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1/91. Small ruptured abdominal aneurysm diagnosed by emergency physician ultrasound.

    Ruptured abdominal aortic aneurysms currently have a high rate of both mortality and misdiagnosis. Aneurysms smaller than 4 cm are not commonly considered for surgical repair. This report describes the case of a ruptured abdominal aneurysm measuring less than 4 cm diagnosed by the emergency physician utilizing bedside ultrasound. Within 30 minutes of arrival at the emergency department the patient's abdominal pain resolved spontaneously after defecation. If the bedside ultrasound had not been performed it is possible the patient would have been discharged from the hospital without surgical intervention. Bedside ultrasound by emergency physicians may improve the diagnosis of ruptured aortic aneurysms, particularly if the presentation is atypical.
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2/91. Primary aorto-duodenal fistula secondary to infected abdominal aortic aneurysms: the role of local debridement and extra-anatomic bypass.

    Gastrointestinal bleeding secondary to spontaneous rupture of an infected abdominal aortic aneurysm into the duodenum is a rare and highly lethal clinical occurrence, representing roughly a third of all primary aortoduodenal fistulas. diagnosis is problematic due to the subtleties in the clinical presentation and course, and surgical treatment is usually delayed, representing a challenge even for the experienced vascular surgeon. The overall mortality is over 30% and the operative approaches are still controversial. Two cases of ruptured infrarenal aortic aneurysms complicated with aortoduodenal fistula were recently treated at our institution. Bacterial aortitis was documented by arterial wall cultures positive for klebsiella and salmonella species respectively. The clinical courses and outcomes of the two patients (one survivor ) treated with retroperitoneal debridement and extra-anatomic bypass and a review of the modern surgical treatment are herein described.
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3/91. salmonella mycotic aneurysms: traditional and "alternative" surgical repair with arterial homograft.

    salmonella infection of the abdominal aorta with formation of mycotic aneurysm is rare, but associated with a high mortality and morbidity. Prompt surgical treatment and selective and prolonged antibiotic therapy are required because of its rapid and impredictable evolution in a short period of time, even if an infectivous etiology is only suspected. methods of revascularization can be different: the traditional two are in situ or extraanatomic bypass using synthetic graft. Both these solutions are subject to complications. An "alternative" method of revascularization with low risk of infection and good patency is the use of arterial homograft in situ. We report two cases of salmonella mycotic aortic aneurysms successfully treated with revascularization respectively by extraanatomic bypass using synthetic graft and in situ arterial homograft. The reasons for our choice are also discussed.
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4/91. Resection of abdominal aortic aneurysm in a patient with left-sided inferior vena cava and horseshoe kidney.

    The presence of vascular and renal anatomical anomalies can create technical problems during abdominal aortic surgery and may give rise to serious intraoperative complications. We present a case of an abdominal aortic aneurysm resected in a patient with the extremely rare coexistence of a left-sided inferior vena cava and horseshoe kidney. The diagnosis of the anomalies was made prior to aortic surgery. CT-scan of the abdomen was the most accurate preoperative investigation. Aortic surgery was performed through a transperitoneal approach which allowed easy access to the aneurysm despite the presence of the left-sided inferior vena cava and horseshoe kidney. Recognition of vascular and renal anomalies on preoperative imaging studies is important in the surgical treatment of abdominal aortic aneurysms. If possible anomalies are recognized in time and treated correctly, the morbidity and mortality of aneurysm repair should not be influenced.
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5/91. Isolated hypogastric artery aneurysms.

    iliac artery aneurysms are rare in the absence of concomitant abdominal aortic aneurysm (AAA), and isolated internal iliac (hypogastric) aneurysms in particular are extremely rare. From 1986 to 1997 we repaired 572 aortic and/or iliac artery aneurysms in 440 patients. Among these there were only seven hypogastric aneurysms and three of these occurred in the absence of, or remote to, AAA. Hypogastric aneurysms are difficult to diagnose, and large aneurysms are associated with significant morbidity and mortality due to compression of adjacent structures and a high rate of rupture. They pose technical challenges in repair because of their location deep in the pelvis and because it is difficult to gain distal control of the hypogastric artery and its branches. However, the technique of obliterative endoaneurysmorrhaphy has made repair of these aneurysms safe and straightforward. Moreover, this method, unlike percutaneous endovascular techniques, eliminates the compressive mass that is often associated with significant symptomatology. We report three isolated hypogastric aneurysms repaired over an 11-year period, illustrating the technique of proximal ligation and obliterative endoaneurysmorrhaphy, and review the literature on the topic.
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6/91. Minimally invasive direct coronary artery bypass combined with abdominal aortic aneurysm repair.

    BACKGROUND: For simultaneously combined coronary artery bypass surgery with infrarenal abdominal aortic aneurysm (AAA) repair, a relatively high operative mortality and morbidity have been reported. methods: From February 1998 to December 1998, simultaneous minimally invasive direct coronary artery bypass combined with the AAA repair was performed for 4 patients (3 males, 1 female; mean age, 74 /-7 years). Three were high-risk patients: 2 were over 75 years of age, 2 had respiratory insufficiency, and 1 had severe renal impairment. RESULTS: There were no mortalities. The endotracheal tube was removed within approximately 12 hours, and the postoperative courses were uneventful. During 4 /-4 months of follow-up, there was neither angina recurrence nor other morbidity. CONCLUSIONS: Minimally invasive direct coronary artery bypass combined with AAA repair was safe even for high-risk patients.
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7/91. rupture of abdominal aortic aneurysms: A concurrent comparison of outcome of those occurring after endoluminal repair versus those occurring de novo.

