Selective management of abdominal aortic aneurysms in a prospective measurement program

PURPOSE

The purpose of this study was to clarify the treatment of patients with small abdominal aortic aneurysms (AAAs) less than 5 cm in diameter and those believed to be unfit for operation with AAAs 5 cm diameter or greater.

METHODS

Four hundred ninety two patients with AAAs less than 5 cm when first seen were entered in a prospective measurement program by ultrasonography or computed tomography scan (exclusively after 1998) every 6 months. A decision regarding operative fitness was made when the AAA was 5 cm. Patients then underwent operation if fit or continued follow-up if their AAA was larger than 5 cm but they were unfit. A further group of 91 patients with aneurysms 5 cm or greater when first seen but unfit for repair were entered in the prospective measurement program.

RESULTS

In the group with AAAs less then 5 cm at entry, operation was performed in 201 patients as a result of increase in AAA size to 5 cm or greater (157), AAA expansion of more than 0.5 cm in 6 months (24), or for other reasons (20). Of those with AAAs smaller than 5 cm at entry, 291 have not undergone operation at a mean follow-up of 42 months. Expansion was significantly related to aneurysm size at entry and was highest in the 4.5 to 4.9 cm group at 0.7 cm/year. In the group of patients deemed unfit for operation with 5 cm AAAs [as a graduate of the less than 5 cm group at entry (85 patients) or first seen with AAA greater than 5 cm (91 patients)], 10 ruptures have occurred. Of these patients with ruptured AAAs, six had AAAs between 5.0 and 5.6 cm.

CONCLUSIONS

Because of the risk of rupture demonstrated in our series in AAAs 5 cm or slightly greater and the progressive increase in expansion to a mean of 0.7 cm/year in those AAAs between 4.5 and 4.9 cm at entry, recommendation for elective operation in patients with AAAs between 4.5 and 4.9 cm at entry, recommendation for elective operation in patients with AAAs between 4.5 and 5.0 cm should be strongly considered in a fit patient.

Absorption characteristics at 1.9 microns: effect on vascular welding

A 1.9 microns laser was used to investigate the acute weld strengths for anastomoses of rat and rabbit aortas and femoral arteries. The wall thicknesses for these vessels approximately matched the optical absorption depth of 125 microns for 1.9 microns radiation in vascular tissues. A low power (150 mW) 1.9 microns laser was used. Laser power was delivered through silica fiber optics for manual control. The fiber tip was held approximately 1 mm from the target resulting in a laser spot size of 0.7 mm at the tissue. The linear delivery rate was approximately 0.3 mm/sec. Acute burst pressures of the welds showed a linear correlation with the reciprocal of the vessel radius. These results suggest that the product of the weld strength times the optical absorption depth is constant over the range of vessel sizes studied. A weld strength for a weld thickness equal to the optical absorption depth was determined to be 4 x 10(6) dynes/cm2, which is comparable to the strength of sutured anastomoses. These acute studies suggest that a laser wavelength with absorption depth in tissue matched to the vessel wall thickness should yield optimum welds. Therefore, a laser operating near 1.9 microns is suitable for small vessel welding.

Arterial laser welding with a 1.9 micrometer Raman-shifted laser

A new 1.9 micron Raman-shifted neodymium:yttrium aluminum garnet (Nd:YAG) laser was used for small vessel welding. Bursting pressures and stresses of sutured and laser-welded arteriotomies created in the rat femoral artery and aorta were measured. Sutured arteriotomies had a significantly higher burst stress than laser-welded arteriotomies. Although there were no significant differences in burst stress at the various laser powers tested, an optimal power was identified. The laser was also used to weld transected rat aortas. The average power delivered was 200 mW for 30 seconds per anastomosis. The average time for completing an anastomosis was 6 minutes compared with 18 minutes when sutures were used. In relation to proximal aortic diameter, there was a 7.9% decrease at the anastomosis immediately (n = 4), and a 6.6% and 4.9% increase occurred at 24 hours (n = 4) and 10 weeks (n = 5), respectively. Acute anastomotic compliance, and compliance at 24 hours and 10 weeks were decreased by 47.2%, 39.5%, and 47.8%, respectively, and were similar to sutured anastomoses. Histology showed little thermal denaturation of the aorta within 0.6 mm of the anastomosis, approximately 1 mm of medial cell death, and nearly normal elastic fiber alignment. One focal false aneurysm was noted at 10 weeks. Although the sutured and laser-welded anastomoses share similar compliance changes, the laser-welded anastomoses are more isodiametric. This preliminary experience with the 1.9 micron laser shows the distinct advantages of a handheld fiber, no requirement for cooling irrigation, speed, and no difference in compliance from sutured anastomoses.

