SIGNIFICANCE OF DELAYED SURGICAL TREATMENT OF SYMPTOMATIC NON-RUPTURED ABDOMINAL AORTIC ANEURYSM/ZNACAJ ODLOZENOG HIRURSKOG LECENJA SIMPTOMATSKE NERUPTURIRANE ANEURIZME ABDOMINALNE AORTE.
Aorta is the largest blood vessel that delivers oxygenated blood to all parts of the body. It belongs to a group of large, conducting, most elastic blood vessels in the body . The aortic wall is composed of three concentric layers: tunica intima - the inner layer, tunica media - the middle layer, and tunica adventitia - the outer layer .
Abbreviations AAA - abdominal aortic aneurysm sAAA - symptomatic abdominal aortic aneurysm rAAA - ruptured abdominal aortic aneurysm MRA - magnetic resonance angiography US - ultrasonography MSCTA - multi-slice computed tomography angiography HTA - hypertension CMP - cardiomyopathy DM - diabetes mellitus COPD - chronic obstructive pulmonary disease AoFF bypass - aortobifemoral bypass AoII bypass - aortoiliac bypass
In addition to the primary function of delivering blood to all parts of the body, the aorta and other elastic blood vessels play an important role in blood pressure control. This function is made possible due to the elasticity of the lamina which gets wider during the systole and thinner during the diastole. Owing to the tunica media, loaded with elastic fibers, the elastic wall of the aorta opposes pressure created after the contraction of the heart chamber, maintaining arterial pressure and blood flow even during relaxation of the chamber .
Aortic diseases are among the most important diseases of the vascular system. Apart from congenital malformations, aortic dissection and atherosclerotic changes, aneurysms are critical aortic diseases that may appear anywhere throughout the circulatory system .
Aneurysm is a permanent focal dilatation of the arterial wall to 1.5 times greater than its normal diameter. The real aneurysm of the aorta is defined as a dilation of all three layers (intima, media and adventitia) of the aortic wall, which differs from pseudo-aneurysms . In addition to the thoracic part, aortic aneurysms are most commonly found in the infrarenal abdominal section  (Figure 1).
According to the latest findings in the United States, about 150,000 new cases of abdominal aortic aneurysms (AAAs) are detected annually , while data in Western Europe show that over 700,000 people have AAAs . The AAA is relatively frequent and sometimes fatal, which primarily affects the elderly, while the younger population is much less affected .
According to the clinical presentation, AAAs may be divided into two groups: asymptomatic AAA and symptomatic AAA (sAAA). Symptomatic aneurysms can be further divided into ruptured and non-ruptured aneurysms .
The pathophysiological basis of the AAA is multifactorial, while the degenerative process of the wall is most often found [10, 11]. The most common and most important etiological factor for aneurysm formation is atherosclerosis of the aortic wall, which is a disease of large and medium blood vessels. However, although much less often, AAA can also develop as a result of various infections including brucellosis, salmonellosis, and tuberculosis .
Other factors for AAA formation include a positive genetic predisposition, age, gender, smoking, hypertension (HTA), and chronic obstructive pulmonary disease (COPD). The significance of diabetes in the pathogenesis and course of AAA are still controversially discussed, often with contradictory results [13-15].
Based on information collected from numerous studies on the development of AAA, factors such as smoking, HTA and gender are listed as important. The process of AAA diameter enlargement mostly depends on the age, severity of heart disease and smoking. The worst potential outcomes, such as AAA ruptures, are associated with female gender, large initial AAA diameter, and elevated mean arterial pressure [16-22].
In addition to its unpredictability, AAA shows the so-called discontinuous growth pattern, unequal expansion of the aneurysm wall. In the natural course of untreated AAA, an aneurysm can be caused by wall stretching. Therefore, although the individual growth pattern cannot be accurately predicted, the average growth is about 3 to 4 mm per year . In the past, the risk of AAA rupture has been overestimated, but recently two very significant studies have attempted to give a more precise estimate that is still in use [23, 24] (Table 1).
Most commonly the AAAs rupture into the retroperitoneal area (83%) and much less likely into the intraperitoneal region (12%). In addition to the previously mentioned sites, aortocaval fistula (3 - 4%) and aortoduodenal fistula, although much less often (< 1%) are considered to be complications of ruptured AAA .
