Abstracts 4. Gemeinsamer Jahreskongress der ... - SWISS KNIFE

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Replanting the inferior mesentery artery during infrarenal aortic aneurysm repair – Influence
on postoperative colon ischemia
Objective: Replanting the inferior mesentery artery (IMA) in order to prevent ischemic colitis
(IC) has been discussed for many years; yet, no prospective studies have been conducted to
compare the incidence of histologically proven IC in patients with and without IMA revascularization.
The aim of this prospective study with histological evaluation of the sigmoid colon
mucosa was to asses the influence of replanting the IMA on IC and mortality.
Methods: 160 consecutive patients with symptomatic (n = 21) and asymptomatic (n = 139)
infrarenal aortic aneurysm operated from January 1999 to December 2003, were prospectively
assessed and randomly assigned either to replanting or ligating the IMA. Sigmoidoscopy
with biopsy was performed on day 4 or 5 after surgery; patients not surviving day 5 after surgery
were autopsied. All patients gave written informed consent.
Results: of the 160 randomized patients, 128 had a confirmed patent IMA and formed the
basis of this study. Their age was 70 ± 8 years (men 70 ± 8 years; women 73 ± 7 years). 67
patients had the IMA replanted (52%) and 61 ligated (48%) intraoperatively. Six patients with
a replanted IMA and 10 with a ligated IMA developed IC (RR = 0.55, CI95% =0.21 – 1.41; c2
= 1.62; P = 0.203). Blood loss in the two cohorts did not differ significantly (P = 0.788), however
patients with IC had a significantly higher blood loss compared to the cohort without IC (P
= 0.012) and were older (P=0.017). Age, sex distribution, clamping time, the use of tube or
bifurcated grafts and intraoperative hypotension did not differ between patients with ligated
or replanted IMA.
Conclusion: Even though in this study replanting the IMA did not confer statistically significant
reduction of perioperative morbidity or mortality, it appears that older patients and patients
with increased intraoperative blood loss might benefit from IMA replantation, because this
maneuver does not increase perioperative morbidity or substantially increase operation time.
4.02
D. Mayer 1 , T. Pfammatter 2 , J. Gauer 3 , M. Wilhelm 4 , M. Genoni 5 , M. Lachat 3
1 Clinic for Cardiovascular Surgery, Universitätsspital Zürich, 8091 Zürich/CH, 2 Institute for
Diagnostic Radiology, University Hospital Zurich, Zurich/CH, 3 Department of Cardiovascular
Surgery, University Hospital Zurich, Zurich/CH, 4 Department of Cardiovascular Surgery,
University Hospital Zurich, 8091 Zurich/CH, 5 Herz Chirurgie, Stadtspital Triemli, 8063
Zürich/CH
EVAR for mycotic aortic aneurysms and aorto-visceral fistulae – how to achieve more than a
bridging procedure
Objective: Endovascular aneurysm repair (EVAR) for mycotic aneurysms (MA) and aorto-visceral
fistulae (AVF) is a controversial issue. Results are poor, especially if considered as a definitive
solution. Therefore, EVAR for MA/AVF has been advocated as a bridging procedure
during the past years, at the most. This paper presents an optimized treatment strategy to
improve postoperative results.
Methods: Retrospective analysis of 11 patients (mean age 69 years; range 55-89) with
MA/AVF treated by EVAR from 1998 to 2006. The following pathologies were treated: 4 aortoduodenal
fistulae, 2 aorto-bronchial fistulae, 4 mycotic thoracic aneurysms (1 with concomitant
mycotic abdominal aneurysm) and 1 mycotic thoraco-abdominal aneurysm. 5 patients
underwent a stepped procedure (4 EVAR first, then surgical fistula excision or infection debridement;
1 fistula repair first, then EVAR) and 6 patients a single step procedure (EVAR only).
All but one patient received long-term antibiotic therapy.
Results: Overall 30 day mortality was 9% (1/11), overall mid-term (15 months) mortality 27%
(3/11). After a follow-up of 15 months all patients with MA (n=5) were alive, whereas 3/6
with AVF succumbed due to persistent infection with consecutive sepsis. All deaths occurred
in patients treated by EVAR only (no fistula excision/infection debridement). There was no
conversion to conventional open aneurysm repair.
