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THE JOURNAL OF CARDIOVASCULAR SURGERY

Rivista di Chirurgia Cardiaca, Vascolare e Toracica


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III. MANAGEMENT OF THE “POLYVASCULAR PATIENT”
2. ABDOMINAL AORTIC ANEURYSMS AND CONCOMITANT CORONARY DISEASE
B. Endovascular repair  THE MULTIFOCAL ATHEROSCLEROTIC PATIENT
DIAGNOSIS AND MANAGEMENT IN 2003


The Journal of Cardiovascular Surgery 2003 June;44(3):459-64

Copyright © 2009 EDIZIONI MINERVA MEDICA

lingua: Inglese

Conservative observational management with selective delayed repair for large abdominal aortic aneurysms in high risk patients

Veith F. J., Tanquilut E. M.,Ohki T., Lipsitz E. C., Suggs W. D., Wain R. A., Gargiulo N. J.

Division of Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY, USA


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Aim. Abdominal aor­tic aneu­rysms (AAAs) larg­er ­than 5.5 cm ­should gen­er­al­ly under­go elec­tive ­repair. However, ­some of ­these ­patients ­have seri­ous comor­bid con­di­tions, ­which great­ly ­increase oper­a­tive ­risk. This ­study eval­u­at­ed ­the out­comes of non­op­er­a­tive, obser­va­tion­al man­age­ment ­and selec­tive ­delayed ­AAA ­repair in ­high-­risk ­patients ­with ­large infra­ren­al ­and par­ar­en­al AAAs.
Methods. Among 226 ­patients ­with AAAs >5.5 cm, we select­ed 72 ­with AAAs 5.6-12.0 cm (­mean 7.0 cm) ­for peri­ods of non­op­er­a­tive man­age­ment ­because of ­their pro­hib­i­tive sur­gi­cal ­risks. Comorbid fac­tors includ­ed a ­low ejec­tion frac­tion of 15-34% (­mean 22%) in 18 ­patients; ­FEV1 <50% (­mean 38%) in 25; ­prior lap­a­rot­o­my in 10; ­and mor­bid obes­ity in 22. Follow-up ­was com­plete in ­the 72 ­patients ­for ­the 6-76 ­months (­mean 23 ­months) ­that ­they ­were treat­ed non­op­er­a­tive­ly. Fifty-­three ­patients ulti­mate­ly under­went ­repair ­because of ­AAA enlarge­ment or ­onset of symp­toms ­after 6-72 ­months (­mean 19 ­months) of obser­va­tion­al treat­ment.
Results. Of ­the 72 select­ed ­patients, 54 (75%) ­are liv­ing ­and 18 (25%) ­are ­dead. Seven ­patients under­go­ing ­only non­op­er­a­tive treat­ment pres­ent­ly sur­vive ­after 28-76 ­months (­mean 48 ­months). Of ­the 18 ­deaths, ­AAA rup­ture ­occurred in ­only 3 ­patients (4%) ­who ­had ­been ­observed ­for 12, 31, ­and 72 ­months ­before rup­ture. Nine oth­er ­deaths (13%) ­occurred ­after 6-72 ­months ­from comor­bid­ities unre­lat­ed to ­the ­patient’s ­AAA. Six of ­the 53 ­patients under­go­ing ­delayed ­AAA ­repair ­died with­in 30 ­days of oper­a­tion (11% mor­tal­ity). The mor­tal­ity ­for ­the 154 ­good ­risk ­AAA ­patients, ­who under­went ­prompt ­open or endo­vas­cu­lar ­repair, ­was 2.2%.
Conclusion. These ­data indi­cate ­that ­some ­patients ­with ­large AAAs ­and seri­ous comor­bid­ities ­are accept­ably man­aged ­for ­long peri­ods (6-76 ­months) by non­op­er­a­tive ­means. Substantial ­delays of 12 to 76 ­months result­ed in an ­AAA rup­ture ­rate of ­only 4%, ­while 13% of ­these ­patients (9 of 72) ­died of ­their comor­bid­ities unre­lat­ed to ­AAA rup­ture or sur­gery ­and mor­tal­ity in ­this ­group of ­patients, ­when oper­at­ed on, ­was 11% (6 of 53). These find­ings sup­port ­the selec­tive ­use of non­op­er­a­tive obser­va­tion­al man­age­ment in ­some ­patients ­with ­large AAAs ­and seri­ous comor­bid­ities.

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