Effect of patient transfer on outcomes after open repair of ruptured abdominal aortic aneurysms.

Patients with ruptured abdominal aortic aneurysms (RAAAs) benefit from treatment in high-volume facilities. This study explored the effect of patient transfer on outcomes and the relationship between hemodynamic status and mortality. We performed a retrospective review of 83 consecutive patients who had open repair for RAAA at a single tertiary facility. The patients were divided into two groups based on arrival in the local emergency department, "local" (n = 44) versus "transfer" (n = 39) from an outside institution, and into three categories of hemodynamic status: (a) no obtainable blood pressure, "pulseless"; (b) requiring vasopressor support, "pressors"; and (c) no vasopressor support, "no pressors." Thirty-day mortality was 21.4%. There was no difference in mortality between the local (18.2%) and transfer (25.6%) patients (p = .41). There were no deaths during transfer. There was no difference in the hemodynamic status of the transfer versus the local group (p = .34). The mortality by category was pulseless, 100% (3 of 3); pressors, 71.4% (10 of 14); and no pressors, 7.6% (5 of 66) (p < .0001). Actuarial survival was 66%, 64%, and 62% at 1, 3, and 5 years, respectively. Patient transfer does not adversely affect mortality after RAAA repair. Patients without a palpable pulse and those requiring hemodynamic support have a significantly higher mortality.

Endovascular repair of ruptured abdominal aortic aneurysms: systematic literature review.

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient -0.378, p< .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.

Ascending and transverse aortic arch repair: the impact of glomerular filtration rate on mortality.

BACKGROUND: Recent studies have described the importance of renal glomerular filtration rate (GFR) as a determinant of perioperative mortality in patients with aneurysms that involve the thoracoabdominal and abdominal aorta. We studied the impact of GFR on mortality following repair of ascending and arch aneurysms. METHODS: Between February 1991 and August 2006, we performed 994 repairs of the ascending and transverse aortic arch. Nine hundred twenty patients had evaluable data for this study. Sixty-two percent were men (566/920); mean age was 65 years (range 17-89). We estimated the GFR using the Cockcroft-Gault equation. Mean preoperative serum creatinine was 1.2 +/- 0.9 mg/dl, mean GFR was 77 +/- 37 mL/min. Renal function data were arrayed in quartiles for univariate analysis and kept continuous for multivariable analyses. Multivariable analyses assessed demographics, extent of disease, acuity of presentation, and renal function measured by both creatinine and GFR. RESULTS: Overall 30-day mortality was 10.8% (99/920). In univariate analyses, GFR (P < 0.0001), serum creatinine (P < 0.0003), coronary artery disease (P > 0.03), acute dissection (P < 0.03), emergency presentation (P < 0.002), age (P < 0.009), pump time (P < 0.0001), cross-clamp time, (P < 0.03) and circulatory arrest time (P < 0.003) were associated with increased mortality. By multivariable analyses, only GFR (P < 0.0001), pump time (P < 0.0001), emergency status (P < 0.002) were significant independent risk factors for mortality. CONCLUSIONS: Preoperative renal function as defined by GFR was the most significant predictor of mortality during repairs of the ascending and transverse aortic arch. The use of GFR provides better preoperative risk stratification during these repairs than creatinine alone.

Intraoperative skeletal muscle ischemia contributes to risk of renal dysfunction following thoracoabdominal aortic repair.

OBJECTIVE: Renal dysfunction is among the most commonly occurring morbidities following descending thoracic and thoracoabdominal aortic repair. We hypothesized that myoglobin nephrotoxicity might arise from leg ischemia caused by femoral artery cannulation, which is required for distal aortic perfusion. Lacking complete historical laboratory data on myoglobinemia, we studied somatosensory evoked potential (SSEP) changes in the leg (a functional marker of leg ischemia), as a surrogate predictor of acute postoperative renal failure. METHODS: Intraoperative leg SSEP function and preoperative glomerular filtration rate (GFR - an essential covariate) were available for 299 patients. Change in SSEP was defined as 10% increase in latency or 50% decrease in amplitude. Postoperative renal dysfunction was 1mg/dl/day increase in creatinine for 2 days, clinical diagnosis of ARF or need for dialysis postoperatively. RESULTS: Change in SSEP in the cannulated leg occurred in 108/299 (36%) of cases intraoperatively. All recovered normal SSEP function at decannulation. Patients with SSEP changes had 41/108 (38%) postoperative renal failure compared to 49/191 (26%) without (odds ratio 1.8, p<0.03). Modeled with GFR, aneurysm extent, and chronic obstructive pulmonary disease (COPD), SSEP changes had an adjusted odds ratio of 1.9, p<0.03. Pre-op GFR was also a highly significant predictor of postoperative renal failure (OR 0.98/ml; p<0.0001). CONCLUSION: This is the first study to show a relationship between intraoperative leg ischemia and postoperative renal failure. It provides epidemiological evidence that the ischemic leg may be an important contributor to rhabdomyolysis-like renal morbidity after thoracoabdominal aortic surgery.

