Open Reconstruction of Huge Abdominal Aortic Aneurysms: Postoperative Complications

Open Reconstruction of Huge Abdominal Aortic Aneurysms: Postoperative Complications

Amr M. Salem1, MD;1 Sameh Moustafa, MD;2 Tarek M. Salem, MD;3

Mohamed E. Salem Ph.D.2

1) Vascular Surgery, Medical Research Institute, Alexandria University, Egypt.

2) Vascular Surgery, Faculty of Medicine, Alexandria University, Egypt.

3) Internal Medicine, Faculty of Medicine, Alexandria University, Egypt.

Purpose: Was to study the results of open surgical reconstruction of huge abdominal aortic aneurysms (HAAAs) & their complications.

Patients and methods: Twenty eight patients with huge abdominal aortic aneurysms were studied in the period from October 2012- March 2015. The diagnosis was done by: history, clinical examination, various imaging which included: Duplex Ultrasound, CTA, MRA, DSA

& Mid-stream aortography. Open aortic reconstruction was done by using Bifurcated graft

(Collagen coated or PTFE ) or aneurysmorrhaphy in two cases of mycotic saccular aneurysms.

Results: The age incidence ranged from 45-78 years with a mean of 64 years. Male sex was predominant than female sex with M:F ratio 6:1. There was a history of Diabetes mellitus, smoking, hypertension, hypercholesterolaemia, obesity, myocardial infarction (seven cases)

& renal impairment (two cases). The most common presentation of AAAs were abdominal pain, back pain, pulsating abdominal mass & acute abdomen (in two leaking AAAs). The size of the aneurysm (diameter) ranged between 12-22 cm with a mean of 16 cm, the size was measured by Duplex Ultrasound & CTA. Postoperative Morbidity: lower limb ischemia due to arterial thrombosis was present in two cases & distal embolization in two cases, thrombectomy

& embolectomy were done respectively & successfully except one big toe amputated after embolectomy. Myocardial infarction occurred in four cases, two of them died. Another two cases developed uraemia, one of them died. Leaking abdominal aortic aneurysms occurred in two cases, one of them died. The overall all mortality rate within thirty postoperative days was four cases (14.3%), no intraoperative mortality.

Conclusion: The morbidity & mortality rates were proportional with increase in size of the aneurysm & increase with the presence of preoperative cardiac, renal dysfunction & risk factors.

Key words: Open reconstruction, abdominal aortic aneurysm (AAA), pulsating abdominal mass, lower limb ischemia & back pain.

Introduction:

Abdominal aortic aneurysm (AAA) is a prevalent threat, affecting approximately 5% of males over the age of 65. Open aneurysm repair (OAR) has been performed since the

1950s with a 30-day mortality of 4–12%.1

Abdominal aortic aneurysms (AAAs) are the 10th leading cause of death in men over

55 years of age. The incidence of AAAs in

60-70 years old patients is 4% in men and 1% in women. The incidence increases with age in both sexes. Family history is an important predictor of aneurysm development.2

The infrarenal aorta is the most common location for clinically significant aneurysms. Among AAAs undergoing surgical repair, about 95% are infrarenal, only 5% involve the suprarenal aorta.3

Most AAAs (about 75%) cause no symptoms unless they rupture. AAAs may cause   chronic   abdominal   or   back   pain, acute ischemia of the lower limbs due to embolization  or  local  dissection  (both  in

2-5%) and usually presented by pulsating abdominal mass. Occasionally AAAs cause local compression.4,5

Rupture continues to be the eventual fate of AAAs, which results in: Sudden abdominal or back pain, hypotension and shock, and a pulsatile abdominal mass. Mortality rates after rupture are ranged from 15% to 94% with an average of 50%.6,7

An abdominal aortic aneurysm is usually diagnosed by history, physical examination, ultrasound, or CTA, plain radiographs, MRA and DSA.8

There are currently two modes of repair available   for   an   AAA:   open   aneurysm repair (OR), and endovascular aneurysm repair (EVAR). An intervention is often recommended if the aneurysm grows more than 1cm per year or it is bigger than 5.5cm.9

Repair is also indicated for symptomatic aneurysms.10

Open repair is indicated in young patients as an elective procedure or in growing or large aneurysm (more than 5.5 cm), symptomatic or ruptured aneurysms, also open repair is indicated if EVAR is contraindicated as in short aortic neck less than 15 mm, angulation more than 45 degrees, dilated aortic neck, the shape of the neck is irregular, conical or reverse conical neck, localized posterior bulge in the neck (double bubble), a symmetry of the wall of the neck and eccentric laminated thrombus. There is strong evidence that open repair is durable.11–13

EVAR: It is generally indicated in older, high risk patients unfit for open repair. The main advantages of EVAR is less perioperative mortality, less time in intensive care and less time in hospital.14–17

Disadvantages of EVAR include a requirement for more frequent ongoing hospital   reviews   and   higher   chance   for further procedures being required. The EVAR does not offer any benefit for overall survival or health-related quality of life compared to

open repair.18–21 There are also significantly higher risks of reintervention and aneurysm rupture after EVAR.22

The postoperative mortality for an already ruptured AAA has slowly decreased over several decades but remain higher than 40%.5

However, if the AAA is surgically repaired before rupture, the postoperative mortality rate is lower: approximately 1-6%.6,23,24

Aim of the work:

The  aim  of  this  work  was  to  evaluate the results of surgically reconstructed huge abdominal aortic aneurysms (HAAAs) as regard morbidity and mortality.

