Surgical Management of 100 Consecutive Abdominal Aortic Aneurysms LT COL C. William Fedde, MC, USA,* Washington, DC LT COL R. W. Hobson, II, MC, USA, Washington, DC COL Norman M. Rich, MC, USA, Washington, DC
Since the report by Dubost, Allary, and Oeconomos [I] in 1952 of the successful treatment of an abdominal aortic aneurysm, surgeons have been concerned about the operative mortality associated with elective repair of abdominal aortic aneurysms. Because of improvements in operative technic, such as the endoaneurysmorrhaphy method described by Creech [2], and because of improved postoperative patient care, operative mortality has decreased as operative experience has increased. Cannon, Van De Water, and Barker [3] reported an operative mortality of 15 per cent in the elective surgical treatment of abdominal aortic aneurysms from 1954 to 1962. In the series of Szilagyi et al [4], the overall operative mortality for elective procedures from 1952 to 1965 was 14.7 per cent; however, during the last two years of their study, operative mortality decreased to 6.3 per cent. In 1967, Friedman et al [5] reported an operative mortality of 4 per cent for elective abdominal aneurysmorrhaphy performed in 1965 and 1966. In 1972, Yashar, Indeglia, and Yashar [6] reported a 5.6 per cent operative mortality for elective repair of abdominal aortic aneurysms. This report analyzes morbidity and mortality for 100 consecutive elective abdominal aortic aneurysmorrhaphies performed at a large military teaching hospital. Postoperative clinical follow-up study of the patients is included. From the Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC. Reprint requests should be addressed to Col Norman M. Rich, MC, USA, Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC 20012. * Present address: Peripheral Vascular Surgery. US Army Medical Center, Fort Gordon, Georgia.
506
Clinical Data At Walter Reed Army Medical Center between June 1966 and December 1973,112 abdominal aortic aneurysmorrhaphies were performed. One hundred of these aneurysmorrhaphies were performed electively. Regardless of symptoms, operation was considered elective unless rupture through the wall of the aorta was found. Ninety-two men, ranging in age from 46 to 86 years (mean 66.2 years), and eight women, ranging in age from 42 to 78 years (mean 66.0 years), were included in the study. Ninety-nine patients were white and one was black. Table I presents the age distribution of patients in this series. The average size of the aneurysm was 7.7 cm. (Table II.) Aneurysms in other major arteries in addition to that in the abdominal aorta were found in 30 per cent of the patients. Associated iliac aneurysms occurred in 18 per cent of the patients, popliteal in 7 per cent,, femoral in 3 per cent, and renal in 2 per cent. Patients were followed up clinically an average of thirteen months from the initial diagnosis of aortic aneurysm to elective repair. The aneurysm was frequently diagnosed and evaluated at a smaller outlying hospital and the patient referred only when the local physician believed the aneurysm to be expanding. Occasionally, patients with a small aneurysm and intercurrent systemic illness were examined periodically until aneurysma1 enlargement prompted repair or until the intercurrent illness became less of a threat. Clinically detectable cardiac disease was present in 45 per cent of the patients. Myocardial infarction was documented in 27 per cent at some time prior to elective operation. In 18 per cent of the patients, there was preoperative angina pectoris without electrocardiographic evidence of myocardial infarction or there were abnormal ST-T wave changes on .the electrocardiogram, conduction defects, arrhythmias, or a history of congestive
Tha Amerkan
Journal of Surgary
Abdominal
heart failure. In 42 per cent of the patients, hypertension with systolic pressures consistently greater than 180 mm Hg or diastolic pressures greater than 90 mm Hg was found. Of the 100 patients, 93 per cent smoked or had smoked .previously. Fourth-year resident surgeons with close staff supervision performed 60 per cent of the elective abdominal aneurysmorrhaphies, vascular surgery fellows performed 35 per cent, and staff surgeons performed 5 per cent. The average operating time was 4.9 hours. Forty different primary surgeons operated on the 100 consecutive patients; however, at least one of the authors was involved in the care of all patients in this series. The endoaneurysmorrhaphy technic described by Creech [2] was used in all cases. Aortoiliac