ABSTRACT
To identify the factors affecting the high mortality rates associated with ruptured abdominal aortic aneurysm (rAAA), a review was made of the records of 35 consecutive patients (33 males, 2 females, mean age 69.9yr.) treated surgically between 1988 and 1997. Preoperatively profound shock (systolic pressure less than 70mmHg) was seen in 19 patients and loss of consciousness in 9. Maximum diameter of the AAA was 79±20mm and the preoperative hemoglobin level was 9.1±2.4g/dl. Proximal aortic clamp was performed at the intrathoracic aorta in 3 cases, the suprarenal aorta in 6, balloon occlusion in 4, and the infrarenal aorta in 22. Since 1994, diltiazem and nitroglycerin have been routinely given for latent myocardial ischemia and early induction of continuous hemodialysis for renal failure was attempted postoperatively. The overall hospital mortality rate was 20%. Multisystem failure was the most frequent cause of hospital death (57.1%), followed by pneumonia with sepsis in 28.6%, and intraoperative cardiac arrest (14.3%). By univariate analysis of various factors associated with the mortality rate, loss of consciousness, abnormality on electrocarciogram (ECG) and duration of shock for more than five hours were statistically significant. Multivariate analysis with stepwise logistic regression demonstrated that an ECG abnormality and duration of shock more than five hours were associated with high mortality, but not at statistically significant levels. These findings suggest that factors that are predictive of death (loss of consciousness and ECG abnormality) may be a reflection of shock in this patient population.
ABSTRACT
Immediate surgical intervention is required for Stanford type A aortic dissection. However, the surgical results of emergency surgery are still poor, especially in patients associated with myocardial ischemia. This study was undertaken to evaluate the surgical results of acute type A aortic dissection in association with myocardial ischemia. In the past six years 7 cases of acute type A aortic dissection underwent surgical repair with simultaneous coronary-artery bypass grafting (CABG). There were 5 male and 2 female with a mean age of 47±16 year-old. The causes of myocardial ischemia were proximal progression of dissection into the coronary orifice in 5 and association of atherosclerotic coronary heart disease in 2. Six patients developed cardiogenic shock before surgery. Bentall's type of operation was performed on 4 patients and prosthetic graft replacement of ascending aorta was performed on 2 patients. Single bypass grafting was performed on 5 patients and double bypass grafting was performed on 2 patients. One patient died due to brain damage and acute renal failure on the tenth postoperative day, and another patient required left ventricular assist device for 9 days due to postoperative low cardiac output syndrome. Ultimately 6 patients (86%) survived and were discharged. In conclusion, surgical management is not easy for the emergency patients with type A acute aortic dissection in association with myocardial ischemia, however, reasonable surgical results can be obtained with supplemental CABG and mechanical support of the left ventricle.