Indications and results in surgical treatment of
 abdominal aortic aneurisms (AAA) in outlying hospital

Autori: M. Franzini, F. Pirondi, P. P. Puviani, A. Lucchini, 
A. Savioli, S. Bicocchi, G. L. Liera

Ospedale Comprensoriale di Guastalla, Reggio Emilia
Divisione di Chirurgia Generale
(Primario: Dr. M. Franzini)
SUMMARY

It's known the greatest frequency of AAA owing to the prolonged longevity and the improved diagnostical techniques. A long debated problem is if it is convenient to effect AAA surgery at non specialized outlying hospitals.
The accumulated experience demonstrates that also major vascular procedures can be dealt with without a significant mortality or morbidity. The preoperative evaluation of the risks is considered fundamental to perform aneurysmal surgery, but the results are strictly related with the training of surgeon staff both in elective and emergency surgery.
This report is concerning 43 consecutive aneurysmectomyes with only one postoperative death performed at a non specialized institution.
 
INTRODUCTION

In the last three decades there has been a considerable increase in the operative treatment of aortic aneurysms.
This condition is encountered with greater frequency owing to some factors such as increase in life span, with a parellel increase in arteriosclerosis, greater awareness of the diagnosis of AAA and improved diagnostical techniques (3,4,6).
Most reports concerning AAA surgical treatment emanate from large or specialized institutions, but also at smaller hospitals aneurysmal repair is considered a common practice.
A survey of vascular surgery in the USA (2) revealed that more than half of the elective operations for aneurysm were performed in "small" hospitals having less than 400 beds or in outlying non specialized hospitals.
Now a long debated problem is if it is convenient to effect AAA surgery in non specialized outlying hospitals.
Purpose of this work is to discuss the results of this major surgery by considering the personal survey including elective and emergency operations.

MATERIAL AND METHODS

A retrospective analysis was made of a consecutive series of 51 patients, 47 males and 4 females, aged between 48 and 84, presented at our Institution with AAA in the period 1981-89.
Each patient in the series had an objectively documented abdominal aneurysm. 10 were expanding, 5 ruptured and the remaining ones were asymptomatic (Tab.1).

Survey of patients and management of AAA
at Guastalla District Hospital
    Number of patients Deaths due to aneurysm Deaths due to other causes
Ruptured aneurysms Not Operated 0 0 0
Ruptured aneurysms Operated 5 1 0
Expanding aneurysms Not Operated 0 0 0
Expanding aneurysms Operated 10 0 0
Intact aneurysms Not Operated 8 0 6
Intact aneurysms Operated 28 0 0

Tab.1


Asymptomatic AAA were detected incidentally at physical examination or were occasional findings of various investigations such as abdominal roentgenograms and ultrasonography.
Other patients had abdominal and/or back pain, or presented limb claudication related to arterial occlusive disease.
Ruptured AAA were suspected upon clinical picture and physical examination and were preoperatively diagnosed with emergency ultrasonography in 4 cases.
All the patients with ruptured AAA were considered to be in a state of shock, as judged by poor skin perfusion, oligo-anuria and systolic blood pressure of less than 100 mmHg.
None of them died before reaching the operation room. In all the other cases the preoperative diagnostic protocol included ultrasonography, angiography and/or computed tomography.
Ultrasonography was considered by us the basic preoperative examination because of its noninvasiveness and angiography was considered indispensable only in case of inadequate accuracy in detecting the location of AAA, if it was infra- or suprarenal, and in some patient of concomitant heavy limb claudication requiring angiographic specification and contemporary treatment.
In no case of our report the diagnosis was in error. Concomitant diseases were present in 3 cases (cholelithiasis, Meckel's diverticulum, nephrolithiasis), but clearly they were not responsible for the clinical picture.
Nevertheless cholecystectomy and diverticulectomy were performed once completed aneurysmectomy and graft peritonization.
Additional procedures performed at the time of aortic replacement included also nephrectomy for nephrosclerosis (1 case) and splenectomy for bleeding (1 case).
Eight patients were excluded from operation because of their compromised conditions, concomitant malignancies or refusal of surgical intervention (Tab.2).

