The Effect of Secondary Operations on Mortality Following Abdominal Aortic Aneurysm Repair in the United States: 1988–2001

Laparoscopic sigmoidectomy postopen aortic replacement for abdominal aortic aneurysm: a case report

Colectomy for colorectal cancer after an open aortic replacement (OAR) for abdominal aortic aneurysms has high perioperative complication and mortality rates.

Case presentation

The authors report the case of an 87-year-old man who underwent laparoscopic sigmoidectomy. The patient presented with edema of the lower legs and face, and blood test results indicated anemia. The patient had a history of OAR for an abdominal aortic aneurysm 9 years prior, a left common iliac artery aneurysm, and a jump bypass graft. A colonoscopy revealed a type 2 lesion in the sigmoid colon; he was diagnosed with moderately differentiated adenocarcinoma. Preoperative computed tomography did not show any obvious lymph node or distant metastases. Laparoscopic sigmoidectomy with D3 lymphadenectomy was planned. During surgery, the use of the lateral approach allowed sigmoid mesocolon mobilization while confirming the presence of the artificial arteries. As the approach to the root of the inferior mesenteric artery was difficult, D1 lymphadenectomy was performed. No evidence of anastomotic leakage or artificial artery infection was observed postoperatively.

Clinical discussion

Intra-abdominal adhesions due to the prior OAR makes sigmoid mesocolon mobilization difficult. In cases where laminar structure cannot be recognized, other landmarks are needed.

Conclusions

After OAR, artificial arteries can be used as landmarks during colectomy. Although laparoscopic surgery is technically challenging, the magnified view provides an advantage in identifying these landmarks. Patients' surgical records for the previous OAR should be checked, and the positions of the vessels and ureters should be elucidated preoperatively using computed tomography.

Mortality rates and risk factors for emergent open repair of abdominal aortic aneurysms in the endovascular era

The background of this paper is to report the mortality at 30 and 90 days and at mean follow-up after open abdominal aortic aneurysms (AAA) emergent repair and to identify predictive risk factors for 30- and 90-day mortality. Between 1997 and 2002, 104 patients underwent emergent AAA open surgery. Symptomatic and ruptured AAAs were observed, respectively, in 21 and 79% of cases. Mean patient age was 70 (SD 9.2) years. Mean aneurysm maximal diameter was 7.4 (SD 1.6) cm. Primary endpoints were 30- and 90-day mortality. Significant mortality-related risk factor identification was the secondary endpoint. Open repair trend and its related perioperative mortality with a per-year analysis and a correlation subanalysis to identify predictive mortality factor were performed. Mean follow-up time was 23 (SD 23) months. Overall, 30-day mortality was 30%. Significant mortality-related risk factors were the use of computed tomography (CT) as a preoperative diagnostic tool, AAA rupture, preoperative shock, intraoperative cardiopulmonary resuscitation (CPR), use of aortic balloon occlusion, intraoperative massive blood transfusion (MBT), and development of abdominal compartment syndrome (ACS). Previous abdominal surgery was identified as a protective risk factor. The mortality rate at 90 days was 44%. Significant mortality-related risk factors were AAA rupture, aortocaval fistula, peripheral artery disease (PAD), preoperative shock, CPR, MBT, and ACS. The mortality rate at follow-up was 45%. Correlation analysis showed that MBT, shock, and ACS are the most relevant predictive mortality factor at 30 and 90 days. During the transition period from open to endovascular repair, open repair mortality outcomes remained comparable with other contemporary data despite a selection bias for higher risk patients. MBT, shock, and ACS are the most pronounced predictive mortality risk factors.

Coding accuracy of abdominal aortic aneurysm repair procedures in administrative databases - a note of caution

BACKGROUND

Administrative databases have been used to compare methods used for abdominal aortic aneurysm (AAA) repair. This requires the use of procedural codes whose accuracy has not been established. In this study we measured the accuracy of procedural codes for open AAA repair and endovascular aneurysm repair (EVAR) in administrative databases.