The impact of selective use of dipyridamole-thallium scans and surgical factors on the current morbidity of aortic surgery

Preoperative cardiac testing in patients undergoing vascular surgery remains controversial. We have advocated selective use of dipyridamole-thallium scans based on clinical markers of coronary artery disease before aortic surgery. The present study assessed both the efficacy of this policy and the role of surgical factors in the current morbidity of aortic reconstruction. Two hundred two elective aortic reconstructions (151 abdominal aortic aneurysms, 51 aortoiliac occlusive disease) performed in the period from January 1989 to June 1990 were reviewed. Preoperative dipyridamole-thallium scanning was performed in 29% of all patients, prompting coronary angiograms in 11% and coronary artery bypass grafting/percutaneous transluminal coronary angioplasty in 9% of patients before aortic reconstruction. The overall operative mortality rate was 2%, with one cardiac-related death. Major cardiac (nonfatal myocardial infarction, unstable angina) and pulmonary complications occurred in an additional 4% and 6%, respectively, of patients. Coronary artery disease clinical markers and surgical factors were analyzed with stepwise logistic regression for the prediction of operative mortality rates and major cardiopulmonary complications. Variables retaining significance in predicting postoperative death or cardiopulmonary complications included prolonged (more than 5-hour) operative time (p less than 0.004), operation for aortoiliac occlusive disease (p less than 0.010), and a history of ventricular ectopy (p less than 0.002). Prolonged operative time (p less than 0.006) and the detection of intraoperative myocardial ischemia (p less than 0.030) were predictive of major cardiac complications after univariate analysis.(ABSTRACT TRUNCATED AT 250 WORDS)

Patterns of porphyrin accumulation in response to chemicals in chick embryo liver cells

Four patterns of porphyrin accumulation were observed by high-pressure liquid chromatography when chemicals were added to chick embryo liver cells. These patterns provide a guide to the site of action of the chemicals. Protoporphyrin accumulated in response to 3,5-diethoxycarbonyl-1,4-dihydro-2,4,6-trimethylpyridine (DDC), a result consistent with its ability to inhibit ferrochelatase. Uroporphyrin and heptacarboxylic acid porphyrin accumulated in response to 3,3',4,4'-tetrachlorobiphenyl, 2,2',4,4',6,6'-hexachlorobiphenyl, and 3,5-diethoxycarbonyl-2,4,6-trimethylpyridine, a result suggesting inhibition of uroporphyrinogen decarboxylase. Coproporphyrin was the major porphyrin to accumulate in response to allylisopropylacetamide, aromatic amides, and steroids, a result suggesting inhibition of coproporphyrinogen oxidase. A mixture of uroporphyrin, heptacarboxylic acid porphyrin and coproporphyrin accumulated in response to aromatic di- and mono-esters, aliphatic diesters, and aliphatic amides. The pattern observed after addition of excess delta-aminolevulinic acid (ALA) the endogenous substrate of the pathway to the cells was proto- greater than copro- greater than uro-porphyrin. This pattern resembled that produced by DDC but by none of the other chemicals. It was concluded that porphyrin accumulation can not be attributed solely to the induction of ALA-synthetase. It appears that porphyrin-inducing chemicals exert an additional effect on one or other of the enzymes of the heme biosynthetic pathway.

Alterations in the heme biosynthetic pathway as an index of exposure to toxins

Under normal circumstances the heme biosynthetic pathway is carefully controlled and porphyrins are formed in only trace amounts. When control mechanisms are disturbed by xenobiotics, porphyrins may be formed and serve as a signal of the interaction between a xenobiotic and the heme biosynthetic pathway. For example, porphyrinuria was an early manifestation of a hexachlorobenzene-induced porphyria outbreak in Turkey. In humans exposed to polybrominated biphenyls and to 2,3,7,8-tetrachlorodibenzo-p-dioxin the urinary porphyrin pattern was significantly different from normal in a large number of exposed individuals. The question is raised whether measurement of urinary porphyrin profiles by improved methods will enable an estimate to be made of the extent of exposure to haloaromatic hydrocarbons in the human population. A wide variety of xenobiotics interact with the prosthetic heme of cytochrome P-450 forming novel N-alkylporphyrins. Identification of these N-alkylporphyrins in body fluids might provide a means of assessing exposure to a variety of xenobiotics in human populations.

Second derivative-high-performance liquid chromatographic-fluorometric detection of porphyrins in chick embryo liver cell culture medium

A high-performance liquid chromatographic system is described which is suitable for the separation and quantitative determination of a mixture of porphyrin esters in nanogram quantities from the culture medium used for maintenance of a monolayer culture of chick embryo liver cells. The desired sensitivity was obtained by coupling a high-performance liquid chromatograph with a second derivative-fluorometric detection system. The most effective method for preparation of the porphyrin methyl esters prior to chromatography was found to be lyophilization of the culture medium prior to esterification with 5% sulphuric acid in methanol.