Patients:

After local ethical committee of the Faculty of Medicine, Alexandria University approval and obtaining fully informed patients consent, the current study was conducted on twenty eight patients with huge abdominal aortic aneurysms (HAAAs) who admitted to the Alexandria Main University Hospital, Faculty of Medicine, Alexandria University and Moustafa Kamel Millitary Hospital, Alexandria, Egypt , in the period from October 2012- March 2015.

Methods:

All      cases      were      diagnosed      by: history, clinical examination, laboratory investigations, Duplex US, CTA, MRA and DSA. ECG and echocardiogram were done for every case. Aortic reconstruction was done by using artificial bifurcated grafts (collagen coated graft and PTFE graft). Aneurysmoraphy was done in two cases of mycotic saccular type.

Results:

The age incidence ranged between 45-75 years with an average of 64 years. Male sex was predominant than female sex with a M:F ratio 6:1.

All cases were subjected to routine laboratory investigations which were normal or controlled. Diagnosis was done by Duplex US and CTA for all cases, while MRA & DSA were used in three cases. Plain X-ray

Case 1

Case 1

Figure (1): CTA of huge AAA with a diameter

15 cm.

Figure (2): CTA of AAA with angulated &

dilated asymetrical neck.

Case 1

Case 1

Figure  (3):  Photo  of  the  abdomen  before operation showing abdominal bulge.

Figure (4): Photo of the huge size of the aneurysm 15 cm during operation after opening of the abdomen.

was done to visualize calcifications in the aneurysmal wall in five cases.

Open repair was done for all cases. 26 cases reconstructed by using bifurcated grafts:  Collagen  coated  in  14  cases  and PTFE in 12 cases. Two cases with saccular aneurysms  were  treated  by  lateral  repair using artificial patch graft. Three cases were represented  in  the  result  before  and  after

30 days of aortic reconstruction: Case (1): Figures (1‑8). Case (2): Figures (9‑14). Case (3): Figures (15,16).

The size and the diameter of AAAs were measured by Ultrasound and CT scan. The largest diameter of the aneurysms ranged between 12-22 cm. with an average of 16 cm. we consider any AAA with diameter ten cm or more is a huge AAA

Case 1

Figure (5): Photo of the laminated thrombus outside the aneurysm.

Case 1

Figure (6): Photo of the bifurcated graft after aortic reconstruction.

Case 1

Case 1

Figure (7): Photo of the abdominal wound after 30 days of the operation.

Figure (8): Postoperative CTA showed the two limbs of the bifurcated graft, 30 days after operation.

Case 2

Figure (9): Duplex US showing AAA.

Case 2

Figure (10): CTA showed aneurysm 18cm in diameter compressing the abdominal aorta to the left side and simulating Rt. renal artery aneurysm.

Discussion:

There are currently two types of repair available for AAA. Open aneurysm repair (OR) and endovascular aneurysm repair (EVAR).20

Open repair is indicated in young patients as an elective procedure or growing or large (more than 5.5 cm), symptomatic or ruptured

aneurysms. Also, if EVAR is contraindicated. There is strong evidence that open repair is durable.12 Endovascular repair is associated with more reinterventions and requires periodic imaging for the remainder of the patient's life. The clearest indication for endovascular repair had been assumed to be patients who are at higher risk from open repair.

Case 2                                                    Case 2

Figure (11): MRA showed normal Rt renal artery. It was saccular AAA arising from the frant of the aorta (juxta renal).

Figure (12): Photo of the abdomen before operation (aneurysm bulge).

Case 2

Figure  (13):  Postoperative  photo  of  the abdomen after 30 days (healed wound).

Case 3

Figure (15): CTA of leaking AAA, 12 cm in diameter.

Case 2

Figure (14): Postoperative CTA after 30 days showed that the abdominal aorta was intact.

Figure  (16):  Postoperative  CTA  after    30 days of operation of AAA, showing the two limbs of the graft.

Table (1): The clinical presentation of AAAs.

Table (2): The preoperative risk factors in 28 patients with huge AAAs.

Table (3): The site & types of AAAs.

Table (4): The morbidity of AAAs within 30 postoperative days.

* The two cases with renal failure had preoperative renal insufficiency with serum creatinine

level of 1.6 and 1.9 mg/dl.

Table (5): The mortality of AAAs within 30 postoperative days.

* The case which was presented with leaking AAA confirmed by CTA and urgent operation

was done.

The early benefit of EVAR was completely lost in long-term, with higher aneurysm- related mortality than in the open repair. It was found that no significant difference in total mortality between the two techniques. Secondary rupture was reported only after EVAR (endograft rupture). This explained long-term    increase    in    aneurysm-related

mortality.9

In this study, we consider that AAA 10 cm in diameter or more is huge abdominal aortic aneurysm. All the huge AAA are treated by open repair, because all the contraindications of EVAR are present in huge size, in addition, to the presence of huge pulsating abdominal mass. If we put endovascular graft the mass

still  present.  Also,  endograft  migration  is common, endograft rupture or death.15

The total mortality rate in our study was four cases (14.28%), two of myocardial infarction, one with renal failure (3.57%) and one with leaking AAA (3.57%). Because most of the morbidity & mortality of AAAs repair are caused by cardiac, renal and pulmonary dysfunction, so preoperative care of these organs is important to improve the survival rate.6

For these reasons, open aneurysm repair is mandatory in the treatment of huge abdominal aortic aneurysms, (HAAAs).

Conclusions:

We consider any AAA ten cm or more in diameter as a huge aneurysm.

Huge Abdominal Aortic Aneurysm is one of contraindications of EVAR.

Open repair of the huge abdominal aortic aneurysm is mandatory and can be performed safely, despite of associated medical risks.

Preoperative care of cardiac, renal and pulmonary systems decreases the morbidity and mortality of open repair of huge abdominal aortic aneurysm and improves the survival rate.

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