The aim of this study was to analyze demographic and medical history data, as well as the course and outcome of sAAA treatment. We also evaluated the results of the symptomatic non-ruptured aneurysms in regard to the diameter of ruptured and non-ruptured symptomatic aneurysms and the impact of the time elapsed from admission to surgery on the surgery outcome.
Material and Methods
The study was approved by the Ethics Committee of the Faculty of Medicine Novi Sad, and the authors strictly followed the principles and indications recommended and by the Declaration of Helsinki.
The retrospective study included 133 patients who underwent surgery for AAA in the period from January 2015 to the end of December 2017. Of these patients, 45 patients underwent open surgery for symptomatic non-ruptured abdominal aortic aneurysm, while 88 patients had emergency treatment of ruptured aneurysm of the abdominal aorta. Data were collected from the Medical Registry of the Clinic of Vascular and Endovascular Surgery of the Clinical Center of Vojvodina in Novi Sad and the Emergency Center Novi Sad (surgery protocols, medical histories, clinical, biochemical and radiological data, discharge letters, etc.).
In addition to medical history and initial clinical examination, the precise diagnosis was set by multislice computed tomography angiography (MSCTA), and sometimes magnetic resonance angiography (MRA) and ultrasonography (US).
In order to analyze the results of previous AAA, the following parameters were preoperatively followed:
- Gender and age of the patients,
- Associated diseases (HTA, cardiomyopathy (CMP), diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD), nicotinism),
- Diagnosis and clinical state of aneurysm (symptomatic non-ruptured/ruptured),
- Size of aneurysm.
The following parameters were monitored intraoperatively and postoperatively:
Applied surgical techniques (Dacron tube prosthesis, AoII-bypass (aortoiliac bypass), AoFF-bypass (aortobifemoral bypass)
- Blood products loss (ml),
- Recovery of blood (ml) from Blood Cell Saver,
- Intraoperative complications (cardiac arrest, lethal outcome),
- Treatment outcome,
- Length of survival after successfully performed surgery (intrahospital death/within the first 7 days after surgery/within the first 7 days after discharge).
All patients were operated in the operating rooms of the Clinical Center of Vojvodina and Emergency Center in Novi Sad. Interventions were carried out in collaboration with vascular surgeons and anesthesiologists, and all patients were operated under general endotracheal anesthesia. Postoperatively, patients were relocated to the Department of Vascular and Endovascular Surgery, and discharged after a recovery period with precise medication dosages and scheduled follow-ups.
Descriptive and comparative statistics were made between the groups with symptomatic non-ruptured and ruptured aneurysms. As part of the descriptive statistics, the following parameters were used: statistical mean and median, minimum and maximum values, as well as standard deviation. The Pearson [chi square]-test was used to compare the differences between the tested groups regarding the non-parametric characteristics.
The study included 133 patients, of which 107/133 (80.5%) were male, while 26/133 (19.5%) were female. The average age of patients was 71.6 years and the median age was 69 years. The oldest patient was 93 years old and the youngest 55.
Based on the initial medical history data and a detailed clinical examination of all the patients, 45/133 (33.83%) patients had the diagnosis of non-ruptured sAAA. In this group, 10/45 (22.22%) patients were female, while the remaining 35/45 (77.77%) were male. The remaining 88/133 (66.15%) patients had the diagnosis of ruptured AAA (rAAA). In this group, 16/88 (18.18%) patients were female, while the remaining 72/88 (81.81%) were male.
Radiological diagnosis included preoperative assessment of the size of aneurysms. In the sAAA group (Table 2), the average size was 77.24 mm while the mean size was 76 mm. The recorded minimum and maximum was 50 mm and 110 mm. In the rAAA group, the average size was 83.08 mm while the mean size was 76 mm. The recorded minimum and maximum were 50 mm and 150 mm.
Of the observed preoperative comorbidities, the most common were: arterial hypertension (HTA) in 88/133 (66.16%) patients and CMP in 51/133 (38.34%) patients. Nicotinism was present in 34/133 (25.56%) patients, DM in 10/133 (7.52%), while COPD was found in 20/133 (15.4%) patients.