replacement procedures account for 70 per cent of the reconstructions, sleeve replacements for 15 per cent, and aortofemoral replacement procedures for 7 per cent. Renal artery bypass grafting with an aortoiliac prosthesis or a combination of aortofemoral bypass to one extremity and aortoiliac bypass to the other extremity was included in 8 per cent of the procedures. In this series the average volume of blood replacement was 3,800 cc (median, 3,000 cc); the range of blood loss was 1,000 to 11,500 cc. To diminish postclamping hypotension, 500 cc of whole blood was frequently given prior to release of the aortic clamps. Associated operative procedures were carried out in 19 per cent of the patients, which may have increased the risk of postoperative graft infection. Twelve appe?dectomies, seven cholecystectomies, and two vagotomy and pyloroplasty procedures were performed in nineteen patient.s. However, there was no postoperative graft infection in these patients or in the others. Prophylactic antibiotics were used routinely in all patients. The administration of streptomycin (0.5 gm intramuscularly) in combination with penicillin (600,000 units intravenously every six hours) or lincomycin (500 mg intravenously every six hours) was begun the evening prior to operation and continued three to five days postoperatively. Patients with symptoms of cerebrovascular insufficiency or carotid bruits on physical examination were studied angiographically prior to operation. Seven of our patients underwent eight carotid endarterectomies prior to elective aneurysmorrhaphy. Three of these patient.s had asymptomatic bruits and hemodynamically significant stenosis of an internal carotid artery was found by arteriography. Of the four symptomatic patients, two had had amaurosis fugax, one was having localized transient cerebral ischemic episodes, and one with previous hemiparesis had total occlusion of one internal carotid artery and significant stenosis of the opposite side. No complications occurred after carotid endarterectomy and there were no postaneurysmorrhaphy strokes in this series of patients. Major postoperative complications in this series were few. One patient was returned to the operating room because of hemorrhage at the suture line, which was suc-
Volume 129, May 1975
TABLE
Aortic
Age Distribution*
I
Number of Patients
Age (yr) 80-86 70-79 60-69 50-59 40-49
5 27 42 22 4
Total * Average,
TABLE
Aneurysms
100
66.2 years,
II
Size
range,
42 to 86 years.
of the Aneurysm
Size (cm)
Number of Patients
3-5 6 7 8 9-15 Total
31 19 22 12 16 100
cessfully controlled. Arterial embolization loss of limb did not occur.
or subsequent
The operative mortality was 3 per cent. There were no deaths in the operating room. There was one early postoperative death and two deaths occurred more than thirty days postoperatively while the patients were still hospitalized. (Table III.) None of these deaths could be attributed to technical failure. All three patients had a history of significant myocardial disease and smoking.
Results Clinical follow-up information is available for all but one patient in this series. Twenty-six of the one hundred patients are known to have died. The twenty-three patients who were discharged from the hospital and subsequently died had an average survival of 2.7 years, ranging from 6 weeks to 6 years. The average size of the aneurysm in these twenty-three patients was 8.3 cm, ranging from 5 to 15 cm. Associated atherosclerotic disease accounted for the majority of deaths. Ten patients died from myocardial infarction, two from cerebrovascular accident, and two from dissecting aortic arch aneurysm. One patient died from emphyTABLE
Age (yr) 72
69 69
Deaths
III
Time after Operation (days) 1
34 39
Cause of Death Disseminated
intra-
vascular coagulation and renal failure Heart failure Respiratory failure
Year of Death
Size of Aneurysm
1972
10 cm
1969 1970
9cm 10 cm
(cm)
507
Fedde, Hobson, and Rich
