Selection and preparation of high-risk patients for repair of abdominal aortic aneurysms.

OBJECTIVE: To discuss the most important risk factors in patients who undergo surgical repair of an abdominal aortic aneurysm (AAA). DESIGN: This update in vascular surgical repair highlights the criteria that identify high-risk patients, the useful preoperative tests, and the perioperative measures that can aid surgical recovery. MATERIAL AND METHODS: In elective repair of AAAs, high-risk patients are those with severe coronary or valvular heart disease, decompensated chronic obstructive pulmonary disease, severe cerebrovascular disease, chronic renal failure, hepatic cirrhosis with portal hypertension, and chronic hematologic disorders associated with bleeding dysfunction. Patients with unstable or severely symptomatic heart disease should undergo preoperative coronary angiography and ventriculography. Pharmacologic stress testing is recommended for patients with clinical markers of serious coronary artery disease and other medical or physical factors that prevent any type of standard exercise stress testing. RESULTS: Our experience with high-risk patients supports conventional repair of AAAs. Our preference for the midline abdominal incision in high-risk patients is substantiated by an operative mortality rate of 5.7% in comparison with a reported 7% mortality rate for nonresective therapy. Approximately one in three high-risk patients will have a serious postoperative complication, the most common of which is a cardiac event. Most patients recover after a slightly prolonged hospital stay. CONCLUSION: Despite an increased operative risk, patients with a stable medical condition and an AAA larger than 6 cm in diameter should be considered for elective repair. High-risk patients with smaller aneurysms (5 to 6 cm in diameter) should undergo efforts to stabilize or to improve their general medical condition before elective operation.

Surgical resection of carotid body tumors: long-term survival, recurrence, and metastasis.

We retrospectively reviewed a 20-year experience with 59 carotid body tumors in 55 patients examined at our institution in order to determine the long-term results of surgical resection, including the rates of distant metastasis, local recurrence, and long-term survival. Complete surgical excision was possible in 52 of the 55 patients (95%). Perioperative mortality was only 2% (1 of 59 procedures), and no operative deaths occurred during the last 10 years of the study. Survival of patients after resection of a carotid body tumor was equivalent to that for sex- and age-matched control subjects. Only one patient (2%) had development of metastatic disease during long-term follow-up. Three patients (6%) had recurrence of the carotid body tumor after complete excision. All recurrent tumors were observed in patients with multiple paragangliomas or a family history of cervical paragangliomas. Therefore, we advocate early surgical resection of all carotid body tumors in low-risk patients. Such early resection maximizes the possibility of cure and minimizes the risks of neurovascular complications associated with large and neglected tumors.

Myocardial revascularization before abdominal aortic aneurysmorrhaphy: effect of coronary angioplasty.

Percutaneous transluminal coronary angioplasty (PTCA) has assumed an increasing role in the preoperative preparation of patients with an abdominal aortic aneurysm (AAA). The influence of this modality on perioperative morbidity and long-term outcome has not been substantiated. To determine the effect of PTCA, we analyzed a cohort of 2,452 patients who underwent repair of an AAA between 1980 and 1990 at our institution. We compared the cardiac morbidity, mortality, and survival of patients who had preoperative coronary revascularization by PTCA or coronary artery bypass grafting (CABG). The overall perioperative mortality for the 2,452 patients was 2.9%. Preoperative coronary revascularization was necessary in 100 patients (4.1%)--86 had CABG and 14 had PTCA. Of these 100 patients, 95% had cardiac symptoms. Patients selected for PTCA, in comparison with CABG, had significantly less three-vessel disease but not significant differences in cardiac history or ejection fraction. During the study period, the use of PTCA increased significantly. The perioperative rate of myocardial infarction for patients with prior CABG was 5.8% in comparison with 0% for those with prior PTCA. No hospital deaths occurred in either group. The median interval between coronary revascularization and repair of an AAA was 10 days for PTCA and 68 days for CABG. The 3-year survival was not statistically different between CABG (82.8%) and PTCA (92.3%) groups. The rate of late cardiac events (at 3 years) was 56.5% in the PTCA group and 27.3% in the CABG group. We conclude that PTCA as part of a highly selective approach to coronary revascularization before repair of an AAA minimizes cardiac-related events and death.(ABSTRACT TRUNCATED AT 250 WORDS)

Endovascular repair of abdominal aortic aneurysms: where do we stand?

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Isolated iliac artery aneurysms.