Of the observed comorbidities in the group with sAAA (Graph 1), the most commonly present was HTA 82.22%, followed by CMP 46.67% of patients, and 4 from DM (4.44%). COPD was present in 11.11% of patients, while nicotinism was present in 28.89% of patients. Of the observed comorbidities in the group of patients with rAAA, the most commonly present were HTA 57.95%, then 34.09% of patients were suffering from CMP, and from DM 9.09% of patients. COPD was found in 17.04% of patients and nicotinism in 23.89%.
All patients underwent a surgical procedure, but at different time after admission. Of 133 patients, 100 (75.18%) underwent surgery in the first 24 hours after admission, and the remaining 33/133 (24.81%) were operated after 24 hours.
The operated patients underwent various procedures: Dacron tube interposition was performed in 98/133 (73.68%), aorto-biiliac-bypass (AoII-bypass) in 16/133 (12.03%), and aorto-bi-femoral bypass (AoFF-bypass) was performed in the remaining 19/133 (14.28%) patients.
The intraoperative procedure of patients with sAAA also varied; the Dacron tube interposition was performed in 36/133 (80%) patients, AoII-by-pass in 4/133 (8.88%), and AoFF-bypass in the remaining 5/133 (11.11%). In patients with rAAA, the intraoperative procedures also varied: the Dacron tube interposition was performed in 62/133 (70.45%) patients, AoII-bypass in, 12/133 (13.63%), and AoFF-bypass was performed in the remaining 14/133 (15.9%) patients.
Intraoperative blood loss and blood replacement were also measured. In all the patients, the average blood loss was 2174 ml, while the median was 1500 ml. The minimum blood loss was 160 ml, and the maximum was 10 000 ml. The average blood products recovery by Cell Salvage was 786 ml and the mean was 570 ml. The minimum recorded value was 40 ml and the maximum was 6700 ml.
Intraoperative blood loss, blood replacement and cell salvage in the sAAA group were also precisely measured. The average loss of blood elements was 958.44 ml, while the median was 800 ml. The minimum loss was 160 ml, and the maximum was 2500 ml. The average value of blood product reimbursement was 342 ml and the mean value was 300 ml. The minimum value was 40 ml and a maximum 900 ml.
Intraoperative blood loss, blood replacement and cell salvage in the rAAA group were precisely measured too. The average loss of blood elements was 2796.64 ml, while the median loss was 2300 ml. The minimum loss was 250 ml, and the maximum was 10000 ml. The average value of blood products compensation was 1013 ml, and the median 820 ml. The minimum was 100 ml and the maximum 6700 ml.
In regard to complications, in the group of patients with sAAA, there were no cases of cardiac arrest, 0/45 (0%) or intraoperative lethal outcome, 0/45 (0%). In the group of patients with rAAA, the results of complication monitoring showed that intraoperative cardiac arrest was recorded in 6/88 (6.81%) patients, while intraoperative lethal outcome occurred in 2/88 (2.27%) cases.
As the last item, the surgical outcome was followed and of the total sample, 42/133 (31.57%) patients died in the hospital, while the remaining 91/133 (68.42%) patients were released from the hospital. In the group of patients with sAAA, 5/45 (11.11%) died in the hospital, while the remaining 40/45 (88.88%) patients were released home. In the group of patients with rAAA, 37/88 (42.04%) died in the hospital, while the remaining 51/88 (57.95%) patients were released home.
In the observed sample of patients with sAAA, 12/45 (26.67%) patients were operated in the first 24 hours after admission, and the remaining 33/45 (73.33%) patients were operated after 24 hours from the moment of admission to the hospital.
Out of the patients who underwent surgery in the first 24 hours (Table 3) after admission, 2/12 (16.67%) died in the hospital, while 10/12 (83.33%) patients were released from the hospital.
Out of the patients who were operated after the first 24 hours (Table 3) after admission, 3/33 (9.91%) patients died in the hospital, and the remaining 30/33 (90.09%) patients were discharged from the hospital.
Comparative statistics of comorbidity and other parameters in relation to the diagnosis are shown in Table 4.