sema, one from metastatic prostatic carcinoma, and one from hemorrhage associated with bronchial biopsy fourteen months after aneurysmorrhaphy. Six of the twenty-three patients died from undetermined causes; autopsy was not performed. Fifteen of the twenty-six patients who died had abnormal electrocardiographic findings prior to aneurysmorrhaphy. Nine of the twenty-six patients who died had documented myocardial infarction prior to elective aneurysmorrhaphy. Eleven of the twenty-six patients had preoperative hypertension. Twenty-five of the twenty-six patients in this series who died had a long history of smoking. Comments The elective repair of abdominal aortic aneurysms can be a safe procedure. The operative mortality of 3 per cent in our series is acceptable and compares favorably with that in other reported series [5-71. This low operative mortality was attained despite the fact that 95 per cent of the primary surgeons in this series were in training, either as residents or vascular fellows. Every surgical procedure was closely supervised by staff surgeons, and we believe this supervision was in part responsible for the acceptable morbidity and mortality in this series. We agree with Tompkins and co-authors [8] that associated intra-abdominal conditions requiring surgical correction at the time of aneurysmorrhaphy can be accomplished with minimal risk of infection. We have performed the additional procedures described previously only after the posterior peritoneum was closed over the aortic prosthesis. Appendectomy was performed when the appendix appeared indurated or edematous at the end of the operative procedure or when there was a palpable fecalith. Because the morbidity of prophylactic carotid endarterectomy at our institution is low, 0 per cent in this series, we recommend this procedure in patients with a potentially high risk of postaneurysmorrhaphy stroke. We agree with Wesolowski in his discussion of the report of Bernstein, Fisher, and Varco [9] that aneurysms of sufficient size to be diagnosed by abdominal palpation are large enough to warrant resection. In our series there were no operative deaths among the seventy-two patients with aneurysms 7 cm or less in diameter. Gleidman, Ayers, and Vestal [IO], in their study of untreated aneurysms, reported that 18 per cent of aneurysms
508
smaller than 7 cm rupture. Others [11,12] report similar rates of rupture for aneurysms of this size. As a result of our present study, we believe that patients with small aortic aneurysms who do not have associated severe cardiac or pulmonary disease should undergo elective aneurysmorrhaphy. Summary One hundred consecutive elective abdominal aortic aneurysmorrhaphies were performed at Walter Reed Army Medical Center from 1966 to 1973. The overall hospital mortality was 3 per cent. There were no operative deaths in patients with aneurysms smaller than 9 cm. In view of our favorable overall statistics, we recommend elective abdominal aortic aneurysmorrhaphy in all cases unless there is severe associated cardiac and pulmonary disease. Preoperative carotid endarterectomy is recommended for symptomatic cerebrovascular insufficiency or for asymptomatic carotid bruits and/or hemodynamically significant carotid stenosis. When necessary, associated gastrointestinal procedures can be accomplished without increased risk of infection. References 1. Dubost C, Allary M, Oeconomos N: Resection of an aneurysm of the abdominal aorta. Reestablishment of the continuity by a preserved human arterial graft with results after five months. Arch Surg 64: 405, 1952. 2. Creech 0 Jr: Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg 164: 935. 1966. 3. Cannon JA, Van De Water J, Barker W: Experience with the surgical management of 100 consecutive cases of abdominal aortic aneurysm. Am J Surg 106: 128. 1963. 4. Srilagyi DE, Smith RF, De Russo FS, Elliott JP, Sherrin FW: Contribution of abdominal aortic aneurysmectomy to prolongation of life: 12 year review of 480 cases. Ann Surg 164: 678, 1966. 5. Friedman SA, Hufnagel CA, Conrad PW, et al: Abdominal aortic aneurysms. Clinical status and results of surgery in 100 consecutive cases. JA#A 200: 1147, 1967. 6. Yashar J, lndeglia RA, Yashar J: Surgery for abdominal aortic aneurysms. Am J Surg 123: 398, 1972. 7. Gardner RJ. Lancaster JR, Tarnay TJ, et al: Five year history of surgically treated abdominal aortic aneurysms. Surg GynecolObstet 130: 981, 1970. 8. Tompkins WC, Chavez CM, Conn JH, Hardy JD: Combining intra-abdominal arterial grafting with gastrointestinal or biliary tract procedures. Am J Surg 126: 598. 1973. 9. Bernstein EF, Fisher JC, Varco RL: Is excision the optimum treatment for all abdominal aortic aneurysms? Surgery 61: 83, 1967. 10. Gleidman ML, Ayers WB. Vestal BL: Aneurysms of the abdominal aorta and its branches. A study of untreated patients. Ann Surg 146: 207, 1957. 11. David JP, Marks C, Bonneval M: A ten year institutional experience with abdominal aneurysms. Surg Gynecol Obstet 138: 591, 1974. 12. Sommerville RI. Allen EU. Edwards JE: Bland and infected arteriosclerotic abdominal aneurysms: a clinical-pathologic study. Medicine 38: 207, 1959.