The records of 50 patients with isolated iliac artery aneurysms seen between January 1970 and January 1982 were reviewed. Forty-seven were men and three were women. Their ages ranged from 41 to 92 years (mean 69.7 years). Aneurysm diameter ranged from 2 to 20 cm (mean 4.7 cm). Seventeen patients had multiple aneurysms. Sixty-two percent of aneurysms were on the right side. Eighty-nine percent were located in the common iliac artery, 10% in the internal iliac artery, and 1% in the external iliac artery. Twelve patients had symptoms; all presented with sudden pain. Rupture occurred in seven patients; only three patients survived. Twenty-four patients had surgical treatment. Aneurysmorrhaphy with graft interposition was the most common procedure. There were no deaths during elective operation. Nineteen patients who did not undergo operation were followed from 0.25 to 11 years (mean 4.9 years). Enlargement occurred in nine patients and rupture in one. We conclude that the natural history of isolated iliac artery aneurysms is similar to that of other atherosclerotic aneurysms. Elective resection and arterial reconstruction are recommended.

Arteriomegaly: classification and morbid implications of diffuse aneurysmal disease.

Ninety-one patients with arteriomegaly and diffuse aneurysmal disease below the level of the renal arteries have been classified according to the extent and location of aneurysmal change. There exists a high incidence of thrombotic and embolic complications, and treatment entails increased rates of morbidity and mortality when compared to surgical treatment of simple abdominal aneurysms of peripheral artery aneurysms. Complete revascularization at the initial operation would appear to give the best result, but this approach must be tempered by the individual patient risk factors and the urgency of the mode of presentation of the patient.

Abdominal aortic aneurysm repair combined with a second surgical procedure--morbidity and mortality.

Some patients who undergo repair of an abdominal aortic aneurysm require a concomitant procedure. This study compares the morbidity and mortality rates of patients who undergo combined procedures with those who undergo aneurysmorrhaphy alone. Five hundred sixty-three elective aneurysmorrhaphies were performed in the years 1971, 1976, and 1980. Three hundred thirty-five individuals underwent aneurysm repair alone (group I), while 115 underwent at least one additional vascular procedure (group II), and 113 underwent one or more nonvascular procedures (group III) concomitant with aneurysmorrhaphy. Mortality rates for the three groups were 2.6%, 3.5%, and 6.0%. Morbidity rates were 12.8%, 26.1%, and 18.5%. The differences in rates do not achieve statistical significance, but causes of death and complications varied slightly in each group. Deaths in group I were largely due to myocardial infarction, while deaths in groups II and III were largely due to complications of operation or underlying disease. Patients who required concomitant renal artery revascularizations had the greatest number of serious complications in group II. Patients with concomitant cholecystectomy appeared to have an increase in serious complications, but concomitant herniorrhaphy or lumber sympathectomy appeared to be free of any additional morbidity.

Thoracic aortic aneurysms: a population-based study.

Thoracic aortic aneurysms were detected in 72 residents (44 women and 28 men) in a stable midwestern community over a 30-year period, for an age- and sex-adjusted incidence of 5.9 new aneurysms per 100,000 person-years. The incidence was equal in both sexes and decreased slightly over the 30 years. Ages ranged from 47 to 93 years (median 65 years for men and 77 years for women). The ascending aorta was involved in 37 patients, the aortic arch in 8, and the descending aorta in 27. Pathologic examination was performed in 51 patients. The cause was aortic dissection in 27 patients (53%), atherosclerosis in 15 (29%), aortitis in 4 (8%), cystic medial necrosis in 3 (6%), and syphilis in 2 (4%). All autopsied patients had pathologic evidence of significant hypertension. Eleven patients (25%) had concomitant abdominal aortic aneurysms. Rupture occurred in 53 patients (74%) and 50 died. Thirty-seven of these patients had no prior diagnosis of aneurysm. The median interval between diagnosis and rupture in the 16 remaining patients was 2 years (range 1 month to 16 years). Ninety-five percent of aortic dissections ruptured and 51% of nondissecting aneurysms ruptured. The actuarial 5-year survival for all 72 patients was 13%; for patients with aortic dissection, 7% and for patients without dissection, 19.2%.

Klippel-Trenaunay syndrome: the risks and benefits of vascular interventions.

