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The correlation between abdominal aortic dilatation and arteriosclerotic risk factors was studied in 2514 Japanese residents (947 men, 1567 women, mean age 70 years old). The aortic diameter was measured by ultrasound and an aortic dilatation was defined as above 30 mm in diameter, including abdominal aortic aneurysm (AAA). Forty-three (1.7%) patients with a dilated aorta and 2471 with a normal-sized aorta were compared. Abdominal aortic dilatation was significantly (p < 0.01) more frequent in men than in women (3% vs 0.7%). Obesity and hyperlipidemia were slightly (p < 0.1) more frequent in patients with a dilated aorta than in those with a normal-sized aorta. There were no significant differences between the two groups in mean age, frequency of smoking, diabetes mellitus, and coronary artery disease. In conclusion, male obesity and hyperlipidemia may be risk factors for aortic dilatation in Japan. Women may not be screened because of cost-effectiveness. The prevalence of aortic dilatation in Japan was lower than in European countries. However, screening for AAA using ultrasound would be advantageous when considering the grave prognoses of ruptured AAA.
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PMID:Abdominal Aortic Dilatation in Japanese Residents. 982 3

During a recent 30-month period, we repaired 10 ruptured abdominal aortic aneurysms (RAAA) at our institution. To evaluate the survival, postoperative morbidity, and financial impact of treating RAAA, we compared these patients with 10 randomly selected patients undergoing elective AAA (EAAA). Both groups were comparable for age, gender, and incidence of diabetes, hypertension, coronary artery disease, chronic obstructive pulmonary disease (COPD), and renal failure. Although we have noted a dramatic increase in survival for RAAA (90%), the morbidity continues to be unacceptably high (60%). Efforts should be made toward better detection of AAA prior to rupture as well as development of strategies to minimize or prevent these major complications. Potential average savings accrued from one patient undergoing EAAA repair rather than RAAA repair ($93,139. 21) can be used to perform screening abdominal ultrasound tests in patients at increased risk of having an AAA.
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PMID:Ruptured versus elective abdominal aortic aneurysm repair: outcome and cost. 1054 16

The study was set up to investigate the awareness of elderly patients and medical doctors of medical restrictions to driving. Separate questionnaires were completed by patients and doctors. All were interviewed face-to-face, without prior warning and their immediate answers were recorded. In total, 150 elderly patients from the acute elderly care wards, rehabilitation wards and day hospital, and 50 doctors (including all grades from consultant to junior house officer) were interviewed. The main outcome measures were numbers of patients currently driving and previously driving; patients' awareness of how their medical condition affected their ability to drive; doctors' spontaneous knowledge of medical conditions which restrict driving, current licensing policy, and restrictions for five specific medical conditions (epilepsy, myocardial infarction, stroke, 5-cm abdominal aortic aneurysm, and diabetes). Only 21 patients were current drivers, and six of these should not have been driving. While 103 perceived themselves eligible to drive, 46 had medical restrictions to driving. Seventeen of the 47 patients who perceived themselves not eligible to drive possibly did not have restrictions to driving. Doctors' knowledge of the current licensing policy and action to be taken if a patient was not eligible to drive was very poor. Knowledge of medical restrictions to driving was scanty, with few doctors giving the correct driving restrictions for the five specific conditions. We recommend that education of doctors regarding medical restrictions to driving should begin at an undergraduate level and be continued throughout their postgraduate career.
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PMID:Medical restrictions to driving: the awareness of patients and doctors. 1090 92

Abdominal aortic aneurysms (AAAs) have historically been considered to be a manifestation of atherosclerosis. However, there are epidemiologic and biochemical differences between occlusive atherosclerotic disease and aneurysmal disease of the aorta. A case-control study was performed to investigate risk factors for AAA at the two tertiary care hospitals in Winnipeg, Manitoba, Canada, between June 1992 and December 1995 to investigate risk factors for AAA. Newly diagnosed cases of AAA (n = 98) were compared with non-AAA controls (n = 102), who underwent ultrasound for indications similar to those of the cases. Compared with that for never smokers, the adjusted odds ratio (OR) was 2.75 (95% confidence interval (CI): 0.85, 8.91) for 1-19 pack-years, 7.31 (95% CI: 2.44, 21.9) for 20-34 pack-years, 7.35 (95% CI: 2.40, 22.5) for 35-49 pack-years, and 9.55 (95% CI: 2.81, 32.5) for 50 or more pack-years. Other factors significantly associated with AAA were male gender (OR = 2.68, 95% CI: 1.26, 5.73), diastolic blood pressure (OR per 10 mmHg = 1.88, 95% CI: 1.31, 2.69), and family history of AAA (OR = 4.77, 95% CI: 1.26, 18.1). There was an inverse association between diabetes mellitus and AAA (OR = 0.32, 95% CI: 0.12, 0.88). Neither clinical hypercholesterolemia nor serum levels of total cholesterol, low density lipoprotein cholesterol, and high density lipoprotein cholesterol was associated with AAA. The results of this study suggest that the risk factors for AAA differ from those for atherosclerosis and that atherosclerosis per se is not an adequate explanation as the cause of AAAs.
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PMID:Risk factors for abdominal aortic aneurysm: results of a case-control study. 1073 39

