Priority of resection in concomitant abdominal aortic aneurysm (AAA) and colorectal cancer (CRC): review of the literature and experience of our clinic

Endovascular Exclusion of Abdominal Aortic Aneurysms and Simultaneous Resection of Colorectal Cancer

BACKGROUND

No consensus exists on the optimal strategy for treatment of abdominal aortic aneurysm (AAA) associated with colorectal cancer (CRC). The purpose of this study was to evaluate the results of endovascular treatment of AAA with simultaneous resection of CRC.

METHODS

Twenty-two consecutive patients presenting with AAA associated with a CRC were treated by endovascular AAA exclusion and simultaneous CRC resection. Median diameter of the aneurysm was 6.5 cm (range, 4.8-8 cm). Two patients (9%) had grade I cancer, 5 patients (23%) grade II, 13 patients (59%) grade III, and 2 patients (9%) grade IV. The 2 surgical procedures were performed under the same general anesthesia. Aneurysm exclusion was achieved using an infrarenal aorto-bi-iliac endoprosthesis (13 patients) and using an aorto-bi-iliac endoprosthesis with suprarenal fixation (9 patients), with 1 patient receiving bilateral renal chimney stent implantation. In all cases, vascularization of the hypogastric arteries was preserved. After AAA exclusion, colic resection was carried out by laparotomy with right colectomy (7 patients) and anterior rectocolic resection (15 patients). In all patients, AAA exclusion was controlled by a computed tomographic angioscan (CTA) at 1 month and duplex ultrasound every 6 months, and at some later stage, it was through inclusion of CTA as part of oncology surveillance. The mean duration of follow-up was 42 months (10-120 months). The primary endpoint was composite and regrouped any death occurring during the first 30 days after procedures, any type I endoleak, any aortic reintervention, and any AAA-related mortality.

RESULTS

No patient died during the first 30 postoperative days, and no patient was lost to follow-up. No aortic endoprosthesis infection and no type I endoleak were observed. Five endoleaks arising from the lumbar arteries (n = 4) or from the inferior mesenteric artery (n = 1) were identified. As they were not associated with an increase of the AAA diameter >5 mm, they were not treated. 1 colic anastomotic leak and 2 incisional abscesses were successfully cured by local care only. Nine patients (41%) died of cancer evolution during the follow-up period.

CONCLUSIONS

In this series, treatment of AAA and CRC during the same operative session yields results comparable to those observed when surgery is performed in 2 distinct operative sessions. Synchronous treatment reduced waiting time of colic resection. It may also shorten total hospitalization duration, although this last hypothesis is not supported by comparison with a control group.

Meta-analysis of Outcomes Following Aneurysm Repair in Patients with Synchronous Intra-abdominal Malignancy

OBJECTIVES

The management of concomitant intra-abdominal malignancy (IAM) and abdominal aortic aneurysm (AAA) remains a challenge, even though malignancy is common in an elderly population. By means of systematic review and meta-analysis, the aim was to investigate outcomes in patients undergoing open (OAR) or endovascular AAA repair (EVAR) that have a concomitant malignancy.

METHODS

A systematic literature review was performed (Medline and EMBASE databases) to identify all series reporting outcomes of AAA repair (OAR or EVAR) in patients with concomitant IAM. Meta-analysis was applied to assess mortality and major morbidity at 30 days and long term.

RESULTS

The literature review identified 36 series (543 patients) and the majority (18 series) reported on patients with colorectal malignancy and AAA. Mean weighted mortality for OAR at 30 days was 11% (95% CI: 6.6% to 17.9%); none of the EVAR patients died peri-operatively. The weighted 30-day major complication rate for EVAR was 20.4% (10.0-37.4%) and for OAR it was 15.4% (7.0-30.8%). Most patients had their AAA and malignancy treated non-simultaneously (56.6%, 95% CI, 42.1-70.1%). In the EVAR cohort, three patients (4.6%) died at last follow-up (range 24-64 months). In the OAR cohort 23 (10.6%) had died at last follow up (range from 4 to 73 months).

CONCLUSION

In this meta-analysis, OAR was associated with significant peri-operative mortality in patients with an IAM. EVAR should be the first-line modality of AAA repair. The majority of patients were not treated simultaneously for the two pathologies, but further investigation is necessary to define the optimal timing for each procedure and malignancy.