Proximal reoperations after repaired acute type A aortic dissection.

BACKGROUND: Concerned with the associated risks of proximal reoperation, some have proposed an aggressive approach of aortic root replacement during emergent repair of acute type A aortic dissection. Because few data exist regarding late reoperations, we report outcomes of proximal reoperation after repaired type A aortic dissection. METHODS: Between January 1991 and March 2006, 63 patients underwent reoperation after previous repair for acute type A aortic dissection. Procedures performed at reoperation included ascending (94%, 59 of 63), total arch (62%, 39 of 63), elephant trunk (56%, 35 of 63), aortic valve replacement (38%, 24 of 63), aortic root (27%, 17 of 63), and coronary artery bypass graft (8%, 5 of 63). Preoperative, operative, and postoperative variables were analyzed retrospectively with regard to early and late mortality. RESULTS: Thirty-day mortality was 11.1% (7 of 63). No strokes occurred. Incidence of renal failure, respiratory failure, and bleeding was 6% (4 of 63), 23% (15 of 63), and 6% (4 of 63), respectively. Mean time from initial repair to reoperation was 69 months (range, 1 to 258). Procedure performed (root versus ascending/resuspension) at initial repair did not affect the time to reoperation (p > 0.05). Median follow-up was 40 months; and 1-, 5-, and 10-year survival was 82%, 74%, and 62%, respectively. Multivariate predictors of late mortality were prior coronary artery bypass graft surgery (odds ratio = 6.5, p < 0.003), bypass time (odds ratio = 3.6, p < 0.02), and renal dysfunction (odds ratio = 3.7, p < 0.05). CONCLUSIONS: Proximal reoperations for repaired acute type A aortic dissection can be performed with acceptable early and late mortality. The concern for proximal reoperation should not dictate the initial procedure choice during acute type A aortic dissection. Continued clinical and radiographic surveillance of repaired type A aortic dissection is warranted.

Successful descending thoracic aortic aneurysm repair during a twin pregnancy: case report and literature review.

A 28-year-old woman in the first trimester of a twin pregnancy presented with a symptomatic descending thoracic aortic aneurysm. We report our experience in managing a descending thoracic aortic aneurysm in this patient.

Optimization of aortic arch replacement: two-stage approach.

BACKGROUND: Aneurysms of the aortic arch seldom occur alone. They usually involve the ascending aorta. Occasionally, the aneurysm also involves the descending thoracic or thoracoabdominal aorta. We advocate a staged approach for repair of these extensive aortic aneurysms, with the ascending and arch generally being repaired in the first stage and the descending thoracic or thoracoabdominal aorta being repaired in the second stage. METHODS: Between February 1991 and December 2005, we repaired aneurysms of the ascending, arch, descending thoracic, and thoracoabdominal aorta in 2120 patients. Of these, 254 (12.0%) involved the ascending, arch, and descending aorta (extensive aortic aneurysm). A first-stage repair was done in 254 patients, and 115 returned for a second-stage repair for a total of 369 procedures performed. RESULTS: First-stage 30-day mortality was 6.3% (16/254), with the glomerular filtration rate (GFR) exceeding 70 mL/min in 2.9% of patients and less than 70 mL/min in 10.5% (p < 0.03). Second-stage 30-day mortality was 9.6% (11/115), with GFR exceeding 70 mL/min in 4.9% and less than 70 mL/min in 9.8% (not significant). The incidence of postoperative stroke for the first stage was 2.0% (5/254), and the rate of neurologic deficit (paraplegia and paraparesis) was .9% (1/115) in the second stage. The mortality for the interval of 31 days to 6 weeks after the first-stage operation was 2.9% (7/238). CONCLUSIONS: Aneurysms involving the transverse arch with extensive involvement of the ascending and descending thoracic or thoracoabdominal aorta can be effectively repaired using the two-stage technique with acceptable morbidity and mortality. GFR correlates to surgical outcome in the first-stage repair. After the first stage, prompt treatment of the remaining segment of aorta is crucial to success.

