Inflammatory abdominal aortic aneurysms: A case-control study

AbstractPurpose: This study was designed to identify significant differences in the clinical and radiologic characteristics and outcome between patients with inflammatory and noninflammatory abdominal aortic aneurysms (AAAs).Methods: We reviewed 29 consecutive patients who underwent repair of an inflammatory AAA between 1985 and 1994. This group was matched in a case-control fashion by date of surgery and by the performing surgeon to a group of 58 patients who underwent repair of noninflammatory AAAs.Results: The two groups had comparable characteristics of age, gender, and cardiovascular risk factors. Patients with inflammatory AAAs were significantly more symptomatic than those with noninflammatory AAAs (93% vs 9%, p < 0.001), were more likely to have a family history of aneurysms (17% vs 1.5%, p = 0.007), and tended to be current smokers (45% vs 24%, p = 0.049). Thi most significant laboratory difference was an elevated sedimentation rate in patients with inflammatory AAAs (mean, 53 mm/hr vs 12 mm/hr, p < 0.00001). Inflammatory AAAs also were significantly larger than noninflammatory AAAs at presentation (6.8 cm vs 5.9 cm, p < 0.05). Although operative mortality was low in both groups, patients with an inflammatory AAA tended to have higher morbidity, including sepsis ( p < 0.01) and renal failure ( p = 0.04). Five-year survival rates, however, were similar for the two groups (79% for inflammatory and 83% for noninflammatory AAAs). On follow-up computed tomographic scans, the retroperitoneal inflammatory process resolved completely in 53% of the patients, but 47% of patients had persistent inflammation that involved the ureters in 32% and resulted in long-term solitary or bilateral renal atrophy in 47%.Conclusions: This case-control study provides preliminary evidence that inflammatory AAAs may have a relatively strong familial connection and that current smoking may play an important role in the inflammatory response. The study also documents that persistent retroperitoneal inflammation may be more prevalent than has been previously reported, and stresses the need for an improved understanding of the pathogenesis and long-term management of inflammatory AAAs. (J Vasc Surg 1996;23:860-9.

Reconstruction of the superior vena cava: Benefits of postoperative surveillance and secondary endovascular interventions

AbstractPurpose: Superior vena cava (SVC) reconstructions are rarely performed; therefore the need for surveillance and the results of secondary interventions are unknown. Methods: During a 14-year period 19 patients (11 male, 8 female; mean age 41.9 years, range 8 to 69 years) underwent SVC reconstruction for symptomatic nonmalignant disease. Causes included mediastinal fibrosis (n = 12), indwelling foreign bodies (n = 4), idiopathic thrombosis (n = 2), and antithrombin III deficiency (n = 1). Spiral saphenous vein graft (n = 14), polytetrafluoroethylene (n = 4), or human allograft (n = 1) was implanted. Results: No early death or pulmonary embolism occurred. Four early graft stenoses or thromboses (spiral saphenous vein graft, n = 2, polytetrafluoroethylene, n = 2) required thrombectomy, with success in three. During a mean follow-up of 49.5 months (range, 4.7 to 137 months), 95 imaging studies were performed (average, five per patient; range, one to 10 studies). Venography detected mild or moderate graft stenosis in seven patients; two progressed to severe stenosis. Two additional grafts developed early into severe stenosis. Four of 19 grafts occluded during follow-up (two polytetrafluoroethylene, two spiral saphenous vein graft). Computed tomography failed to identify stenosis in two grafts, magnetic resonance imaging failed to confirm one stenosis and one graft occlusion, and duplex scanning was inconclusive on graft patency in 10 patients. Angioplasty was performed in all four patients with severe stenosis, with simultaneous placement of Wallstents in two. One of the Wallstents occluded at 9 months. Repeat percutaneous transluminal angioplasty was necessary in two patients, with placement of Palmaz stents in one. Only one graft occlusion and one severe graft stenosis occurred beyond 1 year. The primary, primary-assisted, and secondary patency rates were 61%, 78%, and 83% at 1 year and 53%, 70%, and 74% at 5 years, respectively. Conclusions: Long-term secondary patency rates justify SVC grafting for benign disease. Postoperative surveillance with contrast venography is indicated in the first year to detect graft problems. Endovascular techniques may salvage and improve the patency of SVC grafts. (J Vasc Surg 1998;27:287-301.