    AIM: to compare the outcome of patients whose abdominal aortic aneurysm (AAA) ruptured following endoluminal repair with those whose AAA ruptured prior to treatment. patients: over a 4-year period 434 patients underwent treatment for AAA with conventional open (n=253) and endoluminal repair (n=181). Of those having open repair, 216 patients had elective operations while 41 had operations for ruptured AAA. Four patients with ruptured AAA had undergone endoluminal repair previously (Group I) while the remaining 37 patients ruptured de novo (Group II). The patients in both groups were similar in age and sex but differed clinically. All four patients in Group I had major medical co-morbidities versus 56% in Group II (p<0.05). All patients in group I had a known endoleak following endoluminal repair. All patients underwent open repair. RESULTS: the proportion of patients presenting with hypotension in Group I (1/4) was significantly less than in Group II (30/37). The difference in 30-day mortality for Group I (0%) compared with that for Group II (43%) was significant. The four patients in Group I remain alive and well at follow-up 22 months after operation. The outcome for Group I was better than Group II despite the higher incidence of medical co-morbidities. CONCLUSION: endoluminal AAA repair complicated by a persistent endoleak does not protect from rupture, which may not be accompanied by such major haemodynamic changes and high mortality as rupture de novo. Further long-term results in more patients are required to confirm this intermediate level of protection.
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8/91. Surgical treatment of abdominal aortic aneurysms located close to the visceral arteries: report of three cases.

    The standard surgical treatment for abdominal aortic aneurysms (AAA) is in situ replacement of the infrarenal aorta, which is associated with a low mortality rate. On the other hand, thoracoabdominal aortic aneurysms (TAA) remain a formidable challenge and the complications that can occur may be severe including neurologic dysfunction and renal failure. We report herein three cases of patients with AAA located very close to the visceral arteries, for which in situ replacement of the infrarenal aorta was not feasible due to severe inflammation and adhesion. Therefore, aortic stump closure and in situ bypass grafting was performed to avoid reconstruction of the visceral arteries. No major complications or operation-related deaths occurred. Thus, while in situ replacement is usually recommended over bypass grafting for patients whose aneurysms are located very close to the visceral arteries, aortic stump closure and in situ bypass grafting should be considered as a more effective surgical option.
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9/91. rupture of the abdominal aorta in patients with ehlers-danlos syndrome.

    ehlers-danlos syndrome (EDS) is a heterogeneous inherited disorder of collagen synthesis. Type IV is frequently associated with major vascular catastrophes and challenges the vascular surgeon with its varied clinical presentation and the difficulty of vascular repair. rupture of the abdominal aorta is one of the most serious complications and is associated with nearly 100% mortality rate. We describe here three patients with type IV EDS.
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10/91. Aneurysm rupture after endovascular repair using the AneuRx stent graft.

    OBJECTIVE: The purpose of this study was to determine the cause and frequency of aneurysm rupture after endovascular aneurysm repair. methods: We reviewed each patient who sustained aneurysm rupture among all patients enrolled for endovascular aortic aneurysm repair in phases I, II, and III of the US AneuRx Multicenter clinical trial from June 1996 through October 1999. RESULTS: A total of 1067 patients were enrolled for endovascular aneurysm repair. The AneuRx stent graft was successfully implanted in 1046 patients (98%). Endovascular repair was unsuccessful in 21 patients (2%); 13 patients (1%) were converted to open aneurysm repair. Among these, two patients (0.2%) sustained aneurysm rupture due to procedure-related instrumentation and underwent open surgical conversion. Aneurysm rupture has occurred in seven patients (0.7%) 3 weeks to 24 months (mean, 16 months) after successful endovascular repair. Four patients survived open surgical repair, and three patients died within 30 days. overall rupture-related mortality was 0.5% and included late deaths after rupture. Before rupture, two patients had endoleak and aneurysm enlargement, and five patients had no endoleak and no aneurysm enlargement. After aneurysm rupture all seven patients had evidence suggesting that there was poor fixation of the stent graft at the proximal distal, or iliac junction fixation sites. The two patients with endoleak declined recommended open surgical or endovascular repair, which could have prevented aneurysm rupture. In retrospect, the five patients without endoleak could potentially have avoided rupture with better patient selection, better stent graft positioning, or reinforcement of fixation points with stent graft extenders. The probability of no aneurysm rupture for all patients undergoing endovascular repair is 0.996 /- 0.002 at 1 year and 0.974 /- 0.011 at 2 years by life table analysis with the longest follow-up of 41 months. CONCLUSION: The early risk of aneurysm rupture after endovascular aneurysm repair is low. However, the possibility of rupture persists even in patients with no endoleak after the procedure. Therefore, all patients treated with endovascular aneurysm repair should continue to be monitored after the procedure. patients with evidence suggesting insecure stent graft fixation should undergo further endovascular treatment or open surgical repair.
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