The American Journal
of Surgory
Since the report by Dubost, Allary, and Oeconomos [I] in 1952 of the successful treatment of an abdominal aortic aneurysm, surgeons have been concerned about the operative mortality associated with elective repair of abdominal aortic aneurysms. Because of improvements in operative technic, such as the endoaneurysmorrhaphy method described by Creech [2], and because of improved postoperative patient care, operative mortality has decreased as operative experience has increased. Cannon, Van De Water, and Barker [3] reported an operative mortality of 15 per cent in the elective surgical treatment of abdominal aortic aneurysms from 1954 to 1962. In the series of Szilagyi et al [4], the overall operative mortality for elective procedures from 1952 to 1965 was 14.7 per cent; however, during the last two years of their study, operative mortality decreased to 6.3 per cent. In 1967, Friedman et al [5] reported an operative mortality of 4 per cent for elective abdominal aneurysmorrhaphy performed in 1965 and 1966. In 1972, Yashar, Indeglia, and Yashar [6] reported a 5.6 per cent operative mortality for elective repair of abdominal aortic aneurysms. This report analyzes morbidity and mortality for 100 consecutive elective abdominal aortic aneurysmorrhaphies performed at a large military teaching hospital. Postoperative clinical follow-up study of the patients is included. From the Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC. Reprint requests should be addressed to Col Norman M. Rich, MC, USA, Peripheral Vascular Surgery Service, Walter Reed Army Medical Center, Washington, DC 20012. * Present address: Peripheral Vascular Surgery. US Army Medical Center, Fort Gordon, Georgia.
506
Clinical Data At Walter Reed Army Medical Center between June 1966 and December 1973,112 abdominal aortic aneurysmorrhaphies were performed. One hundred of these aneurysmorrhaphies were performed electively. Regardless of symptoms, operation was considered elective unless rupture through the wall of the aorta was found. Ninety-two men, ranging in age from 46 to 86 years (mean 66.2 years), and eight women, ranging in age from 42 to 78 years (mean 66.0 years), were included in the study. Ninety-nine patients were white and one was black. Table I presents the age distribution of patients in this series. The average size of the aneurysm was 7.7 cm. (Table II.) Aneurysms in other major arteries in addition to that in the abdominal aorta were found in 30 per cent of the patients. Associated iliac aneurysms occurred in 18 per cent of the patients, popliteal in 7 per cent,, femoral in 3 per cent, and renal in 2 per cent. Patients were followed up clinically an average of thirteen months from the initial diagnosis of aortic aneurysm to elective repair. The aneurysm was frequently diagnosed and evaluated at a smaller outlying hospital and the patient referred only when the local physician believed the aneurysm to be expanding. Occasionally, patients with a small aneurysm and intercurrent systemic illness were examined periodically until aneurysma1 enlargement prompted repair or until the intercurrent illness became less of a threat. Clinically detectable cardiac disease was present in 45 per cent of the patients. Myocardial infarction was documented in 27 per cent at some time prior to elective operation. In 18 per cent of the patients, there was preoperative angina pectoris without electrocardiographic evidence of myocardial infarction or there were abnormal ST-T wave changes on .the electrocardiogram, conduction defects, arrhythmias, or a history of congestive
Tha Amerkan
Journal of Surgary
Abdominal
heart failure. In 42 per cent of the patients, hypertension with systolic pressures consistently greater than 180 mm Hg or diastolic pressures greater than 90 mm Hg was found. Of the 100 patients, 93 per cent smoked or had smoked .previously. Fourth-year resident surgeons with close staff supervision performed 60 per cent of the elective abdominal aneurysmorrhaphies, vascular surgery fellows performed 35 per cent, and staff surgeons performed 5 per cent. The average operating time was 4.9 hours. Forty different primary surgeons operated on the 100 consecutive patients; however, at least one of the authors was involved in the care of all patients in this series. The endoaneurysmorrhaphy technic described by Creech [2] was used in all cases. Aortoiliac replacement procedures account for 70 per cent of the reconstructions, sleeve replacements for 15 per cent, and