ORI GI N AL ARTI CLE
La t e sur viva l of pa t ie nt s subm it t e d t o e le ct ive a bdom ina l a or t ic a ne ur ysm
ope n r e pa ir
Fá bio H üse m a nn M e ne ze sI; Ge or ge Ca r ch e di Lu cca sI I; I r e ne Ak ie M a t su iI I I IAssist ant professor of Surgery, Depart m ent of Surgery, Faculdade de Ciências Médicas,
Universidade Est adual de Cam pinas ( UNI CAMP) , Cam pinas, SP, Brazil. Vascular Surgery St aff, Fundação Cent ro Médico de Cam pinas, Cam pinas, SP, Brazil.
I IProfessor, Depart m ent of Surgery, Faculdade de Ciências Médicas, UNI CAMP, Cam pinas, SP, Brazil.
Head, Vascular Diseases, UNI CAMP, Cam pinas, SP, Brazil. Vascular Surgery St aff, Fundação Cent ro Médico de Cam pinas, Cam pinas, SP, Brazil.
I I IPhysician, Clinical St aff, Fundação Cent ro Médico de Cam pinas, Cam pinas, SP, Brazil.
Correspondence
J Vasc Bras. 2007; 6( 3) : 218- 24.
ABSTRACT
Ba ck gr ound:The aut hors perform ed a review of pat ient s who underwent surgery at a com m unit y hospit al t o det erm ine t he cause of lat e m ort alit y, evolut ion of ot her aort ic segm ent s and graft-relat ed com plicat ions.
Obj e ct ive s: To report t he lat e follow- up of a series of 76 pat ient s subm it t ed t o elect ive abdom inal aort ic aneurysm open repair from March 1995 t o January 2007.
M e t hods: Recruit m ent of pat ient s for a follow- up visit ; t hose who could not at t end personally were cont act ed by t elephone.
Re sult s: Thirt y- day operat ive m ort alit y was 5.3% . Lat e survival obt ained by life t able was 95% in 1 year, 88% in 3 years and 72% in 8 years. Cardiovascular diseases were t he m ain cause of lat e m ort alit y, followed by m alignant neoplasia. Dilat at ion of proxim al aort ic segm ent during follow- up occurred in 9.7% of t he pat ient s, and graft- relat ed com plicat ions occurred in four cases ( 5.3% ) : one graft infect ion, one proxim al pseudoaneurysm , one pseudoaneurysm of t he iliac art ery and one branch occlusion.
Conclusion: Open surgery for abdom inal aort ic aneurysm repair has good long- t erm out com e, sim ilar t o t hat in t he nat ional and int ernat ional lit erat ure, and is a good opt ion for pat ient s who have a low surgical risk.
RESUM O
Cont e x t o:Os aut ores fazem um a revisão dos pacient es operados em hospit al privado para det erm inar a causa da m ort alidade t ardia, a evolução dos dem ais segm ent os da aort a e as com plicações relacionadas à prót ese.
Obj e t ivos: Relat ar o seguim ent o t ardio de um a série de 76 casos operados elet ivam ent e para a correção de aneurism a de aort a abdom inal, no período de m arço de 1995 a j aneiro de 2007.
M é t odos: Convocação dos pacient es para um a consult a de ret orno e daqueles que não puderam com parecer pessoalm ent e at ravés de cont at o t elefônico.
Re sult a dos:A m ort alidade operat ória em 30 dias foi de 5,3% . A sobrevida t ardia obt ida por curva at uarial foi de 95% em 1 ano, 88% em 3 anos e 72% em 8 anos. As doenças cardiovasculares foram a principal causa de m ort alidade t ardia, seguidas das neoplasias m alignas. A dilat ação de segm ent o de aort a proxim al à correção cirúrgica ocorreu em 9,7% dos pacient es operados, e as com plicações relacionadas à prót ese ocorreram em quat ro casos ( 5,3% ) , sendo um a infecção de prót ese, um pseudo- aneurism a proxim al, um pseudo- aneurism a em ilíaca e um a oclusão de ram o.