Management of Synchronous Abdominal Aortic Aneurysm and Complicating Colorectal Cancer

Concomitant management of synchronous abdominal aortic aneurysm (AAA) and colorectal cancer (CRC) is mandatory in cases in which both entities are life threatening for the patient. The endovascular aneurysm repair (EVAR) method can contribute toward concomitant management by offering the avoidance of an otherwise threatening vascular graft infection. We present a case of a complicating CRC and a synchronous AAA, which were successfully treated at the same hospitalization. The AAA was treated first by EVAR, and the colon resection followed 3 days later. The patient's postoperative course was uneventful. EVAR, if the standard criteria are met, could comprise an alternative and reliable solution for treating concomitant AAA and CRC even in the acute setting.

Management of concomitant abdominal aortic aneurysm and colorectal cancer

OBJECTIVE

To conduct a systematic review of the literature and perform an analysis of outcomes of treatment of concomitant colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) with a focus on the different treatment options and the related therapeutic outcomes.

METHODS

A review of the English-language medical literature from 1980 to 2015 was undertaken using the PubMed and EMBASE databases to identify studies reporting surgical treatment of patients with concomitant CRC and AAA. The search identified 24 articles encompassing 254 patients (81% male; mean age 73.5 ± 6.1 years).

RESULTS

In 96 patients (37.9%) cancer resection was performed first, followed by AAA repair at a later stage (open aortic repair [OAR], 79.2%; endovascular abdominal aortic repair [EVAR], 20.8%). Eighty-two patients (32.3%) underwent AAA repair (OAR, 47.5%; EVAR, 52.5%) before CRC resection. Seventy-one patients (27.9%) underwent combined OAR and CRC resection, and just five (1.9%) were treated with EVAR and cancer surgery in a single stage. There were eight of 96 interval AAA ruptures (8.3%), mostly in the early postoperative period concerning aneurysms >6 cm in diameter. The mean interval between the two procedures was much shorter in patients treated with EVAR than OAR (11.5 ± 1.8 days vs 103.9 ± 42.3 days). The overall 30-day mortality rate was 10.9%. Data from observational studies showed no significant differences in 30-day mortality between patients treated in one or two stages (P = .89). No mortality was recorded in any of the EVAR-treated patients. There was only one graft infection recorded (0.4%).

CONCLUSIONS

Among different approaches, no significant differences in 30-day outcomes among patients treated in either two or one stage were evident. EVAR showed the lowest mortality and also diminished the delay between the two procedures in <2 weeks for a two-stage approach, although it has been associated with a significant risk for thrombotic events. The coexistence of AAA and CRC seems to favor the use of EVAR in treating those patients.

Simultaneous endovascular aneurysm repair and distal gastrectomy in a patient with concomitant abdominal aortic aneurysm and advanced gastric cancer

The optimal surgical management of patients with concomitant abdominal aortic aneurysm (AAA) and gastrointestinal malignancy remains controversial. A 79 year-old man who presented with hematemesis was found to have advanced gastric cancer concomitant with infrarenal AAA. The patient underwent simultaneous endovascular aneurysm repair (EVAR) and distal gastrectomy. The postoperative course was uneventful. The present case illustrates the clinical utility of EVAR for the high-risk patient with concomitant AAA and gastrointestinal malignancy.

Management of concurrent colorectal cancer and vascular disease in the endovascular era

Concurrent colorectal cancer (CRC) and vascular disease, such as abdominal aortic aneurysm, represents a challenging clinical situation. Both lesions may lead to the demise of the patient and therefore should be treated. Endovascular techniques may enhance decision-making and even permit single-stage treatment.

PATIENTS AND METHODS

Retrospective review of patients in a university department with extensive endovascular experience. Between 2004 and 2010, seven patients with synchronous vascular disease and colorectal cancer were identified.

RESULTS

The mean age was 73 years, and all patients were men. Five patients had concurrent CRC and aneurysmal disease. Two had synchronous critical carotid artery stenosis and CRC. All vascular lesions were treated with endovascular techniques. All CRC were resected with open techniques. In four patients, endovascular repair followed by staged CRC resection was performed. In three patients, single-stage procedures were performed. There was one perioperative death, for a mortality of 14.3% in our series. There were no graft infections.