Comparing two groups of symptomatic non-ruptured and ruptured AAA, hypertension was statistically significantly different (p < 0.05), while intrahospital survival and mortality during hospitalization showed a high statistically significant difference (p < 0.001) after successful surgery.
The study includes 133 patients who underwent a surgical treatment of AAA at the Clinic of Vascular and Endovascular surgery in Novi Sad during the period from January 2015 to December 2017. Of the total number of patients (133), 107 (80.5%) were male and 26 (19.5%) were female. The male to female ratio among the investigated patients was 6 : 1, similar to the distribution found in the literature  of 7 : 1; this difference can be explained by the fact that the sample included almost three times more patients. Although the sample was much larger, in both studies the analyzed patients were mostly 60 years of age: in our case 87% while in the other study 79% .
The average age of our patients was 71.6 years; the oldest patient was 93 and the youngest 55 years of age. These data support the fact that aneurysm is a disease affecting the elderly population, mostly in the seventh decade, which was also confirmed by other available studies [9, 25].
A sAAA was diagnosed in 45 patients, while the remaining 88 had a rAAA, which is similar to the data available in the literature .
The question of the size of the aneurysm and its potential rupture is an abundantly discussed topic. Some studies, such as Ruby Lo et al. , have come to the conclusion that the risk of aneurysm rupture is directly associated with its size, but they have also proved that there was a correlation between the size of the aneurysm and the size of the patient's body. Due to the fact that data on the body size were generally not available to us, we could not check this hypothesis in the retrospective analysis of our patients.
In our patients with non-ruptured aneurysm, the mean size of the aneurysm was 77.24 mm while in the group of patients with ruptured aneurysm, the average size was 83.08 mm. Comparing the diameters of aneurysms in our study with those in the above mentioned study , where the average diameters of aneurysms were smaller than in ours, there were no statistically significant differences in diameters of ruptured aneurysms and symptomatic non-ruptured aneurysms of the abdominal aorta.
Of the preoperative comorbidities among our patients, the most common were HTA 66.16% and CMP 38.34%. DM was found in 28.12%, while 15.03% of patients had COPD. Nicotinism, although a very widespread comorbidity, was present only in 25.56% of patients. The results obtained are very similar to the results in the literature  with differences in response; DM 3% and nicotinism 67%, were much more prevalent in their patients. Thompson et al.  have come to the conclusion that HTA occurs more frequently in patients with rAAA versus sAAA in patients over 65 years of age, while in our sample there were more patients with HTA in those with sAAA.
In regard to the time when the surgical procedures were performed, we created two groups. The first group included patients who were operated in the first 24 hours after admission, while the second group included patients operated after 24 hours after admission. According to our data, 75.19% of patients were operated in the first 24 hours of admission, while the remaining 24.81% were operated after 24 hours.
During each operation, the amount of lost and recovered blood was monitored using the Cell-Saver apparatus. The average value of blood loss in our patients with symptomatic non-ruptured aneurysm was 958 ml, while patients with ruptured aneurysm lost an average of 2796 ml. The amount of blood returned to circulation via Cell-Saver in patients with sAAA was 342 ml, and 1013 ml in the group with rAAA. Other studies have also reported similar results .
Every surgery has risks and complications. In our sample, we followed the intraoperative lethal outcome and cardiac arrest in all operated patients, and found that only 4% of the patients experienced an intraoperative cardiac arrest, while lethal outcome occurred in 1.5%. It is very interesting that all intraoperative complications occurred in patients with rAAA, while patients with sAAA did not have any complications during the surgical procedure. Similar data are found in the literature .
Postoperatively, of the total sample, 68.42% of patients were released from the hospital after recovery, while the remaining 31.57% of patients died during the postoperative period. The highest number of deceased patients had rAAA 42.04% (37/88), and a much lower percentage of patients had sAAA 11.11% (5/45). Previous studies have shown that the postoperative mortality of patients with rAAA is estimated to be approximately 45.4%, which is very close to our 42.04% [28, 29].