Conclusã o: A cirurgia abert a para correção do aneurism a de aort a abdom inal apresent a bom result ado em longo prazo, sem elhant e ao da lit erat ura nacional e int ernacional, sendo um a boa opção para o pacient e que t enha um baixo risco cirúrgico.
Pa la vr a s- cha ve : Aneurism a da aort a abdom inal, cirurgia, análise de sobrevida.
I nt r oduct ion
Survival of pat ient s wit h abdom inal aort ic aneurysm wit h a diam et er great er t han 7 cm is sm all, due t o high incidence of rupt ure.1 The m ain obj ect ive of surgical repair is t o prevent t he pat ient 's deat h
associat ed wit h aneurysm rupt ure. I ndicat ion of surgery essent ially depends on t he balance bet ween im m ediat e risk of aneurysm rupt ure and t he risks associat ed wit h surgical repair. The cut- off point of 5.5 cm is believed t o be t he m ost appropriat e for m ost pat ient s nowadays.2 The safer t he
t echnique, t he m ore advant ageous for t he pat ient . On t he ot her hand, surgical repair should also offer long- t erm out com es, which overcom e t he pat ient 's life expect ancy, so t hat he does not need t o be subm it t ed t o anot her procedure, great er and having m ore risks, at an older age. I nt roduct ion of endovascular procedures allowed a surgical alt ernat ive wit h lower operat ive m ort alit y rat e in pat ient s wit h favorable anat om y, but wit h lower lat e durabilit y, dem anding higher reint ervent ion rat e. Lat e survival of pat ient s subm it t ed t o aort ic aneurysm repair in European count ries and in t he USA is well known,3 - 9 but in Brazil few st udies have been published on t his issue.1 0 - 1 2 This st udy
aim s at present ing a 12- year follow- up of pat ient s who underwent open surgery for abdom inal aort ic aneurysm repair in a Brazilian populat ion receiving care at a m edium- sized privat e hospit al.
Survival, cause of deat h and evolut ion of proxim al aort a during follow- up are report ed, and t he result s are com pared t o t hose in t he lit erat ure.
M e t hods
pat ient s ( 15.8% ) were considered lost , since inform at ion m ore recent t han 1 year before t he research could not be obt ained. Result of t he last im aging cont rol ( ult rasound, t om ography or resonance) perform ed by t he pat ient was also regist ered. All pat ient s cam e from privat e offices and underwent surgery by t he sam e t eam at a m edium - sized hospit al in t he count ryside of t he st at e of São Paulo, Brazil. The result s were t abled in Excel® ( Microsoft 2003) , and lat e survival was
Re sult s
There were 67 male patients (90%) and nine female patients. The patients' mean age was 69 years (53-91), and mean size of aneurysms at surgery was 6 cm (3-18). In one case, aortic size was lower than 5 cm, but it corresponded to indication due to an iliac aneurysm larger than 3 cm. Thirty-day mortality rate was 5.3% (two patients due to acute renal insufficiency, one patient due to acute myocardial infarction and one patient due to systemic inflammatory reaction syndrome after a surgery in which there was prolonged ischemia of the lower limbs). Late survival of patients was 95, 88 and 72% in 1, 3 and 8 years and is presented in the survival curve (Figure 1); causes of death are presented in Table 2. Among survivors, seven (9.7%) had dilatation of other aortic segments, and one patient progressed to dilatation compromising the thoracoabdominal segment (171 months of follow-up). Another patient, who already had dilated proximal neck measuring 3.5 cm maintained this diameter at 27 months of follow-up, and five patients progressed with dilatation of the thoracic aorta; of these, only one was repaired by endovascular technique. Four patients (5.3%) progressed with graft problems – one infection at 6 months of follow-up, leading to removal of aortic graft and axillary-bifemoral bypass, who later died due to depressive status (19 months); one
pseudoaneurysm rupture of proximal anastomosis at 120 months, in which the patient, even
D iscussion
This st udy has a sim ilar result t o m any series published in t he lit erat ure.3 - 7 , 9 - 1 2 , 1 4 - 1 6 Global survival
rat e of pat ient s subm it t ed t o surgery for aort ic aneurysm repair is high ( 72% in 8 years) . Even older pat ient s ( > 75 years) are benefit ed by surgery, since 86% of t hem were st ill alive aft er 4 years.
