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Refinement in surgical technique and perioperative management have considerably improved morbidity and mortality rates of carotid endarterectomy and abdominal aortic surgery, thus allowing a more aggressive approach in the treatment of carotid stenosis, abdominal aortic aneurysm and aorto-iliac occlusive disease in the elderly population (> 70 years). We review our experience with 446 consecutive patients undergoing surgery of the abdominal aorta: 295 patients (mean age 75.5 years) underwent resection of an abdominal aortic aneurysm (asymptomatic but > 5-6 cm, (n = 193), symptomatic (n = 67) or ruptured (n = 35). Additionally, 198 patients were treated surgically for aorto-iliac occlusive disease. A small group of 13 patients was deferred for combined operation, including prior myocardial revascularization and subsequent vascular surgery during the same anesthesia. The majority of patients had several cardiovascular risk factors and/or significant associated diseases. Mortality (< 30 days) was 3.5% following aorto-iliac bypass in the treatment of arterial occlusive disease and 8.4% after aneurysm repair (asymptomatic, symptomatic and ruptured aneurysms all included). 5-year survival was 74% and 64% after repair of aortic aneurysm and treatment of aorto-iliac occlusive disease respectively. On the basis of these results, we believe that major vascular surgery is still justified in elderly patients and can be achieved with reasonable mortality and morbidity. Main goals of the surgery, e.g. to relieve suffering, restore function so as to limit disability and dependency, and prolongation of life expectancy in a dignified and meaningful life-style, are realized the majority of operative survivors.

Severe late complications after reconstruction of the abdominal aorta are unusual; when they occur, they demand a different strategy to treat the patient with success and to achieve a durably favourable long term outcome. These complications include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for the lower extremities. In patients who survived graft removal and extra-anatomic bypass, a source of major arterial inflow should be at least considered in order to secure a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypass and as a valid alternative to avoid dense adhesions in the abdomen or retroperitoneum. We present our experience with 8 patients in whom the aorta had been previously oversewn below the renal arteries (resection of infected graft [n = 4], repair of aorto-enteric fistula [n = 3]) or avoided because of dense adhesions after radiotherapy (n = 1). Temporary extra-anatomic reconstruction consists of an axillo-femoral (-popliteal) bypass on the right side with femoro-femoral cross-over graft. This method avoids surgery in the left thoraco-abdominal region, thus facilitating the definitive repair. Proper preoperative radiographic evaluation with inflow and outflow details is essential before conversion into thoraco-bifemoral bypass. Posterolateral thoracotomy is performed and the chest entered in the 7th interspace. The thoracic aorta is clamped tangentially and a bifurcated graft is anastomosed to the aorta. The bypass is passed through a retroperitoneal tunnel and anastomosed end-to-end with the distal portion of the previously inserted grafts; this technique avoids a second dissection of the vessel itself.(ABSTRACT TRUNCATED AT 250 WORDS)

Reoperative coronary bypass surgery has been encountered with increasing frequency over the last few years. It is associated with several major problems: difficulties with myocardial protection secondary to progression of arterial disease and occluded saphenous vein grafts, left ventricular dysfunction, and concomitant medical and vascular disease. We present our experience with 194 consecutive patients operated on between 1980 and 1992. They represent 4.0% of the overall number of isolated coronary revascularizations performed during the same period. There were 178 men and 16 women, mean age 58.6 +/- 7.4 years. The interval between primary coronary bypass grafting operation and redo-operation extended from 4 to 12 years, mean 8.2 years. At reoperation, 91.7% (178/194) of the patients received at least one arterial conduit, whereas revascularization with arterial conduits only was performed in 16 patients. Perioperative mortality amounted to 4.6% and was significantly higher than mortality of primary isolated coronary operations (1.6%) during the same period; the following significant morbidity was encountered: perioperative myocardial infarction (8.2%), postoperative low output requiring intraaortic counterpulsation (8.7%), postoperative bleeding (8.2%) and infectious complications (9.2%). First postoperative follow-up showed a significant improvement of symptomatology with a decrease of 1.5 point in NYHA functional class. Mid term survival is promising with a 5-year survival rate of 88.5%. Improved myocardial preservation and a trend towards complete revascularization should become routine and will probably reduce perioperative mortality and morbidity.

