PRACA ORYGINALNA

ORIGINAL ARTICLE

Oleksandr V. Liksunov, Nataliya R. Prysyazhna, Andriy V. Ratushnyuk, Pavlo I. Nikulnikov

National Institute of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine named after O.O.Shalimov, Kyiv, Ukraine

ABSTRACT

Introduction: Nowadays, there is an increase number of patients with abdominal aortic aneurysm. The disease has a constantly progressive nature, the result of which is the rupture of aneurysms and a high mortality rate. However, the technologies of operations are still controversial. Unidentified factors of complications and mortality remain with this pathology.

The aim: to determine the risk factors of complications in patients with the aneurysm of the abdominal aorta

Materials and methods: Analyze data of the examination and treatment results of 117 patients with aneurysm of the abdominal aorta. 58 patients were examined and treated according to advanced methods in a treatment group. The control group consisted of 59 patients who were examined and operated according to standard, generally – accepted methods.

Results: According to our observations after the planned operations, the most common were cardiac complications. Analyzing the frequency of complications depending on the type of surgical intervention, we have not established statistically significant differences. More significant volume of blood loss was observed when performing combined operations and aorto-bifem bypass in comparison with aortic bypass and aorto-biiliac bypass.

Conclusions: Combined operations result in a significantly higher blood loss compared to linear prosthetics.The level of intraoperative blood loss in patients with «large» aneurysms is significantly higher than in patients with «small» and «average» aneurysms.

key words: aneurysm of the abdominal aorta, complications, factors of risk

Wiad Lek 2019, 72, 4, 627-630

Introduction

According to modern definition, aortic aneurysm is a progressive chronic degenerative aortic disease that can affect any part of it with life threatening complications [1].

World health statistics point to a steady increase in the incidence of AAA. Today, this pathology is no longer rare and holds a solid position among other cardiovascular diseases [2,3]. According to the data of modern domestic sources in the East European countries, the frequency of observation of aortic aneurysm is an average of 40 people per 100,000 population [4,5]. The disease has a constantly progressive nature, the result of which is the rupture of aneurysms and a high mortality rate. Gaps occur in 6.3 / 100,000 population and in 35.5 / 100,000 populations over 65 years of age[6].

Over the past decade, a development of vascular surgery has led to optimistic results of planned operations with AAA – the numbers of postoperative lethality do not exceed 5-10% [5]. With a development of complications such as aneurysm rupture, postoperative lethality ranges from 67% to 94% [7].

Despite the half-century history of resection of aneurysm, the technique of performing surgical interventions remains controversial. It includes: performing proximal anastomoses with a brittle wall of the aneurysm; methods of minimal dissection of aneurysm to avoid intraoperative trauma of major veins; revascularization of the extremities with combined aortic aneurysm with dilation or stenosis of iliac arteries.

A number of authors in their observations pay attention to the dependence of various risk factors for pre- and postoperative complications and mortality [5,7].

The aim

The aim – to determine the risk factors of complications in patients with abdominal aortic aneurysm.

Materials and methods

The research is based on data analysis of the examination and treatment results of 117 patients suffering aneurysms of the abdominal aorta who were treated in the department of Major Vessel Surgery of the National Institute of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine named after O.O.Shalimov from 2008 to 2015. The treatment group, consisting of 58 patients, was examined and treated according to advanced methods. The control group of 59 patients was examined and operated according to standard, generally – accepted methods.

The duration of observation is from 1 to 9 years (average 4.7 + 2.4 years). Males predominated in a general structure of patients with AAA. The male to female ratio was 12:1. Most of the patients with AAA complained about pain in the abdominal cavity, mainly in the mesogastric area. We have established a direct dependence of clinical manifestations on the size of the AAA in a diameter scale. Namely, the most symptomatic aneurysm appeared in those cases where the transverse diameter reached 80 mm or more.

A large number of concomitant diseases in patients with AAA increase the risk of complications of surgical treatment and can lead to their development, both during the operation and in the postoperative period. The most frequent concomitant pathology was coronary heart disease and arterial hypertension (61.7% and 67.4% respectively). Occlusion-stenotic lesions were observed in 22 patients.

The diagnostic algorithm included general clinical laboratory tests (general blood and urine tests, blood biochemical analysis, lipid spectrum, coagulogram) and instrumental studies: duplex scan of the abdominal aorta and arteries of the lower extremities, ECG in 12 standard leads, X-ray. Additional studies were used when necessary: computer tomography – angiography of the abdominal aorta, visceral and renal arteries, arteries of the lower extremities; duplex scan of the main arteries of the head, determination of the function of external respiration, gastroscopy, echocardiography, measurement of segmental pressure on the lower extremities.

It was compulsory to study the coagulation and anti-congestive systems of the blood before surgery and in the postoperative period.

In the general group of patients, the aortic bypass was performed most frequently, in 46 (39.3%) patients; the aorto-bifem bypass in 31 (26.5%) patients; the aorto-biiliac bypass in 25 (21.4%); and the aorto-iliac-fem bypass- in 15 (12,8%) cases.