Our experience with Klippel-Trenaunay syndrome (KTS), a rare congenital malformation, has increased considerably in recent years and now includes 144 patients (65 male and 79 female patients). Hemangioma was present in 137 patients (95.1%), varicosity in 110 (76.4%), and hypertrophy of the soft tissues or bones in 134 (93.1%). In most patients (71.5%) the disease involved one lower extremity. Diagnostic workup included roentgenogram to document limb length discrepancy, noninvasive arterial and venous evaluation, contrast venography, and nuclear magnetic resonance imaging. Most patients did well without treatment or with elastic compression only. Surgical treatment for the vascular malformation in KTS is rarely needed and it continues to be controversial. To evaluate the risks and benefits of vascular interventions, we examined in detail the clinical histories of nine patients who in the last decade underwent operation for a vascular malformation of the lower extremity. In seven patients we removed varicose veins or resected hemangioma of the lower extremity. Although none was cured, all five who underwent resection of varicose veins and one of the two patients who underwent resection of a hemangioma improved. Two additional patients, however, who underwent resection of varicose veins in another institution had worsening of the symptoms. In one patient we performed deep venous reconstruction for atresia of the superficial femoral vein, using the contralateral saphenous vein. Such operation in KTS has not been reported previously. The patient has a patent graft with a competent valve and clinical improvement 6 months after the operation. Although patients with severe chronic venous insufficiency, disturbing cosmetic appearance, or complications of hemangioma may benefit from surgical treatment, detailed preoperative imaging of the extremity and pelvis with magnetic resonance imaging and contrast venography is needed to decrease complications. Rarely, reconstruction for atresia or hypoplasia of the deep veins may be needed.

Thoracoabdominal aortic aneurysm repair. Analysis of postoperative morbidity.

Between 1980 and 1986, 101 nondissecting thoracoabdominal aortic aneurysms (TAAAs) were repaired at the Mayo Clinic, Rochester, Minn. Overall mortality was 15% with a 9.6% mortality for elective repair. Nonfatal complications occurred in 44% of patients and included myocardial infarction in 9%, paraplegia in 5%, and renal failure in 4%. In an attempt to reduce morbidity and mortality associated with TAAA repair, one of our vascular surgical services set up a routine protocol of preoperative evaluation, standardized operative technique, and specific guidelines for perioperative management. Fifty-five of the 101 patients underwent elective repair on this service without the use of shunts or bypass. Mortality was reduced to 1.8% and the rate of myocardial infarction was reduced to 1.8%; none of these patients developed renal failure. However, paraplegia/paraparesis still occurred in 5.4% and pulmonary insufficiency occurred in 29%. Preoperative cardiac evaluation and intraoperative reduction of cardiac afterload are important factors in reducing myocardial infarction and death associated with TAAA repair and should be integrated into the management of these patients. However, preexisting pulmonary and renal disease in some patients may limit the surgeon's ability to reduce rates of some complications.

Recurrent aneurysms and late vascular complications following repair of abdominal aortic aneurysms.

Between 1970 and 1976, 1,112 patients underwent abdominal aortic aneurysm repair. Follow-up, ranging from six to 12 years, was complete in 1,087 patients (97.7%). The most frequent cause of late deaths was coronary artery disease (45.6%), but significant morbidity related to the peripheral vascular system had developed in 94 patients, and led to 8.4% (48 patients) of all late deaths. Forty-nine true, 14 anastomotic, and five dissecting aneurysms were detected in 59 patients (5.4%) a mean (+/- SD) of 5.2 +/- 3.1 years after the initial aneurysm repair. These aneurysms were located in the thoracic (24), thoracoabdominal (five), or abdominal aorta (11), and in the iliac (six), femoral (17), popliteal (four), and renal arteries (one). Only one of 26 patients presenting with a rupture of one of these secondary aneurysms survived. There was a significant association between preoperative hypertension and recurrent aneurysm. These findings suggest that subsequent vascular disease, including recurrent aneurysms and graft complications, cause significant late morbidity and mortality after repair of abdominal aortic aneurysm. Careful follow-up and adequate control of hypertension may allow reduction in morbidity and an improvement in late survival.

Iliocaval complications of retroperitoneal fibrosis.