Although severe complications after anatomic reconstruction of the abdominal aorta are unusual, when they occur, a different strategy is required to treat the patient with success and a distinct operation is generally required for a durable favourable long term outcome. Late complications after abdominal aortic grafting include prosthetic infection, enteric erosion and graft thrombosis. Treatment by resection of the infected graft and extra-anatomic reconstruction with axillary-femoral or axillary-popliteal bypass leaves the patient with an unreliable arterial inflow for his lower extremities; in those patients who survive graft removal and extra-anatomic bypass, an alternative source of major arterial inflow should at least be discussed to effect a permanent repair. The descending thoracic aorta has been described as an ideal inflow source for definitive intracavitary conversion of extra-anatomic subcutaneous bypasses and as an occasional alternative to avoid a densely scarred abdomen or retroperitoneum. Our experience with 8 patients includes 7 in whom the aorta had been overseen below the renal arteries in a previous operation [after removal of infected graft (n = 4) and after repair of aorto-enteric fistula (n = 3)]. Our technique of primary extra-anatomic reconstruction consists of a right-sided axillo-femoral (-popliteal) bypass with femoro-femoral crossing graft. This method avoids tunneling an extra-anatomic graft in the left thoraco-abdominal region, thus facilitating the definitive repair. Preoperative radiographic evaluation of inflow and outflow details is essential in these complex cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Infrarenal aortic cross-clamping required during surgical treatment of abdominal aortic aneurysm is generally well tolerated but can be occasionally associated with severe cardiac and haemodynamic disturbances, particularly in patients suffering from coronary artery disease. We compared the haemodynamic changes and the ECG-records before and shortly after infrarenal aortic clamping in three groups of 20 patients (group I: without coronary artery disease, group II: with overt coronary disease without indication for prior myocardial revascularization, and group III: patients undergoing combined procedure: coronary artery bypass immediately prior to aortic repair, during the same anesthesia). There was no significant difference in demographical characteristics between the three groups. Aortic cross-clamping lead to an increase in systemic arterial pressure in all patients. Group I demonstrated a decrease in pulmonary artery pressure, pulmonary capillary wedge pressure and central venous pressure, whereas patients of group II demonstrated an increase of each value when the aorta was clamped. 11 patients of this group developed either arrhythmia and/or ischemia during aortic cross-clamping. Haemodynamic and cardiac effects of aortic clamping seen in patients who had received coronary bypass immediately prior to aortic repair (group III) were surprisingly similar to those of patients without coronary disease, probably owing to systematic application of 2 vasodilators. Tolerance to infrarenal aortic cross-clamping differs in patients with and without coronary artery disease. Development of myocardial ischemia may be predicted by an increase in wedge pressure after clamping. Afterload reduction was the best treatment of ischemia occurring when the aorta was clamped.

Extracardial carotid artery disease is a frequent cause of transient ischemic attack and of cerebral infarction. The records of 485 patients who underwent carotid endarterectomy between 1978 and 1991 were reviewed, with special attention to both cardiac and neurological complications. 432 patients had symptomatic carotid disease whereas 53 were asymptomatic but presented with significant carotid stenosis or a large ulceration at doppler-duplex examination and/or angiography. These examinations showed the following lesions in symptomatic patients: unilateral stenosis > 75% (331; 68.5%), ulceration (41; 8.5%), bilateral stenosis (61; 12.5%) and unilateral stenosis with contralateral occlusion (51; 10.5%). Intraluminal shunt was used in nearly all patients whereas special management of cerebral metabolism (intraoperative electroencephalogram, somatosensory evoked potentials) were used in high-risk patients only. Overall early mortality was 1.8%. Three patients died from the sequelae of a neurologic injury, whereas six patients died from myocardial infarction or intractable arrhythmia. Mortality decreased from 2.4% between 1978 and 1984 to 0.8% between 1985 and 1991. At 6 and 8 years, actuarial survival rates of 88.1% and 76.1% and stroke-free survival rates of 86% and 81.5% were observed. Late mortality was essentially due to ischemic cardiac complications (38.5% of the actuarial late mortality at 8 years). Review of the literature shows that carotid endarterectomy is the treatment of choice for symptomatic high-grade extracranial carotid stenosis in patients who are not high-risk candidates.(ABSTRACT TRUNCATED AT 250 WORDS)

Surgery of the suprarenal segment of abdominal aorta is characterized by specific problems of operative techniques and of circulatory support during operative procedure. Ischaemic time of kidneys and other viscera has to be limited and use of femoro-femoral bypass allows perfusion of distal aortic branches during performance of the proximal anastomose. Replacement of the suprarenal abdominal aortic segment was performed in 57 consecutive patients (45 with aneurysm and 12 with para- or suprarenal atherosclerosis). Emergent operation was performed in 10 patients (9 with aortic rupture and 1 with acute renal failure by occlusion of the pararenal aortic segment) with early mortality of 50%. Elective operation was much safer with early mortality of 4.3% (2/47 patients). Following procedures were performed to revascularize the kidney and the other visceral arteries: direct replantation with or without endarterectomy (80%), bypass with prosthetic material or saphenous vein (15%), other procedures (5%). Nephrectomy was done in 3 patients. Overall 6-year survival was 64% in patients with aneurysm and 48% in patients with aortic atherosclerosis. 6-year survival was significant (p less than 0.01) higher in patients with normal renal function postoperatively than patients with persisting creatinine value over 200 micromol/l 3 months after operation (68% vs 15%).

Aortic branch occlusion may constitute the mode of presentation or become an important focus of treatment in patients sustaining acute aortic dissection. The optimal therapeutic approach in patients with acute aortic dissection complicated by cerebral, visceral and peripheral vascular problems, and the implications of such complications, are not well established. We review the outcome in 187 consecutive patients (149 males and 38 females, mean age 58 years) with acute dissection of the thoracic aorta who were admitted and operated on in our department over a 13-year period. We assess the incidence, consequences and specific management of significant stenotic and obstructive lesions of the aorta and its branches. Noncardiac vascular complications occurred in 59 patients (32%); of these complications, 38 were associated with type A dissection (incidence 28%) and 21 with type B dissection (incidence 48%). A trend towards decreasing overall surgical mortality was observed in the second part of the study (1983-1989) compared with the first part (1977-1982) i.e. 28% versus 12%. Although aortic rupture and cardiac tamponade were the strongest correlate of morbidity and mortality, death specifically related to vascular complication was more common when such malperfusion occurred in the carotid, celio-mesenteric and renal circulation. Proximal aortic repair at the site of the intimal tear with obliteration of the false lumen may have restored adequate distal circulation in 27 patients in whom improvement of the visceral or peripheral ischemia was observed after the thoracic aortic repair. Additional procedures (immediately after the thoracic repair or later) were necessary in 15 patients to restore adequate perfusion in the compromised area.(ABSTRACT TRUNCATED AT 250 WORDS)