CONCLUSIONS

Priority of treating concurrent vascular disease and CRC remains a dilemma. Combined treatment with a single-stage procedure is feasible. Risk of graft infection may be lower than expected.

Right retroperitoneal approach for repair of an abdominal aortic aneurysm involving bilateral iliac arteries in a patient with a left-side stoma after abdominoperineal resection

A 78-year-old woman, who had a history of abdominoperineal resection with the associated left-side stoma for rectal cancer, was diagnosed with an infrarenal abdominal aortic aneurysm involving both common and right internal iliac arteries. She underwent in situ graft (bifurcated Dacron) replacement through a right retroperitoneal approach because of limited accessibility to the aorta and iliac arteries due to the left-side stoma. The distal anastomosis of the bifurcated graft was placed to the right external iliac artery and left femoral artery, and the left common iliac artery was excluded by ligating the branching arteries. The patient had an uneventful postoperative course, and the computed tomography scanning at 13 months after surgery revealed thrombosed occlusion of the excluded left common iliac aneurysm. In conclusion, a right retroperitoneal approach may be an option for abdominal aortic aneurysm patients who had a history of transperitoneal abdominal surgery and an associated left-side stoma.

Infrarenal Abdominal Aortic Aneurysm with Concomitant Urologic Malignancy: Treatment Results in the Era of Endovascular Aneurysm Repair

During diagnostic workup for urologic malignancies, an abdominal aortic aneurysm (AAA) is identified in a proportion of patients. In the era of open AAA repair, these patients presented a surgical dilemma with regard to the sequence of the operations: cancer treatment first or AAA repair first? Previous assessments have concluded that irrespective of the followed strategy, the early and mediumterm mortality from the two operative procedures in this patient category was significant. With the introduction of endovascular aneurysm repair (EVAR), the mortality and morbidity associated with the treatment of both pathologic conditions may be more favorable than with open aneurysm repair. The objective of this study was to assess, in an institutional series of patients receiving EVAR, the early and long-term survival and complication rates in patients with urologic malignancies. In a series of 385 patients receiving EVAR, 14 had a concomitant urologic malignancy: renal cell carcinoma (5 patients), prostate carcinoma (6 patients), and carcinoma of the bladder (3 patients). The first-month mortality was nil. Long-term survival was 80%, 83%, and 67% for the three tumor types, respectively. EVAR offers improved treatment in patients with concomitant AAA and urologic malignancy and should be considered the first choice for these patients.

Surgery for rare aneurysm associated with colorectal cancer

The occurrence of concomitant aortic aneurysm and colorectal cancer is a rare medical entity, and controversy surrounds its optimal treatment. We report a case of rectal cancer and concomitant aneurysm from the ascending aorta to the common iliac artery. As with DeBakey type I aortic dissecting aneurysm, our patient was treated by rectal cancer resection, with preservation of the anus (Dixon operation) under controlled hypotension. Blood pressure was maintained at 80-90/50-60 mmHg and the pulse at 70-90 beats/min. The pathological examination of the surgical specimen showed a poorly differentiated T3N0 tumor. The patient had an uneventful recovery without aneurysm rupture, and was discharged from hospital on postoperative day 15 after 3 d adjuvant chemotherapy with oxaliplatin combined with calcium folinate and fluorouracil. The patient was given six courses of adjuvant chemotherapy in 6 mo, without recurrence or metastasis, and the aneurysm was still stable after 2 years follow-up.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature

OBJECTIVES

There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR).

DESIGN, MATERIALS AND METHODS

An observational study of the experience of two centres and a systematic review of the published literature.

RESULTS

Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection.

CONCLUSIONS

In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Treatment of abdominal aortic aneurysm associated with colorectal cancer: presentation of 14 cases and literature review

PURPOSE

The coexistence of abdominal aortic aneurysm (AAA) and cancer is observed with increasing frequency, raising several questions about therapeutic and surgical strategies for management of both diseases. In this study, we present our experience on 14 patients affected by both colorectal cancer (CRC) and AAA, and we have also reviewed the literature from 1988 to 2005 for clinical experiences on this matter.