The combination of operations for AAA with reconstructive operations in other arterial bases and arteries of the lower extremities was in 40 cases (34.2%), including the reconstruction of visceral branches of abdominal aorta in 14 patients (12.1%).

Due to concomitant diseases, after an additional examination of 17 patients, significant coronary artery lesions, major arteries of the head and renal arteries were detected. Such patients had done stage or one-time surgical treatment. The first stage was correction of coronary, cerebrovascular, renal blood circulation; the second stage included the operation on the aneurysm of the abdominal aorta, which was individualized. Aorto- coronar bypass surgery was performed in 3 patients, carotid endarterectomy in 4 patients, direct stenting of coronary arteries in 4 patients, direct stenting of the renal arteries in 2 patients. At the same time, aorto- coronary bypass and aortic bypass were performed in 2 patients. One patient had done carotid endarterectomy, aorta coronary bypass and aortic bypass.

Results and discussion

According to our observations after the planned operations, cardiac complications were most common. Acute coronary insufficiency, rhythm disturbances in the form of flashing arrhythmia and myocardial infarction were observed in 8 patients (6.8%), which in 3 cases (37.5%) resulted in a fatal outcome. Cardiac complications were observed in the main group of 3 patients (4.4%), 1 of them (33.3%) died. In the comparison group, such complications were observed in 5 patients (7.2%), 2 of them (40%) died. Neurological complications were observed in 4 (3.4%) patients. In this group, an ischemic stroke was developed in 1 patient (25%), which eventually led to long-term disability. Immediate acute violation of cerebral circulation was observed in 3 patients (75%) of this group.

A development of acute ischemia of the lower extremities had been observed in 6 patients (5.1%) in a postoperative period due to arterial embolism (thrombosis) and increased chronic arterial insufficiency, which required the implementation of another reconstructive operation.

One patient (16.7%) of this group developed irreversible ischemia and contracture, followed by amputation of the lower limb.

Renal complications, such as development of acute kidney damage (GHP), which required dialysis therapy, were observed in 3 patients (2.6%). 2 (66.7%) patients in this group developed multiple organ failure with a fatal outcome.

Gastrointestinal complications were detected in 3 patients (2.6%). One of them developed a colon infarction, due to which he was operated and died from multiple organ failure. 1 patient (0.9%) had a gastrointestinal bleeding . There was eventration detected in 1 patient (0.9%), who had a surgery on this. In this group we did not consider such complications as postoperative paresis of the intestine, since all patients had a comprehensive prevention of such a complication, but if they arose, they were short-lived and resolved by conservative treatment.

Analyzing the frequency of complications depending on the type of surgical intervention, we have not established statistically significant differences (χ2 = 3.8; p = 0.27 according to Pearson criteria). The data is presented in Table I.

It is well known that the larger volume of surgery, the greater blood loss. Such surgical intervention should be provided with a sufficient amount of donor blood or autologous dasgs, including using hardware reinfusion to fill the circulating volume in order to provide vital functions of the body.

We have analyzed a dependence of intraoperative blood loss on planned operations from the type of intervention and vascular graft that a re-used. It was established that more significant volume of blood loss was observed in performing combined operations and aorto-bifem bypass in comparison with aortic bypass and aorto-biiliac bypass (H = 13.1; p = 0.004).

Since the essential factor determining a level of blood loss during a surgery is an aortic diameter, we analyzed volume of blood loss from a diameter of aneurysm (table II).

As it can be seen from the data presented, small (35-50 mm) size of aneurysms were found in 18 patients, blood loss in the presence of aneurysms of a small diameter was 1133 + 623 ml. Median size (51-70mm) of aneurysms were found in 64 patients. The level of blood loss in the presence of such an aneurysm diameter was 1235 + 695.2 ml. Large aneurysms (> 71 mm) were diagnosed in 35 patients, and the level of inoperative blood loss in patients of this group was 1902 + 830.5 ml, which was significantly higher than in patients with «small» and «average» aneurysms (p <0.05).

In order to establish a direction and strength of the relationship between the diameter of an aneurysm of the aorta and intraoperative blood loss, we observed a positive correlation between these parameters (r = 0.43; p = 0.001).

The operations performed for the AAA were accompanied by high blood loss. Necessary adequate hemotransfusion therapy had led to a coagulopathy development of varying degrees of severity in 4 (3.4%) patients. 2 patients (50%) had hematoma in a peritoneal space, requiring repeated operations to remove the hematoma and hemostasis correction. In 2 other cases (50%), a development of syndrome of acute disseminated intravascular coagulation (DIC) in the phase of deep hypocoagulation and subsequent complete non-coagulation of blood was noted, which resulted in a fatal outcome.

