Diagnosis and management of 17 consecutive patients with inflammatory abdominal aortic aneurysm

Nonaneurysmal Aortoarteritis

Aortoarteritis is an uncommon form of retroperitoneal inflammation, which is not associated with an aortic aneurysm or luminal stenosis. The authors report 3 patients with periaortic inflammation whose presentations were initially suggestive of a symptomatic aortic aneurysm. All 3 patients had pain, an epigastric mass, and weight loss. The correct diagnosis was suggested by imaging techniques and confirmed by computerized (CT) -directed needle biopsy in 2 of the patients. Aortic caliber was not altered significantly in any patient. They were all treated with corticosteroids with prompt relief of symptoms and rapid resolution of the periaortic inflammation as confirmed by CT. There has been no recurrence of symptoms in follow-up. Aortoarteritis appears to be one expression of the spectrum of inflammatory retroperitoneal diseases and is distinct from inflammatory aortic aneurysms and retroperitoneal fibrosis. The authors suggest a logical classification scheme of retroperitoneal inflammation based on the extent of aortic and retroperitoneal involvement. Differentiation between these entities is critical because, in contrast to inflammatory aneurysms and retroperitoneal fibrosis involving the aorta, aortoarteritis can be managed without surgery. Magnetic resonance imaging displays the most detail of the periaortic mass and provides information about intra-aortic flow. Corticosteroids are rapidly effective and are the treatment of choice in aortoarteritis when the diagnosis is established.

Abdominal aortic aneurysm with inferior vena cava compression in association with deep venous thrombosis

Deep venous thrombosis (DVT) of the lower extremity may be caused by external compression of the inferior vena cava (IVC) by a neighboring mass. A 55-year-old male presented with 8 months of intermittent left lower extremity swelling and signs of chronic venous stasis. Duplex ultrasound showed extensive DVT in the left leg. Subsequent imaging revealed a 4.2 cm infrarenal abdominal aortic aneurysm (AAA) compressing the IVC. In cases of chronic, unilateral DVT, work-up should include imaging for an anatomic cause. AAA is a rare cause of IVC compression with DVT, and is most commonly related to inflammatory AAAs. Previously reported cases of IVC compression by non-inflammatory AAAs have been secondary to large aneurysms (greater than 6 cm). This case illustrates that smaller AAAs lacking hemodynamically significant IVC obstruction may be found in association with DVT.

Retroperitoneal fibrosis. Exceptional cause of renal artery thrombosis with secondary hypertension. A case from University Mohamed V, CheikhZaid Hospital, Rabat, March 2013

Retroperitoneal fibrosis is a rare cause of renal artery thrombosis, being the origin of renovascular hypertension, especially in patients less than thirty years old female, without particular medical history. A clinical case we present is a young 24 years old girl with no past history, hospitalized for the discovery of hypertension. She consulted for headache and progressive bilateral back pain, evolving for several months. She also complained for asthenia, accompanied by weight loss in about 7 pounds in 8 months. Clinical examination confirmed a very high blood pressure, bilateral lumbar pain, with a mass located in the left renal lodge. The diagnosis of right renal thrombosis was demonstrated (with dysfunctional right kidney) and a video-laparoscopic nephrectomy was performed. She had satisfactory postoperative clinical course with normalization of blood pressure a few days after, without medical treatment. <Learning objective: The interest is to know that the retroperitoneal fibrosis is a rare cause of renal artery thrombosis. In the search for the cause of renal arterial thrombosis, retroperitoneal fibrosis should not be forgotten; even of patients less than thirty years. The specific pathophysiology is unclear until now, the authors have been controversial. Important thing is to know that when all causes seem to have been discussed without result, retroperitoneal fibrosis can be a possible cause of renal thrombosis.>.

The American Journal of Surgery

In the last of our quarterly digests for 1992, Dr Hiram Polk has this month selected articles from the July to September issues of The American Journal of Surgery, of which he is Editor. Correspondence should be addressed primarily to Dr Polk, although The British Journal of Surgery would be glad to receive a copy.

Retroperitoneal fibrosis presenting as acute renal failure

BACKGROUND

A 60-year-old man with a history of atherosclerotic disease of the carotid and coronary vasculature presented with lower back pain and acute renal failure. Imaging studies revealed bilateral ureteral obstruction by a large retroperitoneal mass.

