for aortic dissection (AD) and severe aneurysmal disease in the thoracic and abdominal aorta.
We studied the incidence of AD and ruptured or surgically treated aneurysms in the abdominal (AAA) or thoracic aorta (TAA) in 30 412 individuals without diagnosis of aortic disease at baseline from a contemporary, prospective cohort of middle-aged individuals, the Malm? Diet and Cancer study. During up to 20 years of follow-up (median 16 years), the incidence rate per 100 000 patient-years at risk was 15 (95% CI 11.7 to 18.9) for AD, 27 (95% CI 22.5 to 32.1) for AAA, and 9 (95% CI 6.8 to 12.6) for TAA. The acute and in-hospital mortality was 39% for AD, 34% for ruptured AAA, and 41% for ruptured TAA. Hypertension was present in 86% of individuals who subsequently developed AD, was strongly associated with incident AD (hazard ratio [HR] 2.64, 95% CI 1.33 to 5.25), and conferred a population-attributable risk of 54%. Hypertension was also a risk factor for AAA with a smaller effect. Smoking (HR 5.07, 95% CI 3.52 to 7.29) and high apolipoprotein B/A1 ratio (HR 2.48, 95% CI 1.73 to 3.54) were strongly associated with AAA and conferred a population-attributable risk of 47% and 25%, respectively. Smoking was also a risk factor for AD and TAA with smaller effects.
This large prospective study identified distinct risk factor profiles for different aortic diseases in the general population. Hypertension accounted for more than half of the population risk for AD, and smoking for half of the population risk of AAA.