BACKGROUND: Retroperitoneal fibrosis can compress ureters, nerves, and blood vessels in the abdomen. However, clinically significant large-vein obstruction secondary to this process is rare. METHODS: Three hundred forty patients with retroperitoneal fibrosis were treated at our institution between 1976 and 1993. The clinical data from seven of these patients, who were treated for iliocaval complications of retroperitoneal fibrosis, were reviewed. RESULTS: Six patients had signs and symptoms of chronic obstruction, and one patient presented with acute iliocaval thrombosis and underwent attempt at venous thrombectomy in the referring hospital. All patients exhibited extremity edema and three had venous claudication. Iliocaval occlusion was confirmed in all patients by venography, computed tomography, or magnetic resonance imaging. The obstructive process involved the iliocaval tree (four patients), the inferior vena cava alone (two patients), and the iliac vein alone (one patient). Five patients were managed conservatively with leg elevation, compression stockings, and anticoagulation. Two patients received prednisone. One patient underwent an iliocaval bypass from the external iliac vein to the juxtarenal cava using a ringed polytetrafluoroethylene graft with a femoral arteriovenous fistula. A second patient with an isolated left common iliac vein obstruction underwent a left-to-right femorofemoral saphenous vein bypass. Four patients treated conservatively continued to have extremity edema. The two patients managed surgically remain asymptomatic from venous insufficiency, with patent grafts at 25 and 12 months after surgery, respectively. CONCLUSION: Iliocaval obstruction is an unusual complication of retroperitoneal fibrosis. Although most cases can be managed conservatively, reconstruction is an option for patients who have failed medical treatment and are symptomatic secondary to chronic venous obstruction. Lifelong anticoagulation should be considered for all patients with progressive iliocaval obstruction secondary to retroperitoneal fibrosis.

Stump pressure, the contralateral carotid artery, and electroencephalographic changes.

Electroencephalographic (EEG) monitoring and measurement of stump pressure are the most widely employed methods of assessing the risk of cerebral ischemia during carotid endarterectomy. The status of the contralateral carotid artery has also been thought to influence the need for placing a shunt. The relationship of EEG monitoring, stump pressure, and the contralateral carotid artery has not been completely delineated. We retrospectively reviewed these three variables in 113 patients undergoing 124 carotid endarterectomies. The contralateral artery was classified as occluded, stenotic (greater than 50% decrease in diameter), or nonstenotic. There was a 48% incidence of EEG changes with contralateral occlusion, 18% with stenosis, and 21% with nonstenotic arteries (p = 0.014). There was a 73% incidence of EEG changes when the stump pressure was less than 25 mm Hg, 32% when the stump pressure was 25 to 50 mm Hg, and 2% when the stump pressure was greater than 50 mm Hg (p less than 0.001). There was no significant difference in the mean stump pressure for patients with occlusion (43.8 mm Hg), stenosis (44.7 mm Hg), or nonstenotic contralateral arteries (51.3 mm Hg). All patients with contralateral occlusion and a stump pressure less than 25 mm Hg had EEG changes. No patient with a stump pressure greater than 50 mm Hg and a patent contralateral artery had EEG changes. Although the incidence of EEG changes in the majority of patients was not accurately predicted by the stump pressure and the status of the contralateral carotid artery, stump pressure less than or equal to 50 mm Hg was sensitive, identifying 97% of patients with EEG changes.

Advanced carotid disease in patients requiring aortic reconstruction.

Perioperative stroke is a devastating complication of abdominal aortic operations. Patients requiring aortic reconstruction with advanced carotid occlusive disease pose a particularly challenging management problem regarding timing of operations. All patients (n = 121) undergoing both carotid artery endarterectomy (CEA) and abdominal aortic reconstruction (AAR) within 1 year of each other between 1979 and 1989 were reviewed. The sequence of operation was analyzed to determine its effect on early and late outcome. CEA was the first operation in 99 patients (group I); AAR was performed first in 22 patients (group II). Age, gender, number, types of risk factors, and associated medical problems were similar in both groups. Indications for CEA were: transient ischemic attacks (TIAs), recent ipsilateral stroke, or high-grade asymptomatic carotid artery stenosis exceeding 80%. Indications for aortic operation included: abdominal aortic aneurysm, aortoiliac occlusive disease, and combined aortic and renovascular disease. There were five perioperative strokes, two in group I (2%) and three in group II (14%) (p < 0.04). All strokes occurred after AAR. There were five perioperative deaths (4%), four in group I (4%) and one in group II (5%). Overall survival was significantly greater in group I compared to group II (p < 0.04); 5-year survival was 77% and 51%, respectively. Multivariate analysis demonstrated age, hypertension, and diabetes to adversely affect survival; CEA as the first procedure, however, had a protective effect. Importantly, eight strokes occurred in group I in late follow-up, but only one was ipsilateral to the CEA. We conclude that CEA in selected patients who require AAR is safe, and, when performed prior to abdominal aortic repair, reduces perioperative stroke and may improve long-term survival.