INVESTIGATIONS

Physical examination, urine and blood analysis, catheterization, radiography of the chest, abdominal and pelvic CT, magnetic resonance angiography, renal ultrasound and biopsy of mass.

DIAGNOSIS

Retroperitoneal fibrosis.

MANAGEMENT

Ureteral stenting, laparoscopic ureterolysis, and immunosuppressive therapy with prednisone and mycophenolate mofetil.

Spontaneous peripelvic extravasation of urine due to an inflammatory aneurysm of the abdominal aorta

A 71-year-old man presented complaining of severe left flank pain. A computed tomography scan of the abdomen disclosed a left peripelvic extravasation of urine and a 4.0-cm abdominal aortic aneurysm with a significant amount of perianeurysmal thickening and prominent left hydroureter. The patient was diagnosed as having an inflammatory aneurysm of the abdominal aorta (IAAA) with peripelvic extravasations of urine. We report the results of a patient with IAAA with ureteral obstruction successfully treated with steroid therapy and a ureteral stent.

[Inflammatory aortic aneurysm after vascular-prosthetic treatment. Morphological findings after years of incorporation]

Until now the causal and formal pathogenesis of the inflammatory aortic aneurysm is poorly known. This report shows the pathological- anatomical findings of surgical and autoptical preparations, on the one hand 78 months and on the other hand 82 months, after vascular-prosthetical treatment of inflammatory aneurysms in the abdominal and thoracal part of the aorta. By morphological studies it was possible to reveal, the over years existing disease, the typical picture of inflammatory aneurysm, focal destruction of the genuine aortic wall and partial substitution by inflammatory-fibrous, less qualitative granulation tissue. Even 6 1/2 years past the implantation of the Dacron-prosthesis, there is still no complete ingrown. In addition to the known findings of the transprosthetical organization with a variable development of the outer connective-tissued coat and neointima, the incorporated granulation-tissue was overlapped by a strong inflammation according to the basic disease. In several parts of the inflammatory destructed aortic wall, there is still no fixed incorporation of the prosthesis after 7 years, so that "hypermobile-prosthetic-parts" can be found as a result.

Periaortitis: Gadolinium-enhanced Magnetic Resonance Imaging and Response to Therapy in Four Patients

The objective of this study was to define clinical and imaging characteristics of periaortitis prior to and after therapy with immunosuppressive drugs. Four consecutive patients with periaortitis (two secondary to atherosclerosis and two with rheumatic diseases) were studied with contrast-enhanced CT and magnetic resonance angiography (MRA), rheumatologic serologies, and acute-phase reactants. All were treated with corticosteroids and two patients received immunosuppressive agents. Patients were followed with serial MRA scans, CT scans, and clinical exams. Prior to treatment, all patients demonstrated a rind of periaortic tissue, which was enhanced with both contrast-enhanced CT as well as gadolinium-enhanced MRA. Clinical symptoms resolved and rind contracture occurred in all cases following therapy. Enhancement of the rind persisted despite the clinical improvement in all patients. No patient developed an aortic aneurysm or retroperitoneal fibrosis during the follow-up period. Corticosteroid/immunosuppressive treatment was continued for an average of 41 months. At 62 months of total follow-up, there has been no recurrence of periaortitis by clinical and/or radiologic exam. Treatment of periaortitis with corticosteroids and immunosuppression therapy leads to resolution of clinical symptoms and radiologic contracture of the periaortic rind. Patients responded to therapy without developing progressive fibrosis or aneurysm. MRA allows safe and repetitive imaging of periaortitis and provides excellent definition of lumenal abnormalities including plaque rupture.

Caval and ureteral obstruction secondary to an inflammatory abdominal aortic aneurysm

Inflammatory abdominal aortic aneurysms (IAAA) represent 3% to 10% of all abdominal aortic aneurysms. Obstructive uropathy is a well-described feature of IAAAs, but venous complications are unusual secondary to IAAA. The authors report a patient presenting with acute renal failure and deep venous thrombosis secondary to an IAAA. We believe this represents the first case of an IAAA manifesting as combined inferior vena cava compression and associated obstructive uropathy. Successful operative repair was performed. With resolution of the retroperitoneal inflammation, long-term follow-up revealed spontaneous release of both ureteral and caval compression.