MATERIALS AND METHODS

From January 1988 to May 2006, 1,012 AAA and 1,480 CRC were observed and treated in our department; in 14 patients (1.3% of AAA and 0.9% of CRC), both diseases were coexistent. We also performed a literature review from 1987 to 2005, and we found 254 cases of AAA associated with CRC.

RESULTS

Priority was given for treatment of vascular disease. The diseases were treated in one stage in nine cases and in two stage in four patients; in the remaining case, only the CRC was treated due to patient's poor cardiac conditions. Postoperative (30-day) complications were seen in 1 of 14 patients (7.1%), whereas there were no postoperative deaths or prosthetic infections. In the literature review, treatment in one stage was performed in 102 cases and in two stage in 118 cases; in the remaining 25 cases, only one disease was treated (in 24 cases, for different reasons, only CRC was treated, whereas in the last case, only the AAA was treated, and the patient died in the postoperative period). Postoperative (30-day) morbidity and mortality in one-stage treatment were 8 and 4.5%, respectively, and 21.3 and 6% in two-stage treatments, respectively. In patients treated for only one disease, 30-day morbidity and mortality were 4 and 24%, respectively. Only one case of prosthetic infection was reported after a two-stage treatment.

CONCLUSIONS

From the analysis of the literature and our experience, it is evident that, when AAA and CRC are coexistent with preoperative diagnosis of both diseases, single-stage intervention, when feasible for patient in general and local conditions, has to be preferred due to the lower morbidity. Single-stage treatment avoids a second surgical and anesthesiologic trauma and eliminates the risks joined with the non-treated lesion, increasing, however, the magnitude of the operation. Endovascular therapy, for its less invasiveness, appears to be an adequate solution for one-stage treatment of the two diseases but its role is still subject of ongoing discussions.

Concomitant colorectal cancer and abdominal aortic aneurysm: evolution of treatment paradigm in the endovascular era

BACKGROUND

Although the incidence of patients presenting with concomitant colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) is low, current treatment strategies in patients with both lesions remains controversial. Given recent advances in endovascular aortic aneurysm repair (EVAR), we sought to analyze the surgical outcomes of patients with concomitant CRC and AAA.

STUDY DESIGN

A retrospective chart review was performed on all patients with CRC and AAA between December 1984 and July 2007.

RESULTS

A total of 108 patients with concomitant CRC and AAA were identified. Forty-six patients presented with symptomatic or obstructing CRC, which was treated with colectomy followed by either open AAA repair (n=35, group A) or EVAR (n=11, group B). Thirty-eight patients underwent either open AAA (n=26, group C) or EVAR (n=12, group D) first, followed by staged CRC resection. Eight patients underwent combined CRC and open AAA repair (group E). The time delays after CRC resection to AAA repair in groups A and B were 42 and 35 days (NS), respectively. The time delays after open AAA or EVAR procedures before CRC resection in groups C and D were 115 days and 12 days (p < 0.0001), respectively. Two patients in group B developed sigmoid ischemia after EVAR and were treated with sigmoid resection. Increased perioperative morbidity and mortality rates were noted in group C (p < 0.002).

CONCLUSIONS

In patients with concomitant colorectal cancer and AAA, the symptomatic lesion should be a treatment priority. Because EVAR results in early recovery and a shorter convalescence compared with open aneurysmorrhaphy, this modality offers potential treatment benefits in patients with suitable anatomy who have concomitant CRC. But EVAR treatment should be offered with caution because of the risk of sigmoid ischemia caused by inferior mesenteric artery occlusion.

Management of simultaneous abdominal aortic aneurysm and colorectal cancer: the rationale of mini-invasive approach

The concomitant occurrence of abdominal aortic aneurysm and malignancy represents a therapeutic dilemma. Both lesions should be treated to achieve best life expectancy; the main controversy remains whether to treat them simultaneously or as staged procedures. Recently, endovascular repair has been suggested as a potential alternative to open standard intervention. We present a case of synchronous abdominal aortic aneurysm and colorectal cancer treated simultaneously by minimally invasive surgery.

Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy

BACKGROUND

The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies.

METHODS

All patients who underwent surgery for a nonruptured infrarenal AAA of > or =5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed.

RESULTS

Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of > or =5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P = NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103)

CONCLUSIONS

With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.