Conclusion: Our results suggest, that EVAR as an isolated treatment fails to achieve a good
outcome in patients with MA/AVF. In comparison, EVAR combined with fistula excision and/or
infection debridement seems to be a more appropriate treatment and heralds the potential to
be more than a bridging procedure.
4.03
R. Seelos 1 , S. Ockert 2 , D. Böckler 2 , J.R. Allenberg 2
1 Gefässchirurgie, Kantonsspital Luzern, 6004 Luzern/CH, 2 Vascular and Endovascular
Surgery, University Heidelberg, 69120 Heidelberg/DE
Outcome after operation of inflammatory aortic aneurysms
Objective: Inflammatory aneurysms (IA) are a rare subgroup among aortic aneurysms more
difficult to treat surgically due to the inflammatory process involving the vessel wall and surrounding
tissues. The morbidity and mortality rates reported are higher than in normal aneurysms.
It is not known if the inflammatory wall process bears the risk of anstomotic tear and
false aneurysm formation after exclusion of the aneurysm. In this paper we focus on the fate
of the inflammatory process and anastomotic aneurysm formation as well as on perioperative
morbidity and mortality.
Methods: In a retrospective study all patients with IA surgery from 01/1995 to 11/2004 were
in-cluded. Patients were operated either by open surgery or EVAR. All Patients had preoperative
and 21 patients had follow up CT/MRI scans.
Results: 45 patients were included in the study (open n=40, EVAR n=5). Median age was 67.3
years (range 51 86 years). 22 patients (48.9 %) were symptomatic at time of operation, 4
had a rupture. Perioperative mortality was 4.9 % without rupture, 2/4 patients with rupture
died. Morbidity was 15.6 %. In the EVAR group there was no mortality. At time of follow up
examination (mean 4.1 years, range 3 months 10 years) 33 patients were alive (73.3 %). No
anastomotic aneurysm could be detected postoperatively. Complete remission of the inflammation
on CT/MRI scan was seen in 10/21 (47.6%), partial remission (>50 % of inflammatory
wall thickening) was seen in 9/21 (42.9 %) and 2/21 remained unchanged.
Conclusion: Postoperatively 90.5 % of patients had a complete or more than 50 % reduction
of the inflammatory vessel wall thickening. The inflammatory process does not seem to
enhance the risk of anastomotic aneurysm formation. Perioperative mortality and morbidity
was in the upper range expected for open repair of non-inflammatory infrarenal aortic aneurysms.
4.04
J. Schmidli 1 , L. Englberger 2 , H.O. Savolainen 3 , P. Jandus1, D. Do 4 , A. Haeberli 5 , M.K. Widmer 5 , I.
Bau mgartner 4 , T. Carrel 2
14 swiss knife 2006; special edition
1 Cardiovascular Surgery, University Hospital, 3010 Bern/CH, 2 Department of Cardiovascular
Sur-gery, University of Berne, Bern/CH, 3 Vascular Surgery, Swiss Cardiovascular Center, 3010
Bern/CH, 4 Division of Angiology, University Hospital, 3010 Bern/CH, 5 Clinical Research,
University Hospital, 3010 Bern/CH
Activated coagulation during open and endovascular abdominal aortic aneurysm repair
Objective: Biological responses to surgical trauma and ischemia/reperfusion injury include
complex inflammatory response and activation of coagulation and fibrinolysis. This study
was conducted to determine activation of coagulation in patients undergoing open (OAR)
and endovascular infrarenal abdominal aortic aneurysm repair (EVAR).
Methods: In a prospective, non-randomized, comparative study 30 consecutive patients
undergoing OAR (n = 15) or EVAR (n = 15) were investigated. Blood samples to determine
fibrinopeptide A (FPA), fibrin monomer (FM), thrombin-antithrombin complex (TAT), and Ddimer
were taken up to five days postoperatively. Routine hematologic and hematochemical
parameters as well as clinical data were collected.
Results: No statistically significant demographic differences were seen between the groups
with respect to mean age, gender, history of concomitant disease, cardiovascular risk profile,
aneurysm diameter or involvement of the iliac vessels. No mortality and no major complications
occured. Operating time was longer in OAR (249 ± 77 min. versus 186 ± 69 min., p