Sensitivity and specificity of CT in the diagnosis of inflammatory abdominal aortic aneurysms

PURPOSE

The purpose of this study is to assess the diagnostic ability (sensitivity and specificity) of CT in the diagnosis of inflammatory abdominal aortic aneurysm (IAAA) and to quantitatively evaluate its features.

METHOD

A retrospective survey of 355 consecutive patients with abdominal aortic aneurysm and iliac artery aneurysm who underwent CT examination and surgical repair yielded 18 patients with operatively confirmed IAAA. The sensitivity, specificity, and diagnostic accuracy of CT were evaluated in this review. Eighteen IAAAs were then analyzed in terms of distribution and degree of perianeurysmal fibrosis as well as time-dependent change of CT values of the aneurysmal wall on contrast-enhanced CT. Complications related to IAAA were also determined.

RESULTS

Fifteen of the 18 cases of IAAA could be easily diagnosed on CT prior to surgical repair. Three false-negative and one false-positive case were found. This gives a sensitivity rate of 83.3% for this imaging technique, with specificity and accuracy rates of 99.7 and 93.7%, respectively. Thickening of the aortic wall was noticed mostly in the anterolateral wall of the aneurysm as compared with the posterior wall. The thickness of the perianeurysmal fibrosis correlated neither with the size of aneurysm nor with the inflammatory reaction such as erythrocyte sedimentation rate, C-reactive protein level, and white blood cell count. CT indicated the complications in 7 of 18 patients with IAAA. These included hydronephrosis, aortoenteric fistula, and infected iliac aneurysm.

CONCLUSION

CT scan with contrast enhancement was a highly reliable imaging modality for the diagnosis of IAAA.

Perianeurysmal fibrosis: a relative contra-indication to endovascular repair

OBJECTIVE

Perianeurysmal fibrosis (PAF) with involvement of neighbouring viscera can render open repair of inflammatory aneurysms technically difficult and therefore hazardous. For this reason, endovascular repair (EVAR) has been advocated as the preferred approach for this condition. EVAR is known to induce a systemic inflammatory response in patients but the nature of the local response remains unknown. If significant, such a response could exacerbate rather than ameliorate PAF. The aim of the study was to examine the incidence, course and consequences of perianeurysmal fibrosis detected by computerised tomography (CT) before and after EVAR.

MATERIAL AND METHODS

The clinical records of patients treated by EVAR and followed for at least 6 months were reviewed. Pre and post-operative CT images were independently graded for PAF by three radiologists according to a standard protocol.

RESULTS

PAF was documented preoperatively in six out of a total of 61 patients. In two of these PAF worsened after EVAR resulting in ureteric obstruction and hydronephrosis requiring ureteric stents. In the remaining 4 patients PAF did not reduce postoperatively. PAF of low grade developed postoperatively in 10 out of 55 patients (18%) in whom there was no evidence of PAF on preoperative imaging. Median follow-up was 18 months (range 6-36 months). The development of periaortic fibrosis de novopostoperatively was statistically significant (McNemar's test p=0.002).

CONCLUSION

EVAR does not seem to reverse PAF if this is present preoperatively and it induces this condition in approximately one sixth of patients without evidence of preoperative PAF. The potential for this adverse inflammatory local response should be taken into account when considering EVAR for treatment of aneurysms with perianeurysmal fibrosis and must be weighed against the perceived benefits of this approach.

Acute aortic abnormalities

Aneurysm and type B dissections account for most acute abdominal aortic abnormalities. The postsurgical aorta deserves special attention owing to the risk of complications. Most aortic abnormalities presenting acutely are emergencies that carry a high risk of mortality, and imaging plays a critical role in patient evaluation. Modern helical CT scanners provide excellent spatial resolution, are readily available, and allow for rapid imaging. For these reasons, helical CT angiography is the imaging modality of choice for initial evaluation of the acute aorta.

Fifteen-year experience of transperitoneal management of inflammatory abdominal aortic aneurysms

OBJECTIVES

to assess the long-term outcome of patients with inflammatory abdominal aortic aneurysms.