Only t wo pat ient s ( 2.8% ) died due t o com plicat ions relat ed t o t he graft ( 19 m ont hs and 10 years aft er t he surgery) , and only one pat ient died direct ly due t o rupt ure of false aneurysm of proxim al anast om osis in t he aort a. Cause of lat e deat h in t his series was relat ed especially t o cardiovascular com plicat ions ( acut e m yocardial infarct ion, st roke and congest ive heart failure) , followed by
m alignant neoplasm s. There was no difference in age bet ween t he group t hat died due t o neoplasm s or cardiovascular disease, and survival of t hese pat ient s was nearly 7 years in average. However, a high occurrence of m alignant neoplasm s draws at t ent ion in t his group of pat ient s, which is in accordance wit h t he lit erat ure.6
As t o procedure durabilit y, t he present populat ion reinforces t he concept t hat convent ional open surgery, wit h graft sut ure direct ly t o t he aort a, has excellent long- t erm result , wit h low incidence of graft com plicat ions ( 4.2% in 8 years) . The m ost frequent com plicat ion was anast om ot ic false aneurysm , which can be det ect ed by abdom inal ult rasound and repaired at a suit able t im e. I nfect ious com plicat ion is rare, corroborat ing t he fact t hat graft s for aneurysm repair should preferent ially be m aint ained inside t he abdom inal cavit y, avoiding t he inguinal region, a conduct t hat was rout inely followed in t his series. The pat ient wit h graft infect ion in our populat ion had duodenal com pression syndrom e by t he superior m esent eric art ery,1 7 and had t o be subm it t ed t o
t he lit erat ure,3 probably because t he dist al art erial bed was pat ent in m ost of t hese pat ient s.
For t he pat ient , from t he perspect ive of post operat ive qualit y, t he lit erat ure has shown t hat t he qualit y of life of pat ient s subm it t ed t o laparot om y is not lower t han t hat of pat ient s subm it t ed t o endovascular surgery, when analyzed by st andardized quest ionnaires ( Medical Out com es St udy Short - Form SF- 36, Short - Form Healt h Survey SF- 12 and Karnofsky Score for Funct ional
Aut onom y) .1 8 - 2 0 I n addit ion, cont rol of pat ient s subm it t ed t o convent ional surgery can be perform ed
annually by sim ple abdom inal ult rasound. Thus, m ore expensive exam inat ions and use of pot ent ially nephrot oxic cont rast are avoided for t hese elderly pat ient s.
