Aneurysm: Vascular Disease

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Vascular Disease: Aneurysmal
  • Overview: Morbidity/mortality
    •  Abdominal aortic aneurysm:
      •  Following rupture: very high mortality (> 50%)
      •  Surgical Intervention: morbidity/mortality
        • Mortality from elective abdominal aneurysm surgery: about 8% {twofold higher than that associated with occlusive major vascular disease}
      • Approximate median survival following surgery:
        • abdominal aneurysmal repair: about 6 years
        • aorticoiliac revascularization: about 11 years
    •  Basis for Morbidity/ mortality:
      •  Secondary to myocardial dysfunction {correlation may be as high as 100% -- death due to cardiac disease}
      •  Conservative treatment, i.e. observing aneurysmal growth until size becomes > 6 cm, has NOT been well  accepted despite relatively high surgical risk
      •  Since 1990, perioperative mortality has declined; however high mortality {45%-90%} continues to be associated with emergency surgery for ruptured aneurysm
        • Predicting which patients will suffer in aneurysmal rupture: unreliable
      • Patients undergoing aneurysmal surgery tend to be older (10 years) than patients undergoing aortic revascularization.  
        • Older patients tend to higher risk of adverse outcome; after correcting for age, life expectancy following aneurysmal surgery is less than that for revascularization.

Other Factors Affecting Outcome

Cardiovascular Disease

  • "Normal left coronary angiogram. Left  anterior oblique view (45 degrees) {Left}; Left coronary angiogram.  Left anterior oblique view.  Narrow area from disease proximal end of circumflex and top of anterior descending.  Male age 37. Severe angina not controlled by medical treatment": courtesy of SouthBank University, London; used with permission (http://www.skiagram.com/im0.html)

  • Most patients undergoing aortic reconstruction had clinical evidence of coronary vascular disease

  • Strongest preoperative indicator of postoperative my guarded complications was the presence of both preexisting cardiac disease and diabetes

  • Age: Significant increase in risk with increasing age

    • Greater effect on mortality than coronary vascular disease presents or aortic aneurysm rupture history

  • Renal Disease/Failure

    •  Factors that increase mortality risk:

      • Postoperative renal failure {if serious enough to record analysis}

      • Preexisting renal disease

    •  Factors that decreased risk:

      • improved intravascular volume management by anesthesia providers

  • Smoking & pulmonary disease

    • Unclear relationship between smoking and vascular surgery outcome

    •  Smoking increases respiratory complications following bypass surgery

    • Smoking cessation two months before surgery may reduce risk for complications by 66% (compared to patients who stop smoking < two months before the procedure)

  • Diabetes mellitus

    •  Diabetic patients are usually classified as type III, associated with a  reduced five-year survival rates { 65%,secondary to small vessel disease}

    • Also associated with increased likelihood of surgical wound complication. 

 

 

  • Primary Reference: Katz, J.,  Evaluation Risk Assessment of Patients with Vascular Disease in Principles and Practice of Anesthesiology (Longnecker, D.E., Tinker, J.H. Morgan, Jr., G. E., eds)  Mosby, St. Louis, Mo., pp. 201-218, 1998.

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