MATERIALS AND METHODS

over a fifteen-year period 598 cases of abdominal aortic aneurysm were treated and, of these, 32 cases (5.3%) were inflammatory in nature. The diagnosis was made on preoperative (CT) computed tomography in fifteen cases. Twenty-six patients were symptomatic on presentation and ten cases were repaired on an emergency basis. Only six were repaired electively. The transabdominal transaortic approach without dissection on the nearby adherent structures was used routinely.

RESULTS

there was one postoperative death from a respiratory arrest leading to a thirty-day mortality of 3.1%. Early graft thrombosis occurred in three cases (9.3%) and all underwent successful thrombectomy. Colonic ischaemia was encountered in one patient who later developed an aortoenteric fistula. Two patients suffered a non-fatal myocardial infarction postoperatively leading to an overall morbidity of 18.7%.

CONCLUSIONS

patients with inflammatory aortic aneurysms fare worse than patients with aortic aneurysms in general. Preoperative suspicion assists in planning surgery. We believe that the transperitoneal approach with an anterolateral aortotomy and minimal dissection of adherent structures offers excellent results in dealing with this difficult group of patients.

Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review

BACKGROUND

Single-dose antimicrobial prophylaxis for major surgery is a widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple-dose antimicrobial prophylaxis for major surgery and across surgical disciplines.

METHODS

Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 x 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, a high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple-dose regimens and a low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed.

RESULTS

Combined OR by both fixed (1.06, 95% CI, 0.89-1.25) and random effects (1.04, 95% CI, 0.86-1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple-dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other).

CONCLUSIONS

Continued use of single-dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.

L'eziopatogenesi della fibrosi retroperitoneale: Etiopathogenesis of retroperitoneal fibrosis

The etiopathogenesis of retroperitoneal fibrosis is still obscure and probably multifactorial. Among the secondary forms due to demonstrable causes, the one caused by aorto-iliac atherosclerosis has recently been recognised. Its pathogenesis is linked to the low density oxidised lipoproteins of the atheromatous plaque, which are responsible for a local immunologic reaction. The most common form is still idiopathic or primitive, hypothetically related to genetic, environmental, vascular and/or immunologic factors. Idiopathic retroperitoneal fibrosis is sometimes associated with other sclerosing syndromes and/or systemic diseases. In such cases a common pathogenesis, probably immunologic may be postulated. After having illustrated the different categories of retroperitoneal fibrosis, the authors report their experience with 25 patients of whom 14 had idiopathic fibrosis and 11 secondary fibrosis. In the former group 11 patients (78.5%) smoked more than 10 cigarettes a day, while there was a history of prolonged professional exposure to asbestos in one case. The following associated pathologies were observed: hypertension in 7 cases (50%), ischemic cardiopathy in 2 (14.3%), diabetes mellitus in 2 (14.3%), multiple myeloma in 1 (7.1%) and juvenile rheumatoid arthritis in 1 (7.1%). The disease was also associated with other sclerosing pathologies in 3 cases: sclerosing cholangitis in 2 and Dupuytren's contracture in 1. The location of the fibrosis was typically periaortic in 13 cases (92.8%), as shown by CT. Lastly, 10 patients underwent immunosuppressive therapy with a favourable response, suggesting the probable immunologic pathogenesis of the disease.

Tamoxifen for retroperitoneal fibrosis

Retroperitoneal fibrosis, either idiopathic or associated with aortic inflammatory aneurysm, is a chronic fibrotic disease that causes progressive obstruction of ureters and vessels around the lower abdominal aorta. Treatment is often difficult (surgery) or hazardous (steroids). We report a case of a woman with retroperitoneal fibrosis associated with aortic inflammatory aneurysm, who was successfully treated with oral tamoxifen.

Inflammatory aortic aneurysms: regression of fibrosis after aneurysm surgery

OBJECTIVES

To evaluate the fate of perianeurysmal fibrosis (PF) following aneurysm surgery.

METHODS

In this single centre study, pre- and postoperative abdominal CT-scans on 21 consecutive patients with inflammatory abdominal aortic aneurysms were compared. CT-scans of 10 randomly chosen patients operated on for abdominal aortic aneurysms without PF in the same period, served as reference group.