To clarify carotid arterial changes in female patients with arteriosclerosis obliterans (ASO) and aortic aneurysm (AA), ultrasonographic (US) findings of the extra-cranial carotid arteries were studied in 26 patients with ASO (ASO group), and 31 patients with AA (AA group), compared to 38 controls (control group) with neither ASO nor AA. ASO was diagnosed with an ankle pressure index less than 0.9, while AA was done with computed tomography or angiography. Half of the patients with ASO were in stage II of the Fontaine clinical staging, and angiography, performed in 12, showed femoral arterial obstruction in 10. Most AA patients were abdominal aortic aneurysm. Using a high-resolution, real-time, B-mode US instrument, the diameter and wall thickness of the common carotids were measured bilaterally in the end-diastolic phase, and occlusive changes and plaque were estimated. As a risk factor for arteriosclerosis, hypertension, diabetes, hyperlipidemia, and cigarette smoking were assessed, in addition to the age, body height and weight. Mean ages of each group were 73 to 76.3 year-old. There was no significant difference between them in body height and weight. Diabetes, cigarette smoking, and cerebrovascular disease were frequent in the ASO group, whereas ischemic heart disease was frequent in the AA group. US findings revealed that carotid lesions were mostly plaque, and bilateral carotid lesions were significantly more frequent in the ASO and AA groups. The mean wall thickness of the carotids was greater in the AA and ASO groups, although dilated carotid arteries, namely arteriomegaly, was more frequent in the AA group than in the ASO and control groups. Stepwise regression analyses demonstrated that strong correlations were seen between carotid lesion and two variables [vessel diseases (ASO/AA) and cigarette smoking], between carotid diameter and three variables (age, AA, and wall thickness), and between the wall thickness and three variables (age, vessel diseases and diameter). These findings showed that atherosclerosis was not only frequent in female patients with ASO and AA, but arteriomegaly was characteristic in female patients with AA. Therefore, it suggested that circulatory disturbance in whole organs due to arteriosclerosis should be paid attention even in female patients with ASO and AA as well as male patients. Furthermore, it is considered that systemic fragility of the arterial media and ectasia could be present extensively in patients with AA.
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PMID:[Ultrasonographic findings of carotid arteries in female patients with arteriosclerosis obliterans and aortic aneurysm]. 1087 74

The third Adult Treatment Panel guidelines from the National Cholesterol Education Program, released in May 2001, depart from previous guidelines in several ways. As in previous guidelines, treatment and treatment goals are based not only on lipid levels but also on the patient's risk status. The method for calculating risk, however, has been refined considerably. Patients are classified in the highest-risk group if they have any of these disorders: known coronary artery disease, diabetes mellitus, peripheral vascular disease, abdominal aortic aneurysm, carotid artery disease, or a 10-year risk of a coronary event of more than 20% (as determined by use of a scoring method).
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PMID:Using the new cholesterol guidelines in everyday practice. 1145 73