A critical period for survival was also monitored; 42/133 (31.57%) patients died during the hospitalization, and the remaining 91/133 (68.42%) were released home. Patients who underwent surgery with sAAA were operated at different time after admission. Of the total sample of patients (45), 12/45 (26.67%) underwent surgery in the first 24 hours after admission, and the remaining 33/45 (73.33%) patients were operated after 24 hours after admission. In the group that was operated during the first 24 hours, 16.67% died, as well as 9.91% of the patients in the group operated after 24 hours, which is 1.6 times less compared to patients who were operated during the first 24 hours. Compared to two groups of symptomatic non-ruptured and ruptured AAA, HTA showed a statistically significant difference (p < 0.05), and our data for the period 2015 - 2017 largely coincide with those published for the period 2005 - 2007 . One can only speculate that the cause of higher mortality of patients with HTA is the chronic change in the structure and elasticity of the blood vessels in general, as well as a greater prevalence of complications in the cardiovascular system such as cardiac insufficiency, chronic kidney disease, etc. .
We are aware of certain limitations of this study. Because of the retrospective nature of the study and the quality of the data collected from the registry, there are definitely some data that may have influenced the final results of the analysis, but were not recorded. It would also be more informative to quantify the status of comorbidity, but it was not possible to use the currently available data. Here, for example, we are thinking about nicotinism, for example concerning the period of smoking, the number of packs per day, as well as the duration of the abstinence period if it was present. We are also aware that the design of a prospective study in order to solve this problem would be extremely difficult. Another clear limitation is that this analysis involved only patients with sAAA and rAAA who have been admitted to the tertiary vascular center of the Clinical Center Novi Sad. According to some information, it is estimated that one third to half of all patients with rAAA dies before reaching the hospital. There is a high possibility that patients, who died at home, or during transportation, were older and had more comorbidity. Despite the fact that our study is retrospective with a small number of patients, the volume of the data collected and the results obtained coincide and do not deviate to a large extent from the results of studies from other large centers.
This study shows that the surgery of symptomatic non-ruptured aneurysm of the abdominal aorta in the first 24 hours has a higher mortality rate than after 24 hours after admission. Early elective surgery is a method of choice in the treatment of symptomatic non-ruptured aneurysm of the abdominal aorta. There is no statistically significant difference in the diameter of ruptured and non-ruptured symptomatic aneurysms, but the average size of the aneurysm diameter is higher in ruptured, which confirms the fact that the increase in the diameter increases the risk of rupture as well.
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Slavko BUDINSKI (1,2), Janko PASTERNAK (1,2), Vladimir MANOJLOVIC (1,2), Vladimir MARKOVIC (1,2) and Dragan NIKOLIC (1,2)
Clinical Center of Vojvodina, Novi Sad
Clinic of Vascular and Endovascular Surgery (1)
University of Novi Sad, Faculty of Medicine Novi Sad (2)
Corresponding Author: Dr Slavko Budinski, Klinika za vaskularnu i endovaskularnu hirurgiju, 21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: email@example.com
Rad je primljen 19. VI 2018.
Recenziran 6. III 2019.
Prihvacen za stampu 7. III 2019.