Patients excluded from surgery
  Patients Site of AAA Conditions at diagnosis General clinical conditions of the patient
1 M 60 thoraco-abdominal asymptomatic renal failure, hypertension, diabetes
2 M 74 infrarenal asymptomatic tumor of Vater's papilla
3 M 74 infrarenal ruptured irreversible shock
4 M 71 thoraco-abdominal asymptomatic cardiopathy, hypertension, chronic renal failure
5 F 81 infrarenal asymptomatic refusal of patient
6 F 76 infrarenal ruptured shock, congestive heart failure, hypertension
7 M 82 infrarenal asymptomatic renal and heart failure, pulmonary emphysema
8 M 76 suprarenal asymptomatic refusal of patient

Tab.2


Control of ruptured AAA never required a left sided thoracotomy but was always accomplished through a midline laparotomy.
In all the cases the surgical therapy consisted in aneurysmectomy and bypass graft reconstruction.
Combined vascular procedures were performed frequently and consisted in inferior mesenteric artery reimplantation (9 cases), hypogastric aneurysm resection (1 case), femoral aneurysm resection (2 cases), renal artery reimplantation (1 case).
Three patients were affected with arteriomegaly: one of them presented with acute ischaemia from thrombosis of femoro-popliteal artery, the second with an expanding right femoral aneurysm and the third underwent elective operation owing to his young age of 48 and the localization of aneurysmal degeneration in the aorto-ilio- hypogastric segments.
All three underwent vascular procedures in one or two times to replace aorto-iliac segments and to repair the associated peripheral lesions.

RESULTS AND CONCLUSIONS

Forty-three operations for AAA resulted in only one death, less than 1 per cent, that was referred to a 70 year old man who was operated on in emergency for a ruptured infrarenal aneurysm.
Death occurred in the 2nd postoperative day from renal failure.
Only one intraoperative complication occurred in a patient electively operated on and consisted in rupture of the spleen.
Postoperatively, complications consisted in two cases of bronchopneumonia and three cases of arrythmia, one of which required a temporary pace-maker implantation.
Local complications occurred in two patients and consisted in inguinal seromas without any infective consequence.
Discharge from hospital was possible between the 14th and the 22nd postoperative day in all the cases.
In the present study the mortality rate after elective and emergency aneurysmectomy performed at a district general hospital compares better with the results reported from elsewhere (1,5,6,7), but it must be considered the limits of our case-report consisting of only 43 operated patients.
Striking result is given from the very low mortality, particularly in the group of ruptured AAA. In fact the mortality rates referred for emergency aneurysmectomies and elective resections in the hands of trained vascular surgeons is respectively 45 to 50% and 5.2% (4).
We think that this report indicates that a well trained unit of vascular surgery can deal with a complex pathology such as AAA also at an outlying hospital.
Personal experience of the surgeon is of paramount importance and these results indicate that improvements are to be expected with increasing local experience of major vascular surgery.
It follows that to electively operate AAA the surgeon can achieve a good experience also to be able to satisfactorily take care of patients with ruptured aneurysms.
Delay in diagnosis and treatment in case of ruptured AAA greatly conditions the survival chances of these patients.
This is the reason for which we do not agree with the concept that AAA should be treated only in specialized clinics. Since aortic angiography is a routine diagnostic tool today, it is possible to select patients with unusual or complicated aneurysms (e. g. those extending above the renal arteries) so that they can be sent to a specialized clinic (5).

REFERENCES
  1. CHRISTENSON J., EKLOF B., GUSTAFSON I.: Abdominal aortic aneurysms, should they all be resected? Br. J. Surg., 64, 767, 1977.
  2. DE WEESE J. A.: Vascular surgery. Is it different? Surgery, 84, 733, 1977.
  3. FRANZINI M.: La chirurgia degli aneurismi dell'aorta addominale in un ospedale periferico. Min. Cardioang., 37, 105, 1989.
  4. HAIMOVICI H.: Abdominal aortic aneurysms. In: Haimovici H. ed. Vascular surgery. Norwalk: Appleton-Century-Crofts, 685-737, 1984.
  5. JARHULT J., GANNEDAHL G., MARTENSSON O.: Management of abdominal aortic aneurysms in a small district hospital. Acta Chir. Scand., 147, 179, 1981.
  6. LUNDELL L., NORBACK B.: Abdominal aortic aneurysm: results of treatment in nonspecializedunits. Acta Chir. Scand., 149, 695, 1983.
  7. VIDAL J., HENNESSY V. L., TURNER J. J.: Results of operations upon abdominal aortic aneurysms at acommunity hospital. Surg. Gynecol. Obstet., 153, 363, 1981.