Most cardiovascular events were observed in 6.8% of cases, of which 37.5% resulted in a patient’s death. The second most frequent operation included complications of acute or increased critical chronic lower limb ischemia. Thrombectomy was performed in 3 patients, one patient was supplemented with profundoplastic, one with iliac-fem bypass, two with fem-pop bypass. Reconstruction operations were not always successful, in 16.7% of cases, limb amputation was inevitable.

In our observations neurological complications were less common; there were no lethal outcomes. However, in 25% of cases there were marked disability in patients after severe acute cerebrovascular accidents.

Renal complications were very dangerous and caused death in 66.7% patients. An extremely dangerous complication was a development of coagulopathy in the form of DIC in the phase of deep hypocoagulation with the development of multiple organ failure, which led to 50% lethality.

Conclusions

1. The structure and frequency of postoperative complications were distributed as follows: cardiological – 6.8%, vascular – 5.1%, neurological – 3.4%, hematologic – 3.4%, renal – 2.6%, gastroenterological – 2, 6%.

2. The frequency of complications was almost the same in each group and did not depend on the type of surgical intervention (χ2 = 3.8; p = 0.27 according to Pearson criteria).

3. Completitions of combined operations is accompanied by significantly higher blood loss compared to linear prosthetics (p <0,05).

4. The level of intraoperative blood loss in patients with «large» aneurysms is significantly higher than in patients with «small» and «average» (p <0.05). A positive correlation between a diameter of an aneurysm and a level of intraoperative blood loss is established (r = 0.43; p = 0, 001). Therefore, the size of the aneurysm of the abdominal aorta may be a prognostic factor in massive bleeding. This should be taken into account during the preparation for the surgery and can contribute to a positive result, which is the prospect of further research.

References

1. Mastracci TM. The progression of aortic aneurysms. J Cardiovasc Surg. 2016 ;57:221-3

2. Zatevakhin I.I. i soavt. Anevrizmy abdominal’noy aorty kak problema ekstrennoi khyrurgii. Angiologiya i sosudistaya khirurgia 200;:2:332-334. (in Russia).

3. Kazanchan P.O. I soavt. Razryvy anevrism bryushnoi aorty. Osobennosti klinicheskogo techeniya I klassificaciyi. Angiologiya i sosudistaya khirurgiya 2003:1:9:84-89.(in Russia).

4. Lemenev V.L. i soavt. K voprosu ob uluchshenii rezul’tatov lecheniya bol’nykh s razryvom anevrizmy bryushnoy aorty. Angiologiya i sosudistaya khirurgiya 2004;2:156-157. (in Russia).

5. TeunB.M.et al.The influence of screening on the incidence of ruptured abdominal aortic aneurysm. Jornal of Vasc.Surg.;2009;30(2):203-208.

6. Heikkinen M, SaleniusJP, Auvinen O. Raptured abdominal aortic aneurysm in a well-definded geographic area. J Vasc Surg 2002;36:291-6.

7. De Martino R R , Goodney PP, Nolan BW,et al. Optimal selection of patients for elective abdominal aortic aneurysm repair based on life expectancy. J Vasc Surg 2013;58:589-95.

The work was carried out within the framework of the scientific theme “Studying the factors of surgical risk in patients with aneurysm of the abdominal aorta and developing methods of their correction” (state registration number 0106Г011568, 2007-2009) based on the Department of Major Vessel Surgery of the National Institute of Surgery and Transplantation of the National Academy of Medical Sciences of Ukraine named after O.O. Shalimov

Authors’ contributions:

According to the order of the Authorship.

Conflict of interest:

The Authors declare no conflict of interest.

CORRESPONDING AUTHOR

Nataliya Prysyazhna

30, Heroiv Sevastopolya Street, 03680 Kiev, Ukraine

tel: +380979396105

e-mail: dr.prysyazhna@gmail.com

Received: 04.02.2019

Accepted: 02.04.2019

Table I. Dependence on duration of surgical intervention, complications and bleeding from the variant of surgical intervention.

Parameters

Operation

1

Aortic bypass

N=46

2

Aorto-biiIliac bypass

N=25

3

Aorto-iliac-fem bypass

N=15

4

Aorto-bifem bypass

N=31

Duration of operation, min.

201,9+38,9

248,5+97,6

242,9+39,7

269,7+55,8

Kruskal-Wallis test Н=29,9; р<0, 00001

Complication, %

15,2

24

13,3

29

Pearson criteria χ2=3,8 р=0,27

Bleeding, ml

1165,2+627,6

1672+791,4

1377+559,2

1603,2+877,7

Kruskal-Wallis test Н=13,1; р=0,004

Table II. Diameter of aneurysm and volume of blood loss.

Diameter of aortic aneurysm мм

Bleeding, ml

р<0,05

1.

35-50 (small)

n=18

1133+623

1-3

2.

51-70 (middle)

n=64

1235+695,2

2-3

3.

>71 (big)

n=35

1902+830,5

3-1

3-2

Figure 1. Correlation between aortic diameter and volume of blood loss