The lit erat ure has dem onst rat ed t hat , wit h t im e, dilat at ion of ot her segm ent s of t he aort a and pararenal aort a is a com m on fact , including t he residual infrarenal neck.2 1 When t he pat ient is
subm it t ed t o endolum inal repair, t he proxim al neck below renal art eries grows around 1 m m a year over t he first years of t he im plant at ion, and m ay result in proxim al leakage and aneurysm rupt ure even aft er endovascular repair.1 4 , 2 2 - 2 6 St udies t hat reviewed t he sam e problem in convent ional
surgeries report t hat , alt hough t his finding is also present aft er open surgery, it has no significant clinical m eaning if t he aort ic diam et er rem ains below 5 cm and it also does not result in false anast om ot ic aneurysm in m ost cases, confirm ing t hat graft fixat ion by sut ure is a safe repair
m et hod in t he long t erm .2 7 , 2 8 Dist al dilat at ion of iliac art eries, when aneurysm repair was perform ed
by aort o- aort ic graft , does not seem t o be a reason for concern considering t hese pat ient s' life expect ancy.2 9
Expect ancy of durabilit y for an endovascular device, according t o m anufact urers, is 10 years, but t he reint ervent ion rat e for t hese pat ient s is st ill high, around 15- 30% in 3 years.7 , 8 , 3 0 Lat e
reint ervent ion rat e in open surgeries is around 3.5 and 10% in 10 years.3 , 9 , 1 5 St udies analyzing cause of early rehospit alizat ion aft er open aneurysm surgery reveals t hat m ost rehospit alizat ions are relat ed t o cardiac, gast roint est inal causes and presence of neoplasm s.3 0 , 3 1
An im port ant finding of t he present st udy is dilat at ion of t he t horacic aort ic segm ent during follow-up of t hese pat ient s ( 7% ) . Ot her st udies in t he lit erat ure reinforce t his finding, and 1- 4% of t he pat ient s died due t o rupt ure of t hese aneurysm s.7 , 1 4
Cao et al., in a recent st udy,7 com paring pat ient s subm it t ed t o convent ional and endovascular
surgery, concluded t hat lat e survival of pat ient s subm it t ed t o endovascular surgery ( 66.9% in 7 years) is equal t o t hat of pat ient s subm it t ed t o convent ional surgery ( 67.1% over t he sam e period) . The problem of convent ional surgery was higher init ial m ort alit y rat e, which is higher t han t hat of endovascular surgery. Ot her st udies, however, show t hat m ort alit y in endovascular surgery can be equal or even higher t han t hat of convent ional surgery, since indicat ion is usually for high- risk pat ient s.8 , 1 2 , 1 6 Anot her finding in Cao et al.'s series was t he cause of lat e m ort alit y, which was not
relat ed t o aneurysm in pat ient s subm it t ed t o convent ional surgery; only one pat ient died due t o iliac art ery pseudoaneurysm , whereas t he pat ient s subm it t ed t o endovascular surgery had m ort alit y rat e of 1.1% relat ed t o aneurysm rupt ure, whose risk is considered around 2% in ot her st udies.8 The
reint ervent ion rat e for convent ional surgery in t hat sam e st udy was 7.1% in 7 years, whereas reint ervent ion for endovascular surgery was 49.4% .
Over t he past years, t here have been increasingly m ore frequent report s of laparoscopic repair,3 2 , 3 3,
which associat es benefit s of open surgery t o t he fact of not perform ing laparot om y it self, including t he developm ent of m echanical graft sut ure m et hods at t he aort a.3 4 , 3 5 Ot her possibilit ies t o be considered are t he associat ion of endovascular t echnique and laparoscopic fixat ion by sut ure in t he proxim al neck3 6 and endovascular m echanic sut ure.
Based on t he findings of t he present st udy, corroborat ed by findings in t he lit erat ure, it is
choice for young pat ient s wit h long life expect ancy and wit h low surgical risk, unt il durabilit y of t hese new st ent - graft s is confirm ed and a sat isfact ory lat e evolut ion close t o 10 years is assured. Such t echnique should also be em ployed when t he anat om y of t he aort a and iliac art eries is not favorable t o t he endovascular t echnique, since t he unfavorable anat om y increases persist ent risk of rupt ure aft er endovascular repair.2 5 For older pat ient s, or in t hose wit h significant ly higher com orbid
condit ions, endovascular repair undoubt edly has t he advant age of lower operat ive m ort alit y rat es.
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Cor r e sponde nce :
Fábio Hüsem ann Menezes
Rua Deusdet i Mart ins Gom es, 122 - Jardim Novo Barão Geraldo CEP 13084- 723 - Cam pinas, SP, Brazil
Tel.: ( 19) 3521.7204, ( 19) 3289.3540 Fax: ( 19) 3288.0202
Em ail: fm enezes@fcm .unicam p.br, fm enezes@m pc.com .br
This st udy was carried out at Hospit al da Fundação Cent ro Médico de Cam pinas, Cam pinas, SP, Brazil.