Table 1. Annual risk of abdominal aortic aneurysm (AAA) rupture in relation to its size Tabela 1. Godisnji rizik od rupture aneurizme abdominalne aorte (AAA) u odnosu na njenu velicinu Description Diameter Estimated annual rupture risk Opis Dijametar (cm) Procenjen godisnji rizik od rupture (%) Normal aorta/Normalna aorta 2 - 3 0 Small AAA/Mala AAA 4 - 5 1 Medium AAA/Srednja AAA 5 - 6 2 - 5 Big AAA/Velika AAA 6 - 7 3 - 10 Large AAA/Ogromna AAA > 7 >10 Description Estimated five year rupture risk Opis Procenjen petogodisnji rizik od rupture (%) Normal aorta/Normalna aorta 0 Small AAA/Mala AAA 5 - 10 Medium AAA/Srednja AAA 30 - 40 Big AAA/Velika AAA > 50 Large AAA/Ogromna AAA Approaching to 100/Priblizava se 100 Table 2. The comparison of the size of symptomatic abdominal aortic aneurysms (sAAA) and ruptured abdominal aortic aneurysms (rAAA) Tabela 2. Izmerena velicina aneurizmi i uporedena kod pacijenata sa simptomatskom aneurizmom abdominalne aorte (sAAA) i rupturirane aneurizme abdominalne aorte (rAAA) sAAA (mm) rAAA (mm) Average value/Prosecna vrednost 77,24 83,08 Middle value/Srednja vrednost 76 76 Recorded minimum/Zabelezeni minimum 50 50 Recorded maximum/Zabelezeni maksimum 110 150 Table 3. Survival of patients with sAAA in regard to the admission and time of surgical procedure Tabela 3. Prezivljavanje pacijenata sa simptomatskom aneurizmom abdominalne aorte u zavisnosti od pristizanja u bolnicu do pocetka operacije Operated during first 24h Operisan unutar prvih 24h Died during hospitalization/Preminuo u toku hospitalizacije 16.67% Discharged from hospital/Otpusten iz bolnice 83.33% Operated after 24h Operisan posle 24h Died during hospitalization/Preminuo u toku hospitalizacije 9.91% Discharged from hospital/Otpusten iz bolnice 90.09% Table 4. Comparative statistics on comorbidity, intraoperative procedures, complications, intrahospital survival and mortality in relation to sAAA and rAAA Tabela 4. Komparativna statistika komorbiditeta, intraoperativnih procedura, komplikacija, intrahospitalnog prezivljavanja kao i smrtnosti u odnosu na simptomatske (sAAA) i repturirane aneurizme abdominalne aorte (rAAA) Comorbidity/Komorbiditeti sAAA HTA 37 CMP 21 Nicotinism 13 DM 2 COPD/HOBP 5 Intraoperative procedure/Intraoperativna procedura sAAA Dacron tube/Dakron tubus 36 Ao-II bypass 4 Ao-FF bypass 5 Complications/Komplikacije sAAA Exitus letalis/Smrtni ishod 0 Cardiac arrest/Srcani zastoj 0 Intrahospital survival/ Intrahospitalno prezivljavanje sAAA Intrahospital lethality/Intrahospitalno preminuli 5 Mortality during hospitalization/Smrtnost u toku hospitalizacije sAAA From 0 to 7 days/Od 0 do 7 dana 2 Comorbidity/Komorbiditeti rAAA HTA 51 CMP 30 Nicotinism 21 DM 8 COPD/HOBP 15 Intraoperative procedure/Intraoperativna procedura rAAA Dacron tube/Dakron tubus 62 Ao-II bypass 12 Ao-FF bypass 14 Complications/Komplikacije rAAA Exitus letalis/Smrtni ishod 2 Cardiac arrest/Srcani zastoj 6 Intrahospital survival/ Intrahospitalno prezivljavanje rAAA Intrahospital lethality/Intrahospitalno preminuli 37 Mortality during hospitalization/Smrtnost u toku hospitalizacije rAAA From 0 to 7 days/Od 0 do 7 dana 26 Comorbidity/Komorbiditeti p HTA 0,009 CMP 0,221 Nicotinism 0,675 DM 0,539 COPD/HOBP 0,516 Intraoperative procedure/Intraoperativna procedura p Dacron tube/Dakron tubus Ao-II bypass 0,495 Ao-FF bypass Complications/Komplikacije p Exitus letalis/Smrtni ishod 0,790 Cardiac arrest/Srcani zastoj 0,177 Intrahospital survival/ Intrahospitalno prezivljavanje p Intrahospital lethality/Intrahospitalno preminuli 0,000 Mortality during hospitalization/Smrtnost u toku hospitalizacije p From 0 to 7 days/Od 0 do 7 dana 0,000 Legend: HTA - arterial hypertension; DM - diabetes mellitus; Nicotinism - smoking; COPD - chronic obstructive pulmonary disease; CMP - cardiomyopathy; Ao-II bypass - Aorto-biiliac baypas; Ao-FF bypass - Aorto-bifemoral bypass Legenda: HTA - arterijska hipertenzija; DM - dijabetes melitus; Nicotinism - pusenje; HOBP - hronicna opstruktivna bolest pluca; CMP - kardiomiopatija; Ao-II bypass - aortobiilijacni bajpas; Ao-FF bypass - aorto-bifemoralni bajpas