Management of distal femoral and popliteal arterial injuries: an update.

BACKGROUND: The management of combined arterial and musculoskeletal injuries to the lower extremity remains controversial, particularly with regard to the initial order of intervention and the use of intravascular shunting. In this study, we review the contemporary management and outcome of patients treated for acute traumatic distal femoropopliteal arterial injuries. METHODS: From January 2001 to January 2006, we repaired 57 acute traumatic lower-extremity arterial injuries in a level 1 trauma center. Our approach was to perform surgical revascularization without intraluminal shunting as soon as the arterial injury was recognized. There were 44 men (77%). Mean age was 31 years (range, 5-68). The mechanism of injury was blunt in 42 of 57 (74%) patients. Vascular reconstruction was achieved by using an autogenous saphenous vein graft in 52 of 57 (91%), a vein patch in 3 of 57 (5%), or primarily in 2 of 57 (4%) patients. RESULTS: The limb-salvage rate was 92% (53/57). Thirty-six patients (63%) had associated orthopedic fixation: 12 of 36 (33%) before and 24 of 36 (67%) after revascularization. Twenty-one of 57 patients (37%) had vascular repair only without orthopedic fixation. Thirty-four patients (60%) required fasciotomy. Four patients had subsequent above-knee amputation: 3 because of wound complications despite successful revascularization and 1 because of failed revascularization. There were no complications related to the arterial repairs that were performed before orthopedic fixation. CONCLUSION: Our study shows that arterial reconstruction for acute traumatic lower-limb injuries results in a good limb-salvage rate. We advocate prompt vascular repair before orthopedic intervention for combined vascular and skeletal injuries of the lower extremity, without using intravascular shunting.

Glomerular filtration rate is superior to serum creatinine for prediction of mortality after thoracoabdominal aortic surgery.

BACKGROUND: Clinically evident renal disease (dialysis, history of renal insufficiency, or serum creatinine >2.0 mg/dL) is a known risk factor for mortality after thoracoabdominal aortic aneurysm repair. We extended this concept to the questions of whether subclinical renal disease is also a risk factor and how best to identify subclinical disease. We hypothesized that the glomerular filtration rate (GFR) would be a more sensitive determinant of renal function than serum creatinine alone. METHODS: Between 1991 and 2004, we repaired 1106 thoracoabdominal aortic aneurysms and descending thoracic aortic aneurysms. The median age was 67 years. There were 400 (36%) women and 706 (64%) men. We estimated GFR by using the Cockcroft-Gault equation. We divided baseline serum creatinine and baseline GFR into quartiles and estimated the association of the quartiles with 30-day postoperative mortality by chi2 testing. We further subdivided the population into patients with and without clinically evident renal disease and repeated the analysis in the patients without clinically apparent disease (n = 869). RESULTS: Clinically apparent renal disease was highly associated with 30-day mortality (odds ratio, 3.2; P < .0001). In all patients, serum creatinine quartile and GFR quartile were also both highly significantly associated with 30-day mortality (P < .0001). In patients without clinically apparent renal disease, both creatinine and GFR predicted additional mortality, but GFR was a much stronger predictor (P < .02 for creatinine vs < .0001 for GFR). In these patients, mortality ranged from 5% in the best GFR quartile to 27% in the worst. Taken as continuous variables in logistic regression equations, serum creatinine had no discrimination in patients without clinical disease (P = .73), whereas GFR remained strong (P < .0001). CONCLUSIONS: Preoperative renal function is an important determinant of early mortality even in patients without clinically evident disease. Estimated GFR is a much more powerful determinant of mortality risk than serum creatinine alone.