SYMPTOMATIC ANEURYSM OF THE ABDOMINAL AORTA SUCCESSFUL SURGERY
IN
ELDERLY PATIENTS, ONE
WITH A
MASSIVE ANEURYSM
MAHMUD BANGASH, M.D., F.A.C.A., F.R.C.S.(C) ABSTRACT
Three cases of symptomatic aneurysm of the abdominal aorta are presented. One patient age 96, described with this condition, is perhaps the oldest patient in the literature. In another patient the aneurysm measured two feet in length, extending from the diaphragm to the pelvic outlet. This was perhaps the biggest aneurysm yet recorded. All three patients presented difficult medical problems, withstood the operation, and were discharged from the hospitals with successful results. Aneurysm of the abdominal aorta is a serious condition. It is commonly found in patients in their seventh decade. The condition carries a high mortality with advancing age, especially when associated with other diseases. In symptomatic aneurysms where expansion, dissection or frank hemorrhage is suspected, emergency resection and replacement with dacron graft is carried out.
We are reporting three cases, two aged 96 and 91, perhaps the oldest patients in the world literature operated upon for expanding aneurysms of the abdominal aorta with beginning dissection. The third patient had an aneurysm measuring two feet in length, perhaps the biggest aneurysm reported. All patients survived the operation and are living. Case 1. A 70 year old male was admitted with excruciating abdominal and back pain. A large, nonpulsatile mass was palpable in the entire abdomen. Laboratory findings, a complete blood count, SMA-12, and urinalysis, were within normal limits on admission. Electrocardiogram revealed ST/T wave changes. The Hematocrit dropped to 26% in eight hours and the patient became hypotensive. Arteriogram by catheter study revealed a total occlusion of the aorta, just below the renal arteries with a diffuse large opacity in the abdomen. An emergency midline laparotomy was performed. A huge aneurysm of the abdominal aorta which extended from the diaphragm to the pelvic outlet was found. It originated below the renal arteries and involved the bifurcation. The entire aneurysm was full of old clotted blood. The rupture was noted posteriorly and measured six inches in length. The clots were removed and the aneurysm was partially resected. Cooley-Meadox* knitted graft, 14 x 8 mm, was preclotted and inserted as an aorto-bilateral femoral artery bypass. The cross-clamping time was approximately thirty minutes. Postoperatively the patient responded well and had pedal pulses at time of discharge (Figs. 1 and
2). *
Meadox-Medical, Oakland, N.J. 25
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
26
. ’
FIG. 1. Case 1: aneurysm of the abdominal aorta two feet in length. Case 2. A 96 year old female was admitted for extended nursing care. Twelve hours after admission she had multiple loose stools and pain around the umbilicus. A previously palpable aneurysm of the abdominal aorta had doubled in size and was tender on palpation. Laboratory evaluation and X-rays were within normal limits. Emergency resection of the aneurysm was carried out. The cross-clamping time of the aorta was half an hour. A straight tube #16 knitted graft was inserted. Postoperatively the patient recovered satisfactorily and was discharged.
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
27
FIG. 2. Case 1: aortogram by catheter study reveals in the abdomen (aneurysm abdominal aorta).
a
total occlusion of the aorta with
large
opacity
Case 3. A 91 year old female was admitted with known diagnosis of aneurysm of the abdominal aorta. Her family physician stated that upon routine
examination,
no
aneurysm
was
present. During hospitalization,
a
pulsa-
tile mass was found beneath the umbilicus. Laboratory evaluations were within normal limits. Electrocardiogram revealed a left ventricular strain pattern. The patient was scheduled for elective surgery. The morning of the operation she developed pain in the abdomen and back. Laparotomy revealed an expanding aneurysm approximately eight inches in diameter with beginning dissection. Resection of the aneurysm with aorto right common iliac, left external iliac artery bypass was carried out. Cooley-Meadox knitted dacron graft, 16 x 8 mm, was preclotted prior to its insertion. Postoperatively the patient recovered and was discharged.
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
28 DISCUSSION
Prior to the beginning of the century, aneurysm of the abdominal aorta was medical curiosity. In 1905, Osler reported sixteen cases of aneurysms. Later Kampmaier contributed to the literature by describing thoracic and abdominal aortic aneurysms. Present treatment follows the technique described by Dubost’. He resected the aneurysm and replaced it with a homograft. Presently a modification of Dubost’s procedure is carried out. The aneurysmal shell is sutured over the dacron prosthesis. Generally the diagnosis is made on clinical examination and plain X-ray of the abdomen with anterior-posterior and lateral views. In doubtful cases or those with hypertension or aorto-iliac occlusive disease, an aortogram is performed. Pain occurs in expanding, leaking, and dissecting aneurysms of the abdominal aorta. Frank rupture results in rapid exsanguination, shock and death. Only rarely does rupture occur into the duodenum producing a massive a
gastro-intestinal hemorrhage. The treatment is surgical removal and replacement with dacron prosthesis. If the bifurcation is not involved, a dacron tube is inserted. The Cooley-Meadox graft is preferred because of its texture, easy operative suturing, negligible bleeding following the release of occluding clamps, and its tendency to maintain a high degree of postoperative patency. Immediate and expeditious surgery and expert anesthesia are important for successful surgery, especially in old patients with complicating diseases. Mahmud Bangash, M.D. 625 S. Maple Ave. Glen Rork, N.J. REFERENCE 1.
