Watchful waiting in cases of small abdominal aortic aneurysms- appropriate for all patients?

OBJECTIVE: The purpose of this study was to determine the effect of patient compliance on a program of watchful waiting in cases of small abdominal aortic aneurysms and to document the proportion of patients who become prohibitive operative risks during follow-up. STUDY DESIGN: A retrospective review was conducted at a regional military veterans medical center. The subjects were 101 male military veterans with abdominal aortic aneurysms measuring less than 5 cm who did not have medical contraindications to operative repair. The main outcome measures were (1) the proportion of patients who missed three scheduled radiologic tests in a row despite written notifications mailed to their homes and (2) the proportion of compliant patients who had medical illnesses and became prohibitive operative risks during follow-up. RESULTS: During a follow-up (mean +/- SEM) of 34 +/- 2 months, 69 patients (69%) were fully compliant with the watchful waiting program and underwent a mean of 4.5 +/- 0.3 radiologic tests. There were no abdominal aortic aneurysm ruptures in this subgroup. Twenty-five patients (36%) had indications for abdominal aortic aneurysm repair, and 28 (41%) have not met the criteria for repair. Sixteen (23%) of the 69 compliant patients developed prohibitive medical risks during follow-up; eight (50%) of these 16 patients died, all of the causes unrelated to their abdominal aortic aneurysms. Thirty-two (32%) of the 101 study subjects were noncompliant with the watchful waiting program. Twenty-seven (84%) of the noncompliant patients did not keep any scheduled appointments, and five (16%) were lost after one or two examinations. Three of the noncompliant patients experienced documented abdominal aortic aneurysm rupture, and it is suspected in a fourth. Direct contact was made with 28 (88%) of these patients or their families; all acknowledged having received written notifications regarding their watchful waiting program tests and had decided not to continue with surveillance for a variety of socioeconomic reasons. Between the 69 compliant patients and the 32 noncompliant patients, there were no differences with respect to mean age (70 +/- 1 years vs 73 +/- 2 years), distance from home of record to the hospital (62 +/- 14 miles vs 73 +/- 23 miles), or abdominal aortic aneurysm size at initial detection (3.75 +/- 0.5 cm vs 3.8 +/- 0.5 cm). CONCLUSIONS: Watchful waiting programs are imperfect and highly reliant on the motivation levels and means of the individual patients. Watchful waiting is reasonable among compliant patients with abdominal aortic aneurysms, inasmuch as fewer than half will meet the criteria for intervention within a mean of 3 years. Approximately one fourth of these patients will have medical contraindications to abdominal aortic aneurysm repair during follow-up, and many of these will die of causes other than abdominal aortic aneurysm rupture. In our experience, one third of candidates for watchful waiting programs are unable to participate and are at risk of rupture. These patients need special attention so that the reasons for their noncompliance can be determined, and they may be candidates for earlier intervention.

Spontaneous popliteal vascular injury in the morbidly obese.

PURPOSE: Morbidly obese patients who sustained popliteal vascular injury after spontaneous knee dislocation (KD) were studied. METHODS: Seven morbidly obese patients (body mass index [BMI] >35 kg/m2 and >100 lb over ideal body weight) who sustained spontaneous KD while upright were reviewed. RESULTS: Severe popliteal arterial injury accompanied all spontaneous KD. The mean age of patients was 34.1 +/- 6.7 years; the mean weight was 354 +/- 150 lb (range, 220-702 lb); and mean BMI was 53 +/- 21 kg/m2 (range, 37-98.4). All had arterial avulsion and thrombosis. Three had concomitant venous injury. All underwent operative repair. Morbid obesity presented unique challenges to surgical management. Limited positioning, specialized operative tables, large incisions, deep exposure, special retraction, long operative times (mean, 537 +/- 134 minutes), and major blood loss (mean, 2.5 +/- 3 L) were standard. Five arterial injuries were repaired with interposition vein grafts, and 2 required tibial bypass. Venous repairs included thrombectomy and primary repair (n = 2) and interposition grafting (n = 1). Many complications were related to morbid obesity, including deep wound infection (n = 3), diabetic ketoacidosis (n = 2), and cor pulmonale from sleep apnea (n = 1). Despite patent grafts in all patients, 2 above-knee amputations were required for extensive neuromuscular loss. CONCLUSION: Morbid obesity is a specific risk factor for spontaneous KD and vascular injury. In addition, morbid obesity presents unique challenges to operative repair and predisposes patients to unusual major postoperative complications.

Steal syndrome complicating hemodialysis access.

The purposes of this study were to examine potential causes for arterial steal syndrome in patients with hemodialysis shunts and to evaluate the results of treatment. A retrospective analysis was performed on all hemodialysis patients who presented with arterial steal syndrome over a 3-year period. Medical records were reviewed to determine demographic data, time to development of symptoms, operative details, and treatment outcome. Results of upper-extremity arteriography in the last five patients were also documented. Eighteen patients presented with steal syndrome at a mean of 7(4) months after shunt placement. Four patients had prior ipsilateral grafts. Fifteen (83%) patients had forearm shunts in loop configuration between the main brachial artery and a superficial vein, and three had straight upper-arm shunts. Graft sizes were 6 mm in five patients and 4- to 7 step grafts in 13. Graft banding was used to treat steal in 11 shunts, one of which remained patent. All five patients who underwent upper-extremity arteriography had arterial stenoses demonstrated in the inflow circulation. In conclusion, arterial steal is an uncommon complication of hemodialysis shunts. Shunt location and choice of graft do not appear to be major factors: steal can develop regardless of access site, configuration, or use of straight versus step graft. Banding is an ineffective method of treatment. Arteriography may be important to detect unsuspected inflow stenoses in patients with steal syndrome.