METHODS

Between April 2000 and July 2005, we identified all surgeries of non-ruptured AAA using open or EVAR technique at a tertiary-care teaching hospital. During the same time period, we identified all patients who were coded with either an open AAA repair or EVAR.

RESULTS

During the study period, 514 people had an elective AAA repair or were coded with one. Coding quality of open AAA repair was poor (sensitivity 48.1%; specificity 77.4%; accuracy 52.9%) while that for EVAR was slightly better (sensitivity 58.2%; specificity 100%; accuracy 93.6%). We developed an algorithm that included similar procedures and considered anaesthetic type to improve the identification of both open repair (sensitivity 97.7%; specificity 86.9%; accuracy 95.9%) and EVAR (sensitivity 84.8%; specificity 99.5%; accuracy 97.3%).

CONCLUSION

Administrative database codes that are routinely used to identify open AAA repairs or EVARs are inaccurate. However, slight modifications to the coding algorithms permit the use of administrative databases to study AAA repair.

New Surgical Drapes for Observation of the Lower Extremities during Abdominal Aortic Repair

OBJECTIVE

For the early diagnosis and therapy of peripheral thromboembolism (TE) as a complication of abdominal aortic repair (AAR), we developed and evaluated the usefulness of surgical drapes that permit observation of the lower extremities during AAR.

MATERIALS AND METHODS

Between January 2007 and June 2009, the handling, durability, and usefulness of new surgical drapes were evaluated during AAR in 157 patients with abdominal aortic aneurysms and 9 patients with peripheral arterial disease. The drapes are manufactured by Hogy Medical Co. Ltd. and made of a water-repellent, spun lace, non-woven fabric, including a transparent polyethylene film that covers the patients' legs. This transparent film enables inspection and palpation of the lower extremities during surgery for early diagnosis and therapy of peripheral TE.

RESULTS

As a peripheral complication, 1 patient had right lower extremity TE. This was diagnosed immediately after anastomosis, thrombectomy was performed, and the remaining clinical course was uneventful. In all patients, the drapes permitted observation of the lower extremities , and the dorsal arteries were palpable. There were no problems with durability.

CONCLUSIONS

New surgical drapes permit observation of the lower extremities during AAR for early diagnosis and treatment of peripheral TE.

Abdominal aortic aneurysm repair and colonic infarction: a risk factor appraisal

OBJECTIVE

Colonic infarction is a recognized complication of abdominal aortic aneurysm (AAA) surgery. The clinical difficulty in establishing the diagnosis combined with the patient's poor physiological status is usually associated with a fatal outcome. We assessed our experience with this problem to identify a possible risk factor profile for these patients.

METHOD

Patients records were identified from the operative logs, intensive care unit, Hospital Inpatient Enquiry system and vascular unit databases over a 6-year period.

RESULTS

A total of 405 patients underwent AAA repair during this period; 140 as emergency ruptures. Nine patients were identified from the databases with known colonic infarction (2.2%). One was a woman. The mean age was 70 years. Seven patients had emergency ruptures (5%). Twenty independent risk factors were analysed using univariate and multivariate logistic regression models. Significant risk factors identified by using a multivariate analysis included the nature of the presenting patient, preoperative hypotension, prolonged cross-clamp time, intra-operative ischaemia and postoperative acidosis. Confirmatory diagnosis was made by colonoscopy in eight patients. One patient survived following the salvage surgery. The mean duration of survival was 10.5 days. The overall mortality was 89% of patients.

CONCLUSION

In our unit infrarenal AAA repair has a 2.2% rate of colonic infarction. A definitive diagnosis is best made by colonoscopy. A risk factor profile for the development of colonic infarction may be constructed on the basis of specific clinical parameters. Earlier intervention on the basis of this profile may ultimately reduce the current excessive mortality.