Bangash, Mahmud, M.D., Timmes, J. Joseph, Aneurysm of the Abdominal Aorta—The Journal
M.D. Chang, SunII, M.D.: Expanding of The Medical Society of New Jersey 68:
106 1971
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
IN
ELDERLY PATIENTS, ONE
WITH A
MASSIVE ANEURYSM
MAHMUD BANGASH, M.D., F.A.C.A., F.R.C.S.(C) ABSTRACT
Three cases of symptomatic aneurysm of the abdominal aorta are presented. One patient age 96, described with this condition, is perhaps the oldest patient in the literature. In another patient the aneurysm measured two feet in length, extending from the diaphragm to the pelvic outlet. This was perhaps the biggest aneurysm yet recorded. All three patients presented difficult medical problems, withstood the operation, and were discharged from the hospitals with successful results. Aneurysm of the abdominal aorta is a serious condition. It is commonly found in patients in their seventh decade. The condition carries a high mortality with advancing age, especially when associated with other diseases. In symptomatic aneurysms where expansion, dissection or frank hemorrhage is suspected, emergency resection and replacement with dacron graft is carried out.
We are reporting three cases, two aged 96 and 91, perhaps the oldest patients in the world literature operated upon for expanding aneurysms of the abdominal aorta with beginning dissection. The third patient had an aneurysm measuring two feet in length, perhaps the biggest aneurysm reported. All patients survived the operation and are living. Case 1. A 70 year old male was admitted with excruciating abdominal and back pain. A large, nonpulsatile mass was palpable in the entire abdomen. Laboratory findings, a complete blood count, SMA-12, and urinalysis, were within normal limits on admission. Electrocardiogram revealed ST/T wave changes. The Hematocrit dropped to 26% in eight hours and the patient became hypotensive. Arteriogram by catheter study revealed a total occlusion of the aorta, just below the renal arteries with a diffuse large opacity in the abdomen. An emergency midline laparotomy was performed. A huge aneurysm of the abdominal aorta which extended from the diaphragm to the pelvic outlet was found. It originated below the renal arteries and involved the bifurcation. The entire aneurysm was full of old clotted blood. The rupture was noted posteriorly and measured six inches in length. The clots were removed and the aneurysm was partially resected. Cooley-Meadox* knitted graft, 14 x 8 mm, was preclotted and inserted as an aorto-bilateral femoral artery bypass. The cross-clamping time was approximately thirty minutes. Postoperatively the patient responded well and had pedal pulses at time of discharge (Figs. 1 and
2). *
Meadox-Medical, Oakland, N.J. 25
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
26
. ’
FIG. 1. Case 1: aneurysm of the abdominal aorta two feet in length. Case 2. A 96 year old female was admitted for extended nursing care. Twelve hours after admission she had multiple loose stools and pain around the umbilicus. A previously palpable aneurysm of the abdominal aorta had doubled in size and was tender on palpation. Laboratory evaluation and X-rays were within normal limits. Emergency resection of the aneurysm was carried out. The cross-clamping time of the aorta was half an hour. A straight tube #16 knitted graft was inserted. Postoperatively the patient recovered satisfactorily and was discharged.
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
27
FIG. 2. Case 1: aortogram by catheter study reveals in the abdomen (aneurysm abdominal aorta).
a
total occlusion of the aorta with
large
opacity
Case 3. A 91 year old female was admitted with known diagnosis of aneurysm of the abdominal aorta. Her family physician stated that upon routine
examination,
no
aneurysm
was
present. During hospitalization,
a
pulsa-
tile mass was found beneath the umbilicus. Laboratory evaluations were within normal limits. Electrocardiogram revealed a left ventricular strain pattern. The patient was scheduled for elective surgery. The morning of the operation she developed pain in the abdomen and back. Laparotomy revealed an expanding aneurysm approximately eight inches in diameter with beginning dissection. Resection of the aneurysm with aorto right common iliac, left external iliac artery bypass was carried out. Cooley-Meadox knitted dacron graft, 16 x 8 mm, was preclotted prior to its insertion. Postoperatively the patient recovered and was discharged.
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
28 DISCUSSION
Prior to the beginning of the century, aneurysm of the abdominal aorta was medical curiosity. In 1905, Osler reported sixteen cases of aneurysms. Later Kampmaier contributed to the literature by describing thoracic and abdominal aortic aneurysms. Present treatment follows the technique described by Dubost’. He resected the aneurysm and replaced it with a homograft. Presently a modification of Dubost’s procedure is carried out. The aneurysmal shell is sutured over the dacron prosthesis. Generally the diagnosis is made on clinical examination and plain X-ray of the abdomen with anterior-posterior and lateral views. In doubtful cases or those with hypertension or aorto-iliac occlusive disease, an aortogram is performed. Pain occurs in expanding, leaking, and dissecting aneurysms of the abdominal aorta. Frank rupture results in rapid exsanguination, shock and death. Only rarely does rupture occur into the duodenum producing a massive a
gastro-intestinal hemorrhage. The treatment is surgical removal and replacement with dacron prosthesis. If the bifurcation is not involved, a dacron tube is inserted. The Cooley-Meadox graft is preferred because of its texture, easy operative suturing, negligible bleeding following the release of occluding clamps, and its tendency to maintain a high degree of postoperative patency. Immediate and expeditious surgery and expert anesthesia are important for successful surgery, especially in old patients with complicating diseases. Mahmud Bangash, M.D. 625 S. Maple Ave. Glen Rork, N.J. REFERENCE 1.
Bangash, Mahmud, M.D., Timmes, J. Joseph, Aneurysm of the Abdominal Aorta—The Journal
M.D. Chang, SunII, M.D.: Expanding of The Medical Society of New Jersey 68:
106 1971
Downloaded from ves.sagepub.com at EMORY UNIV on August 25, 2015