Outcome and expansion rate of 57 thoracoabdominal aortic aneurysms managed nonoperatively.

BACKGROUND: The prognosis of thoracoabdominal aortic aneurysms (TAAAs) managed nonoperatively is unknown. PATIENTS AND METHODS: To determine the risk of rupture and survival, we retrospectively reviewed the clinical course and computed tomographic data of 57 patients who were evaluated for degenerative, nondissecting TAAAs. Nonoperative management was decided initially for all patients. Data of aneurysm expansion rate were available in 29 patients who underwent 2 or more scans. Follow-up was complete in 52 (91%) patients and averaged 37 months (range 1 to 82). RESULTS: Thirty-four of the 57 (60%) patients died during follow-up, including 3 of 15 patients who underwent subsequent repair of their aneurysm. Two- and 5-year survival rates for the entire group were 69% and 39%, with repair-free survival rates of 52% and 17%, respectively. Eight (14%) aneurysms ruptured, accounting for 24% (8/34) of the deaths. Two- and 4-year risks of rupture were 12% and 32%, respectively. The median expansion rate was 0.2 cm/y and was greater in patients with chronic obstructive pulmonary disease (P < 0.05). All ruptured aneurysms were > 5 cm in diameter. Aneurysms with a diameter > 5 cm at diagnosis had a higher rupture rate than those with a diameter < or = 5 cm (P < 0.05). Expansion rate did not predict rupture. CONCLUSIONS: Mortality of patients with TAAAs preselected for nonoperative management is high, with an overall survival rate of 39% and repair-free survival rate of only 17% at 5 years. Expansion rate of TAAAs (0.2 cm/y) is similar to that of abdominal aortic aneurysms. Our data that support nonoperative management for patients with TAAAs < 5 cm in diameter, but confirm the increase rate of rupture for aneurysms > 5 cm.

Influence of complete revascularization on chronic mesenteric ischemia.

Complete revascularization for chronic intestinal ischemia is controversial. Fifty-eight patients (119 arteries) underwent mesenteric revascularization between 1981 and 1988. There were 46 women and 12 men (mean age: 63 years). Sixty percent of patients had three-vessel disease. Twenty-one patients underwent concomitant aortic reconstruction. Operative mortality was 10%. Four of the six deaths occurred in patients undergoing aortic surgery. Late graft failure occurred in five patients (10%). Five-year survival for patients with three-vessel involvement who underwent three-vessel repair was 73%, compared with 57% for two-vessel repair and 0% for one-vessel repair (p = NS). Similarly, graft patency in patients with three-vessel disease was highest in those patients who had complete revascularization (90%, 54%, and 0%, respectively) (p = NS). We conclude that increased graft patency and survival in patients with three-vessel disease was most frequent with complete revascularization. Diseased inferior mesenteric arteries should be repaired if feasible. Concomitant aortic operations should be avoided if possible.

The results of in situ prosthetic replacement for infected aortic grafts.

BACKGROUND: Treatment of aortic graft infection with graft excision and axillofemoral bypass may carry an increased risk of limb loss, aortic stump blowout, and pelvic ischemia. A review of patients with aortic graft infection treated with in situ prosthetic graft replacement was undertaken to determine if mortality, limb loss, and reinfection rates were improved with this technique. METHODS: The clinical data of 25 patients, 19 males and 6 females, with a mean age of 68 years (range 35 to 83), with aortic graft infection, treated between January 1, 1989, and December 31, 1998, by in situ prosthetic graft replacement were reviewed. Follow-up was complete in the 23 surviving patients and averaged 36 months (range 4 to 103). RESULTS: Twenty aortofemoral, 3 aortoiliac, and 2 straight aortic graft infections were treated with excision and in situ replacement with standard polyester grafts in 16 patients (64%), or with rifampin-soaked collagen or gelatin-impregnated polyester grafts in 9 patients (36%). Fifteen patients (60%) had aortic graft enteric fistulas, 8 patients (32%) had abscesses or draining sinuses, and 2 patients (8%) had bacterial biofilm infections. Thirty-day mortality was 8% (2 of 25). There were no early graft occlusions or amputations. There was one late graft occlusion. There were no late amputations. The reinfection rate was 22% (5 grafts). All reinfections occurred in patients operated upon for occlusive disease. Only one reinfection occurred in the rifampin-soaked graft group (11% versus 29%, P = NS). Reinfection tended to be lower in patients with aortoenteric fistulas and without abscess. Autogenous tissue coverage provided statistically significant protection against reinfection. There were no late deaths related to in situ graft infection. CONCLUSIONS: Patients treated with in situ graft replacement had an 8% mortality and 100% limb salvage rate. Reinfection rates were similar to those of extra-anatomic bypass, but a trend of lower reinfection rates with rifampin-impregnated grafts was apparent. Patients with aortoenteric fistula and without abscess appear to be well treated by the technique of in situ prosthetic grafting and autogenous tissue coverage.