RESULTS

Preoperative thickness of PF was assessed as > 1 cm in 11 and < 1 cm in 10 patients. Ureterolysis was performed in seven patients where the fibrosis caused ureteral obstruction. Postoperative CT-scans performed at a median of 24 (range 3-108) months after surgery showed complete regression of the fibrosis in 29%, partial regression in 57% and no change in 14% of the patients. Progression of the fibrosis or persistence of hydronephrosis was not seen. No sign of fibrosis were seen in the 10 controls.

CONCLUSION

This study supports the findings that PF tends to regress after repair of the abdominal aortic aneurysm.

Inflammatory abdominal aortic aneurysms: a case-control study

PURPOSE

This study was designed to identify significant differences in the clinical and radiologic characteristics and outcome between patients with inflammatory and noninflammatory abdominal aortic aneurysms (AAAs).

METHODS

We reviewed 29 consecutive patients who underwent repair of an inflammatory AAA between 1985 and 1994. This group was matched in a case-control fashion by date of surgery and by the performing surgeon to a group of 58 patients who underwent repair of noninflammatory AAAs.

RESULTS

The two groups had comparable characteristics of age, gender, and cardiovascular risk factors. Patients with inflammatory AAAs were significantly more symptomatic than those with noninflammatory AAAs (93% vs 9%, p < 0.001), were more likely to have a family history of aneurysms (17% vs 1.5%, p = 0.007), and tended to be current smokers (45% vs 24%, p = 0.049). The most significant laboratory difference was an elevated sedimentation rate in patients with inflammatory AAAs (mean, 53 mm/hr vs 12 mm/hr, p < 0.00001). Inflammatory AAAs also were significantly larger than noninflammatory AAAs at presentation (6.8 cm vs 5.9 cm, p < 0.05). Although operative mortality was low in both groups, patients with an inflammatory AAA tended to have higher morbidity, including sepsis (p < 0.01) and renal failure (p = 0.04). Five-year survival rates, however, were similar for the two groups (79% for inflammatory and 83% for noninflammatory AAAs). On follow-up computed tomographic scans, the retroperitoneal inflammatory process resolved completely in 53% of the patients, but 47% of patients had persistent inflammation that involved the ureters in 32% and resulted in long-term solitary or bilateral renal atrophy in 47%.

CONCLUSIONS

This case-control study provides preliminary evidence that inflammatory AAAs may have a relatively strong familial connection and that current smoking may play an important role in the inflammatory response. The study also documents that persistent retroperitoneal inflammation may be more prevalent than has been previously reported, and stresses the need for an improved understanding of the pathogenesis and long-term management of inflammatory AAAs.

Retroperitoneal fibrosis. A true connective tissue disease

Retroperitoneal fibrosis, a disease that can occur at any age, is characterized by a periaortic fibrous mass that often surrounds the ureters, leading to ureteral obstruction. Patients who present with this disease may complain of flank pain and acute renal failure. There is a high correlation with atherosclerotic disease of the aorta, although the pathogenesis of this disease remains unknown. Although recommendations for therapy remain empiric, prednisone seems to be efficacious in treatment; tamoxifen also may be effective. Retroperitoneal fibrosis usually does not lead to long-term morbidity or affect survival.

Significance of radiological diagnosis for detection and staging of inflammatory abdominal aortic aneurysm

Operative morbidity and mortality are elevated in patients with inflammatory abdominal aortic aneurysm. Preoperative identification of inflammatory abdominal aortic aneurysm. the detection of the proximal level and of adhesions to adjacent structures are important for surgical management. The sensitivity and specificity of ultrasonography and computed tomography (CT) for identification and staging in 13 patients with inflammatory abdominal aortic aneurysm were studied. Preoperative radiological diagnoses were validated by intraoperative findings. Correct identification of inflammatory abdominal aortic aneurysm could be achieved in 85% by the use of CT and in 62% by ultrasonography. The proximal level of inflammatory abdominal aortic aneurysm was correctly determined by CT in all patients and by ultrasonography in 62%. Using a transperitoneal approach, the condition was considered inoperable in two patients as a result of the suprarenal extent of the aneurysm and because of unremovable adhesions in two other cases. In the latter pair, it was impossible to predict inoperability by radiological findings. Sensitivity (85%) and specificity (100%) of standard radiological techniques to identify inflammatory changes are high. Inoperability caused by suprarenal extent could be detected correctly by routine radiological procedures. However, identification of dense adhesions appears uncertain.