The physiological infrarenal aortic diameter varies between 12.4 mm in women an 27.6 mm in men. As defined, an aneurysmatic dilatation begins with 29 mm. According to that, 9% of all people above the age of 65 are affected by an abdominal aortic aneurysm (AAA). Compared with the female sex, the male sex predominates at a rate of about 5:1. The disease is predominant in men of the white race. In black men, black and white women the incidence of AAA is identical. 38 to 50 percent of the AAA patients (patients) suffer from hypertension, 33 to 60% from coronary, 28% from cerebrovascular and 25% from peripheral occlusive disease. The AAA expansion rate varies between 0.2 and 0.8 cm per year and is exponential from a diameter of 5 cm on. In autopsy studies, the rupture rates with AAA diameters of < 5 cm, between 5.1 and 6.9 cm, and of > 7 cm were below 5%, 39% and 65%, respectively. 70% of the AAA patients do not die of a rupture, but of a cardiac disease. Serum markers, such as metalloproteinases and procollagen peptides are significantly increased in AAA patients. Thoraco-abdominal aneurysms (TAA) make up only 2 to 5% of all degenerative aneurysms. 20 to 30% of the TAA patients are also affected by an AAA. 80% of the TAA are degenerative, 15 to 20% are a consequence of the chronic dissection--including 5% of Marfan patients--, 2% occur in case of infections and 1 to 2% in case of aortitis. The TAA incidence in 100,000 person-years is 5.9% during a monitoring period of 30 years. In case of TAA, an operation is indicated with a maximum diameter of 5.5 to 6 cm and more and, in case of a Marfan's syndrome (incidence of 1:10,000), with a maximum diameter of 5.5 cm and more. With regard to aorto-iliac occlusive diseases, there are defined 3 types of distribution. Type I refers to the region of the bifurcation itself. Type II defines the diffuse aorto-iliac spread of the disease. Type III designates multiple-level occlusions also beyond the inguinal ligament. Type I patients in most cases are female and more frequently suffer from hyperlipidaemia, while Type II patients are affected by hypertension and diabetes. Compared to Type II patients, Type I patients have a life expectancy that is 10 years higher. Type I and Type II patients often suffer from a pelvic claudication and, unlike Type III patients, are more frequently affected by arterio-arterial embolisms.
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PMID:[Epidemiology of aortic disease: aneurysm, dissection, occlusion]. 1155 76

Newer, minimally invasive catheter-based endovascular technology utilizing stent grafts are currently being evaluated for abdominal aortic aneurysm (AAA) repair. A retrospective review of all (3 years) consecutive, non-ruptured elective AAA repairs was undertaken to document the results of AAA surgical repair in a modern cohort of patients to allow a contemporary comparison with the evolving endoluminal data. One hundred twenty-one AAAs were identified in a male veteran population. Mean age was 68.5 +/-7.7 years. Medical history review showed hypertension in 55%, heart disease in 73.5%, peripheral vascular disease in 21%, stroke and transient ischemic attacks in 22%, diabetes mellitus in 7%, renal insufficiency in 10%, and smoking history in 80%. The AAA size was documented with ultrasound (5.2 +/-1.3 cm, n=40) and computed tomography (5.6 +/-1.3 cm, n=100). Fifty-nine percent had angiography. Intraoperative end points included an operative time of 165 +/-6.3 minutes from incision to dressing placement. A Dacron tube graft was used in 78%, the remaining were Dacron bifurcated grafts. A suprarenal clamp was used in 8% for proximal aortic control with juxtarenal aneurysms. A pulmonary-artery catheter was placed in 69%. A transverse incision was used in 69% of patients and a midline incision was used in the rest. Estimated blood loss was 1505 +/-103 mL; cell saver blood returned 754 +/-53 mL; crystalloid/Hespan 4771 +/-176 mL; banked packed red blood cells 0.75 +/-0.11 U. Time to extubation was, in the operating room (78.5%), on the day of the operation (5.0%), postoperative day (POD) 1 (12.4%), POD2 (1.7%), POD3 (0.8%), and one case was performed with epidural anesthesia only. Postoperative end points included a 30-day mortality rate of 1.6% (two patients). Postoperative morbidity included wound dehiscence 0.8%; sepsis, urinary tract infection, wound infection, leg ischemia, ischemic colitis, and stroke each had an incidence of 1.6%; myocardial infarction, congestive heart failure, pneumonia, re-operation for suspected bleeding, and ileus or bowel obstruction occurred with an incidence of 3.3%. No significant increase in serum creatinine levels was noted. Time to enteral fluids/nutrition was 3.5 +/-0.08 days. Patients were out of bed to a chair or walking by 1.3 +/-0.06 days postoperatively. The length of stay in the intensive care unit (ICU) was 2.0 +/-0.12 days and postoperative hospital stay was 6.6 +/- 0.33 days. Transfusion requirement for the hospital stay was 1.6 +/-0.2 U per patient. This review highlights a cohort of male veteran patients with significant cardiac co-morbidity who have undergone repair with a conventional open technique and low mortality and morbidity rates. This group had rapid extubation, time to oral intake, and ambulation. In addition, ICU and hospital stays were relatively short.
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PMID:Abdominal aortic aneurysm repair. 1156 37