Aorto-caval and ilio-iliac arteriovenous fistulae.

BACKGROUND: To determine optimal management of major abdominal arteriovenous fistulae and define factors affecting outcome. METHODS: We reviewed clinical data of 18 patients, 16 males and 2 females, who underwent repair of major abdominal arteriovenous fistulae between 1970 and 1997. RESULTS: Sixteen patients had primary fistula, caused by rupture of an atherosclerotic aortic or aortoiliac aneurysm into the inferior vena cava (IVC), iliac, or left renal vein. Two had secondary, iatrogenic arteriovenous fistulae. Seventeen patients (94%) were symptomatic, 11 (62%) had acute presentation. Fistula was diagnosed preoperatively in 8 (44%). Fistula closure (direct suture 16, patch 1, iliac vein ligation 1) was followed by aortoiliac reconstruction in all patients. Caval clip was placed in 3 patients. Early mortality was 6%; 7 patients had major complications. During follow-up (mean 6.1 years) 2 patients died of causes related to fistula closure. CONCLUSIONS: Rupture of aortoiliac aneurysms into the iliac veins or IVC carries a better prognosis than intraperitoneal, retroperitoneal, or enteric rupture. Although preoperative diagnosis is ideal, a high index of suspicion, careful repair avoiding pulmonary embolization, and blood salvage were all helpful in keeping morbidity and mortality low. Our data suggest that IVC interruption is seldom warranted.

Ischemic injury to the spinal cord or lumbosacral plexus after aorto-iliac reconstruction.

Between January 1, 1980, and June 30, 1989, 9 patients (6 males and 3 females) developed ischemic injury to the spinal cord or lumbosacral plexus following 3,320 operations on the abdominal aorta (0.3%). The incidence of this complication was 0.1% (2 of 1,901) after elective and 1.4% (3 of 210) after emergency abdominal aortic aneurysm repair, and 0.3% (4 of 1,209) after repair for occlusive disease. Three of the latter had prior clinical evidence of distal embolization. Eight grafts were bifurcated (aorto-iliac:four, aorto-femoral: three, aorto-ilio-femoral:one). One patient underwent extra-anatomic revascularization. Only two patients had supraceliac aortic cross-clamping and one patient underwent exclusion of both internal iliac arteries. Four patients had hypotension. Early mortality was 22% (two of nine). Severe perioperative complications, mostly due to associated visceral and somatic ischemia and sepsis, were present in seven of the nine patients. The extent and type of the neurologic injury correlated with long-term outcome. Patients with ischemic injury of the lumbosacral roots or plexus had better recovery. Attention to the pelvic circulation and the collateral blood supply is important. Use of gentle technique to prevent embolization, avoidance of hypotension and prolonged supraceliac cross-clamping, revascularization of at least one internal iliac artery, and the use of heparin may decrease but not eliminate paraplegia. Once this unexpected complication occurs, careful neurologic evaluation should be done to localize the lesion and aid prognosis.

Unusual manifestations of abdominal aortic aneurysms.

Repair of an asymptomatic infrarenal abdominal aortic aneurysm is straightforward and can be accomplished with low morbidity and mortality rates. However, certain complications of abdominal aortic aneurysm, such as contained rupture, inflammatory aneurysm, aortovenous fistula, infected aneurysm, primary aortoenteric fistula, and lower-extremity atheroembolism can be both limb- and life-threatening. Unusual signs and symptoms in a patient with an abdominal aortic aneurysm should alert the physician to the possibility of one of these complications. Careful history-taking and physical examination and appropriate diagnostic imaging, combined with a well-planned operation, will minimize the morbidity and mortality rates otherwise associated with these complications.