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Pitfalls and progress in the management of abdominal aortic aneurysms

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Abstract

Based on a review of the literature and 241 cases of abdominal aortic aneurysm (AAA) operated at the Mannheim Surgical Clinic, the progress and pitfalls in the management of this lesion are discussed.

Progress in diagnosis is based on noninvasive imaging procedures, e.g., ultrasound, which lead to the detection of more aneurysms before they rupture. Ultrasound also plays a role in the observation of small asymptomatic aneurysms in high-risk patients, helping some to avoid operation as well as rupture.

Progress in the treatment of AAA means simplification: rapid clamping of the aorta in case of rupture, minimal dissection, and aneurysmal repair with straight-tube interposition by the inlay technique. The pitfalls of “trash foot,” colon, or renal ischemia as well as graft infection can be mostly circumvented by observance of technical detail.

In this series, the mortality following repair of asymptomatic AAA was 3.7%; for symptomatic aneurysms, it was 8%; and for ruptured aneurysms, it amounted to 55%.

Résumé

Se basant sur une revue de la littérature et sur 241 cas d'anévrismes de l'aorte abdominale (AAA), opérés dans la Clinique Chirurgicale de Mannheim, les progrès et les échecs dans le traitement de ce type de lésion sont discutés.

Les progrès dans le diagnostic sont basés sur les méthodes d'investigation non invasives, c'est-à-dire, l'échographie, qui permet de détecter de plus en plus d'anévrismes avant leur rupture. L'échographie joue un rôle important dans la surveillance des anévrismes de petite taille, asymptomatiques, chez le patient à haut risque, ce qui aide à éviter l'intervention en même temps que la rupture.

Les progrès dans le traitement des AAA proviennent de la simplification: clampage rapide de l'aorte en cas de rupture, dissection minime et réparation de l'anévrisme par la technique de mise à plat et interposition par un tube droit. Les conséquences néfastes comme le pied “poubelle,” l'ischémie colique ou rénale, ainsi que l'infection de la prothèse peuvent être évitées le plus souvent en observant une technique parfaite.

Dans cette séries, la mortalité après réparation d'un AAA asymptomatique était de 3.7%, d'un AAA symptomatique, de 8%, et d'une rupture d'AAA, de 55%.

Resumen

En este resumen se discuten los avances y peligros en el manejo del aneurisma de la aorta abdominal, con base en la revisión de la literatura y el análisis de 241 casos de pacientes con esta lesión operados en la Clínica Quirúrgica de Mannheim.

Los avances en el diagnóstico se fundamentan en los procedimientos de diagnóstico no invasivos por imágenes, tales como el ultrasonido, que hacen posible la detección de números crecientes de aneurismas antes de su ruptura. El ultrasonido también es de importancia en la observación y seguimiento de aneurismas pequenos y asintomáticos en pacientes de alto riesgo, con lo cual se logra evitar la operación en algunos y la ruptura en otros.

El avance en el tratamiento de los aneurismas de la aorta abdominal ha sido logrado con la simplificación de la técnica operatoria, tanto en los aneurismas rotos, como en las operaciones electivas: oclusión rápida de la aorta en caso de ruptura, mínima disección, y reparación mediante la interposición de una prótesis tubular sobre el lecho del aneurisma. Los peligros y complicaciones que representan la isquemia en parches del pie (“trash foot syndrome”) probablemente producida por embolización de pequeños fragmentos de material trombótico, la isquemia del colon y del riñón, y la infection del injerto, pueden ser evitadas mediante cuidadosa observación de los detalles técnicos.

Esta serie comprende 183 operaciones electivas, 108 para aneurismas asintomáticos y 75 para aneurismas sintomáticos, y 58 operaciones de urgencias por aneurismas rotos, un total de 241 pacientes (228 hombres y 13 mujeres) intervenidos entre enero de 1973 y agosto de 1987. La mortalidad fue de 3.7% para los aneurismas asintomáticos, 8% para los sintomáticos, y 55% para los aneurismas rotos.

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Correspondence to Michael Trede B.A., B.Chir., M.D., Hon. F.R.C.S. (Eng.).

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Trede, M., Storz, L.W., Petermann, C. et al. Pitfalls and progress in the management of abdominal aortic aneurysms. World J. Surg. 12, 810–817 (1988). https://doi.org/10.1007/BF01655484

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Keywords

  • Aortic Aneurysm
  • Como
  • Abdominal Aortic Aneurysm
  • Abdominal Aortic Aneurysm
  • Cual