The objective of this report was to analyze the current surgical results of operative treatment in patients suffering ruptured AAA (abdominal aortic aneurysms) and to define those independent predictive factors for mortality. During a period of 2 years, from January 1996 to December 1997, 144 patients operated on for ruptured AAA in 10 hospitals were included in a multicenter retrospective study. Among the collected variables concerning each patient, those with potential relation to surgical mortality were studied: gender, age, diabetes, hypertension, cardiopathy, pulmonary obstructive disease, preoperative renal dysfunction, symptomatic cerebrovascular disease, peripheral vascular disease, hematocrit on admission, preoperative hypotension < 80 mmHg, loss of consciousness, cardiac arrest, aortic aneurysm location (infrarenal versus non-infrarenal), iliac involvement, aneurysm size, type of rupture, left renal vein ligature, ligature of a patent inferior mesenteric artery, place of aortic cross-clamping, type of grafting, exclusion of both hypogastric arteries, venous technical complications, associated surgery, use of cell saver, intraoperative blood loss, and postoperative complications (renal failure, sepsis, coagulopathy, cardiac complications, pulmonary complications, colon ischemia, prosthetic graft complications, and need for reoperation). Those variables with statistical significance in the univariate analysis were introduced into a multivariate logistic regression model to determine the independent predictors of death. From our results we concluded that surgery for ruptured abdominal aortic aneurysms continues to have an excessively high mortality rate. Even though some preoperative variables could be identified as predictors of mortality, an absolute mortality risk has not yet been determined and the decision to negate surgery should be individualized rather than taken on that basis only. Early diagnosis and treatment of symptomatic aneurysms would improve mortality figures and selective screening should be contemplated.
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PMID:Factors increasing the mortality rate for patients with ruptured abdominal aortic aneurysms. 1176 39

This study reviews our experience with duplex ultrasound arterial mapping (DUAM) for preoperative evaluation in 466 patients (262 men) who underwent 485 lower extremity revascularization procedures from January 1, 1998 to May 30, 2001. Preoperative imaging consisted of DUAM alone in 449 procedures and DUAM and contrast angiography (CA) in 36. An attempt to image from the distal aorta to the pedal arteries was made in all the patients. The selection of optimal inflow and outflow bypasses anastomotic sites was based on a schematic drawing following DUAM examination. Inflow disease was also assessed by intraoperative pressure gradient (IPG) between the distal anastomosis and radial arteries, and completion arteriography of the runoff vessels was obtained, which was correlated with the preoperative findings. Indications for surgery were severe claudication in 91 (19%) limbs, tissue loss in 197 (40%), rest pain in 113 (23%), acute ischemia in 46 (10%), popliteal aneurysm in 18 (4%), superficial femoral artery aneurysm in 1, abdominal aortic aneurysm with claudication in 1, and failing graft in 18 (4%). Age ranged from 30 to 97 years (mean 72 +/- 12 (SD) years) and risk factors such as diabetes, hypertension, use of tobacco, coronary artery disease, and end-stage renal disease were present in 45%, 45%, 44%, 44%, and 13% of the patients, respectively. One hundred twenty-one (25%) limbs had at least 1 previous ipsilateral revascularization. The mean DUAM time was 66 +/- 20 (SD) min (30-150 min). Additional preoperative imaging was deemed necessary in 36 cases due to extensive ulcers, edema, severe arterial wall calcification, and very poor runoff. The distal anastomosis was to the popliteal artery in 173 cases and to the tibial and pedal arteries in 255. Inflow procedures to the femoral arteries, embolectomy, thrombectomy, balloon angioplasty, and patch angioplasty accounted for the remaining 57 cases. Overall, 6-, 12-, and -24- month secondary patency rates were 86%, 80%, and 66%, respectively. This early experience shows that high-quality arterial ultrasonography performed by a highly skilled vascular technologist may represent an alternative to conventional arteriography for patients in need of lower extremity revascularization. Because of limitations inherent to the technique and very poor runoff observed on ultrasonographic examination, additional preoperative imaging procedure's are needed for certain patients.
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PMID:Lower extremity revascularization without preoperative contrast arteriography: experience with duplex ultrasound arterial mapping in 485 cases. 1190 14


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