aortofemoral replacement procedures for 7 per cent. Renal artery bypass grafting with an aortoiliac prosthesis or a combination of aortofemoral bypass to one extremity and aortoiliac bypass to the other extremity was included in 8 per cent of the procedures. In this series the average volume of blood replacement was 3,800 cc (median, 3,000 cc); the range of blood loss was 1,000 to 11,500 cc. To diminish postclamping hypotension, 500 cc of whole blood was frequently given prior to release of the aortic clamps. Associated operative procedures were carried out in 19 per cent of the patients, which may have increased the risk of postoperative graft infection. Twelve appe?dectomies, seven cholecystectomies, and two vagotomy and pyloroplasty procedures were performed in nineteen patient.s. However, there was no postoperative graft infection in these patients or in the others. Prophylactic antibiotics were used routinely in all patients. The administration of streptomycin (0.5 gm intramuscularly) in combination with penicillin (600,000 units intravenously every six hours) or lincomycin (500 mg intravenously every six hours) was begun the evening prior to operation and continued three to five days postoperatively. Patients with symptoms of cerebrovascular insufficiency or carotid bruits on physical examination were studied angiographically prior to operation. Seven of our patients underwent eight carotid endarterectomies prior to elective aneurysmorrhaphy. Three of these patient.s had asymptomatic bruits and hemodynamically significant stenosis of an internal carotid artery was found by arteriography. Of the four symptomatic patients, two had had amaurosis fugax, one was having localized transient cerebral ischemic episodes, and one with previous hemiparesis had total occlusion of one internal carotid artery and significant stenosis of the opposite side. No complications occurred after carotid endarterectomy and there were no postaneurysmorrhaphy strokes in this series of patients. Major postoperative complications in this series were few. One patient was returned to the operating room because of hemorrhage at the suture line, which was suc-
Volume 129, May 1975
TABLE
Aortic
Age Distribution*
I
Number of Patients
Age (yr) 80-86 70-79 60-69 50-59 40-49
5 27 42 22 4
Total * Average,
TABLE
Aneurysms
100
66.2 years,
II
Size
range,
42 to 86 years.
of the Aneurysm
Size (cm)
Number of Patients
3-5 6 7 8 9-15 Total
31 19 22 12 16 100
cessfully controlled. Arterial embolization loss of limb did not occur.
or subsequent
The operative mortality was 3 per cent. There were no deaths in the operating room. There was one early postoperative death and two deaths occurred more than thirty days postoperatively while the patients were still hospitalized. (Table III.) None of these deaths could be attributed to technical failure. All three patients had a history of significant myocardial disease and smoking.
Results Clinical follow-up information is available for all but one patient in this series. Twenty-six of the one hundred patients are known to have died. The twenty-three patients who were discharged from the hospital and subsequently died had an average survival of 2.7 years, ranging from 6 weeks to 6 years. The average size of the aneurysm in these twenty-three patients was 8.3 cm, ranging from 5 to 15 cm. Associated atherosclerotic disease accounted for the majority of deaths. Ten patients died from myocardial infarction, two from cerebrovascular accident, and two from dissecting aortic arch aneurysm. One patient died from emphyTABLE
Age (yr) 72
69 69
Deaths
III
Time after Operation (days) 1
34 39
Cause of Death Disseminated
intra-
vascular coagulation and renal failure Heart failure Respiratory failure
Year of Death
Size of Aneurysm
1972
10 cm
1969 1970
9cm 10 cm
(cm)
507
Fedde, Hobson, and Rich
sema, one from metastatic prostatic carcinoma, and one from hemorrhage associated with bronchial biopsy fourteen months after aneurysmorrhaphy. Six of the twenty-three patients died from undetermined causes; autopsy was not performed. Fifteen of the twenty-six patients who died had abnormal electrocardiographic findings prior to aneurysmorrhaphy. Nine of the twenty-six patients who died had documented myocardial infarction prior to elective aneurysmorrhaphy. Eleven of the twenty-six patients had preoperative hypertension. Twenty-five of the twenty-six patients in this series who died had a long history of smoking. Comments The elective repair of abdominal aortic aneurysms can be