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[Surgical treatment of abdominal aortic aneurysms in severe ischemic coronary disease]
V Sefranek1, J Tomka, P Janotik
1Dpt of Vascular Surgery, Slovak Institute of Heart and Vascular Diseases, Bratislava, Slovakia.
Insights
Improved preoperative management, especially for coronary heart disease (CHD), significantly reduces mortality in abdominal aortic aneurysm (AAA) surgery. This enhanced patient selection and care strategy dramatically lowers risks for emergency AAA repairs.
Area of Science:
- Vascular Surgery
- Cardiology
- Anesthesiology
Context:
- Abdominal aortic aneurysm (AAA) presents significant surgical challenges due to high patient comorbidity, particularly coronary heart disease (CHD).
- Conventional AAA treatment remains prevalent despite advancements in endovascular methods.
- Mortality rates for elective and emergent AAA surgery show a persistent, striking difference.
Purpose:
- To analyze strategies for improving outcomes in elective abdominal aortic aneurysm (AAA) surgery.
- To evaluate the impact of enhanced patient selection and preoperative preparation, focusing on CHD management.
- To compare surgical results before and after implementing a modern CHD management algorithm.
Summary:
- A retrospective analysis of 343 AAA patients over 20 years compared outcomes before and after implementing a focused CHD management protocol.
- The second group, with enhanced CHD care, showed a non-significant decrease in elective surgery mortality (5.5% to 3.6%) but a significant reduction in emergency surgery mortality (76% to 40%).
- The incidence of perioperative myocardial infarction (MI) decreased significantly from 87.2% to 28.5% in the second group.
Impact:
- Improved diagnostics, patient selection (especially for CHD), and preoperative management enhance AAA surgical outcomes.
- Enhanced surgical techniques, intensive care, and a modern CHD management algorithm contribute to better results.
- The study demonstrates the critical role of comprehensive perioperative care in reducing AAA surgery mortality and morbidity.
Background:
The abdominal aortic aneurysm (AAA) is one of the most serious problems of vascular surgery and general medicine, as well. Endovascular methods of treatment have been developing very rapidly, however, the conventional treatment of the AAA still predominates. The results of operative treatment have been influenced besides the delayed diagnostics of the AAA resulting in a high rate of ruptured AAA by the high comorbidity of the AAA patients population. The accentuation of the proper preoperative and perioperative management of patients could therefore significantly influence the results of the surgery. MAIN PURPOSE AND STARTING POINTS: Striking difference between the mortality of elective and emergent surgery of AAA has been unchanged despite the intensive effort of many centers. One of the main factors of mortality is the concomitant serious coronary heart disease (CHD), predominantly the acute myocardial infarction (MI). The paper analyses the possibilities to improve the results of AAA surgery by means of the patients selection and effective preparation before the elective surgery. The risk factors and concomitant diseases of patients suffering from the AAA, the elective and emergent surgery ratio and the operative mortality are referred. The results of surgical treatment before and after accepting the modern CHD management algorithm are compared.
Methods:
The present study is a retrospective analysis of the data of 343 consecutive patients with AAA operated on during the 20-years period from 1 January 1979 to 31 December 1998. The 1st group of 249 patients operated on during the 18-years period from 1. January 1979 to 31 December 1996 was not subjected to special attention concerning the CHD and was compared with the 2nd group of 93 patients operated on from 1 January 1997 to 31 December 1998. In this group of patients special attention was focused on the improvement of surgical techniques, intensive care and comprehensive diagnostics, evaluation and proper management of the concomitant CHD.
Results:
The mortality rate of the elective surgery in the 1st group was 5.5%, in the 2nd group decreased to 3.6%, the difference was not statistically significant. Evident improvement of the results was apparent in emergency operations for ruptured AAA. The mortality rate in the 1st group of 76% dropped to 40% in the 2nd group (p < 0.05). The improved policy in the management has lead to statistically significant decrease of the MI incidence in the perioperative period (87.2% to 28.5%, p < 0.001).
Conclusion:
The improved diagnostics, selection of patients with special concern to the CHD and management of the patients before surgery, improved surgical techniques and intensive care lead to evident improvement of the results in the surgical management of the AAA. This fact is confirmed by improved results of the 2nd group of patients because of improved CHD management algorithm. (Tab. 5, Fig. 1, Ref. 35.)