a safe procedure. The operative mortality of 3 per cent in our series is acceptable and compares favorably with that in other reported series [5-71. This low operative mortality was attained despite the fact that 95 per cent of the primary surgeons in this series were in training, either as residents or vascular fellows. Every surgical procedure was closely supervised by staff surgeons, and we believe this supervision was in part responsible for the acceptable morbidity and mortality in this series. We agree with Tompkins and co-authors [8] that associated intra-abdominal conditions requiring surgical correction at the time of aneurysmorrhaphy can be accomplished with minimal risk of infection. We have performed the additional procedures described previously only after the posterior peritoneum was closed over the aortic prosthesis. Appendectomy was performed when the appendix appeared indurated or edematous at the end of the operative procedure or when there was a palpable fecalith. Because the morbidity of prophylactic carotid endarterectomy at our institution is low, 0 per cent in this series, we recommend this procedure in patients with a potentially high risk of postaneurysmorrhaphy stroke. We agree with Wesolowski in his discussion of the report of Bernstein, Fisher, and Varco [9] that aneurysms of sufficient size to be diagnosed by abdominal palpation are large enough to warrant resection. In our series there were no operative deaths among the seventy-two patients with aneurysms 7 cm or less in diameter. Gleidman, Ayers, and Vestal [IO], in their study of untreated aneurysms, reported that 18 per cent of aneurysms
508
smaller than 7 cm rupture. Others [11,12] report similar rates of rupture for aneurysms of this size. As a result of our present study, we believe that patients with small aortic aneurysms who do not have associated severe cardiac or pulmonary disease should undergo elective aneurysmorrhaphy. Summary One hundred consecutive elective abdominal aortic aneurysmorrhaphies were performed at Walter Reed Army Medical Center from 1966 to 1973. The overall hospital mortality was 3 per cent. There were no operative deaths in patients with aneurysms smaller than 9 cm. In view of our favorable overall statistics, we recommend elective abdominal aortic aneurysmorrhaphy in all cases unless there is severe associated cardiac and pulmonary disease. Preoperative carotid endarterectomy is recommended for symptomatic cerebrovascular insufficiency or for asymptomatic carotid bruits and/or hemodynamically significant carotid stenosis. When necessary, associated gastrointestinal procedures can be accomplished without increased risk of infection. References 1. Dubost C, Allary M, Oeconomos N: Resection of an aneurysm of the abdominal aorta. Reestablishment of the continuity by a preserved human arterial graft with results after five months. Arch Surg 64: 405, 1952. 2. Creech 0 Jr: Endo-aneurysmorrhaphy and treatment of aortic aneurysm. Ann Surg 164: 935. 1966. 3. Cannon JA, Van De Water J, Barker W: Experience with the surgical management of 100 consecutive cases of abdominal aortic aneurysm. Am J Surg 106: 128. 1963. 4. Srilagyi DE, Smith RF, De Russo FS, Elliott JP, Sherrin FW: Contribution of abdominal aortic aneurysmectomy to prolongation of life: 12 year review of 480 cases. Ann Surg 164: 678, 1966. 5. Friedman SA, Hufnagel CA, Conrad PW, et al: Abdominal aortic aneurysms. Clinical status and results of surgery in 100 consecutive cases. JA#A 200: 1147, 1967. 6. Yashar J, lndeglia RA, Yashar J: Surgery for abdominal aortic aneurysms. Am J Surg 123: 398, 1972. 7. Gardner RJ. Lancaster JR, Tarnay TJ, et al: Five year history of surgically treated abdominal aortic aneurysms. Surg GynecolObstet 130: 981, 1970. 8. Tompkins WC, Chavez CM, Conn JH, Hardy JD: Combining intra-abdominal arterial grafting with gastrointestinal or biliary tract procedures. Am J Surg 126: 598. 1973. 9. Bernstein EF, Fisher JC, Varco RL: Is excision the optimum treatment for all abdominal aortic aneurysms? Surgery 61: 83, 1967. 10. Gleidman ML, Ayers WB. Vestal BL: Aneurysms of the abdominal aorta and its branches. A study of untreated patients. Ann Surg 146: 207, 1957. 11. David JP, Marks C, Bonneval M: A ten year institutional experience with abdominal aneurysms. Surg Gynecol Obstet 138: 591, 1974. 12. Sommerville RI. Allen EU. Edwards JE: Bland and infected arteriosclerotic abdominal aneurysms: a clinical-pathologic study. Medicine 38: 207, 1959.
The American Journal
of Surgory
