Outcomes after surgical repair of abdominal aortic aneurysms in young patients

Abstracts

CONTEXTO: A presença de aneurisma da aorta abdominal (AAA) é rara em pacientes jovens. OBJETIVO: Avaliar os resultados da cirurgia do AAA em pacientes com idade < 50 anos. MÉTODOS: De junho de 1979 a janeiro de 2008, 946 pacientes foram operados eletivamente do AAA infrarrenal pelo primeiro autor. Desses, 13 pacientes (1,4%) tinham idade < 50 anos no momento da cirurgia. Foram analisadas as características demográficas e cirúrgicas bem como os resultados precoces e tardios da cirurgia nesses pacientes. RESULTADOS: A média de idade foi 46±3,4 anos (variando de 43 a 50 anos), sendo a maioria homens (76,9%), hipertensos (76,9%) e tabagistas (61,5%). Não ocorreu nenhum óbito perioperatório, e a morbidade cirúrgica atingiu dois pacientes (15,4%) (um paciente com infecção respiratória e outro com angina instável). O seguimento mediano foi de 85,5 meses, ocorrendo dois óbitos devido a cardiopatia isquêmica em um paciente e acidente vascular cerebral em outro, durante o seguimento. CONCLUSÃO: A cirurgia do AAA é um procedimento seguro com bons resultados a longo prazo, pois, em nosso estudo, apresentou mortalidade perioperatória nula e boa sobrevida a longo prazo.

Aneurisma da aorta abdominal; pessoas jovens; cirurgia

ORIGINAL ARTICLE

Outcomes after surgical repair of abdominal aortic aneurysms in young patients

Telmo P. Bonamigo^I; Márcio Luís Lucas^II; Lígia Caon Pereira^III

^IProfessor titular, Cirurgia Vascular, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil. Chefe, Serviço de Cirurgia Vascular, Irmandade Santa Casa de Misericórdia de Porto Alegre (ISCMPA), Porto Alegre, RS, Brazil

^IICirurgião vascular, ISCMPA, Porto Alegre, RS, Brazil

^IIICirurgiã vascular, ISCMPA, Porto Alegre, RS, Brazil

Correspondence

ABSTRACT

Background: Abdominal aortic aneurysms (AAA) are rare in young patients.

Objective: To evaluate outcomes after AAA repair in patients aged ≤50 years.

Methods: Between June 1979 and January 2008, 946 patients underwent elective repair for an infrarenal AAA performed by the first author. Of these, 13 patients (1.4%) were ≤50 years old at surgery. Demographic characteristics and surgical data were analyzed, as well as early and late outcomes after surgical intervention.

Results: Mean age was 46±3.4 years (ranging from 43 to 50 years). Most patients were men (76.9%), hypertensive (76.9%) and smokers (61.5%). Perioperative morbidity and mortality rates were low (15.4% and 0%, respectively); one patient had respiratory infection and another patient had unstable angina. Median follow-up was 85.5 months, and two patients died due to ischemic cardiopathy and cerebrovascular accident during the follow-up period.

Conclusion: AAA repair in young patients is a safe procedure, with good long-term results. In our study, there were no perioperative deaths, and a good long-term survival was observed.

Keywords: Abdominal aortic aneurysm, young people, surgery.

Introduction

Prevalence of abdominal aortic aneurysm (AAA) increases as age advances, occurring primarily in patients in the seventh and eighth decades of life.^1,2 There are relatively few studies on outcomes after vascular surgery in young patients, especially in patients with AAA.^3,4

Our objective was to evaluate outcomes after surgical repair of degenerative (atherosclerotic) AAA in patients aged ≤50 years, comparing the results with those obtained by other authors in the literature.

Methods

We reviewed medical records and protocols developed by the first author of patients who underwent elective repair for infrarenal AAA between June 1979 and January 2008. We collected data from patients aged ≤50 years, with degenerative AAA, submitted to surgery during this time period. Patients with congenital aneurysms, pseudoaneurysms, arteritis, suprarenal aneurysms, or mycotic aneurysms were excluded from the study.

Demographic characteristics and surgical data were abstracted from medical records and protocols. Follow-up consisted of scheduled appointments, telephone interviews or mail surveys requesting the patient's physician to fill out the questionnaire. Such approach allowed long-term follow-up and identification of the causes of late deaths.

Perioperative mortality and morbidity data were also reported. Perioperative complications were described according to Copeland et al.:⁵ Perioperative complications were described according to Copeland et al.:5 hemorrhage (surgical-wound or intra-abdominal), infection (surgical-wound, respiratory, urinary, septicemia), surgical-wound dehiscence, pulmonary thromboembolism, deep venous thrombosis of the lower limbs, stroke, acute myocardial infarction, ventilatory failure, heart failure, renal failure, vascular graft thrombosis, and ischemic colitis.

The data obtained were expressed as absolute and relative (percentage) values, mean and standard deviation of these values being calculated when necessary.

Results

A total of 946 patients underwent elective repair for infrarenal AAA between June 1979 and January 2008. We identified 13 patients (1.4%) aged ≤50 years, mean age was 46±3.4 years (ranging from 43 to 50 years). Ten patients were men (76.9%), 10 were hypertensive (76.9%), and 8 with a history of smoking (61.5%) (Table 1).

Table 1
– Comorbidities and demographic characteristics of patients aged ≤50 years submitted to abdominal aortic aneurysm repair

Comorbidities	n (%)
Proportion M/W	10/3
Mean age	46±3.4 years
Hypertension	10 (76.9)
Smoking	8 (61.5)
Ischemic cardiopathy*	3 (23.1)
COPD	2 (15.4)
Previous renal dysfunction†	1 (7.7)
Diabetes mellitus	0 (0)

Most patients (69.2%) presented with asymptomatic AAA at surgery. Among symptomatic patients (30.8%), 2 patients reported low back pain and 2 patients reported diffuse abdominal pain, but with no diagnosis of ruptured AAA. The highest mean aneurysm diameter was 5.6±1.5 cm (ranging from 3.5 to 9 cm), with iliac artery involvement in 2 cases (15.4%) and presence of inflammatory aneurysm in other 2 cases (15.4%).

As a complementary examination, plain abdominal radiographs were performed (n = 3), mainly in patients in the initial phase of study; color Doppler ultrasound (n = 5); aortography (n = 3); and abdominal computed tomography (n = 4).

All patients received general anesthesia, using transperitoneal approach for aortic surgery, often with an incision from the xiphoid process to the pubis (n = 12), with retroperitoneal approach in one patient. Mean operating time was 183.2±49.2 minutes (120-270 minutes), with mean aortic clamping time of 42.8±16.7 minutes (23-75 minutes). Aortic reconstruction included aorto-aortic (n = 5); aorto-biiliac (n = 5); left aorto-iliac and right aortofemoral (n = 5); and aortobifemoral (n = 2) anastomosis.

There were no perioperative deaths. Two patients presented complications (15.4%), one patient had respiratory infection and another patient had unstable angina. Mean preoperative creatinine levels (1.34±0.3 mg/dL) were not statistically different from postoperative levels (1.0±0.08 mg/dL) (p > 0.05).

Median follow-up was 85.5 months (ranging from 10 to 232 months). Follow-up data were available in 12 of 13 patients, data loss occurring only in one case (7.7%). Two patients died during the follow-up period: one patient due to acute myocardial infarction 64 months after surgery; and one patient due to stroke 60 months after surgery (Table 2).

Table 2
– Surgical outcomes in patients aged ≤50 years submitted to abdominal aortic aneurysm repair

Morbidity, n (%)	2 (15.4)
Causes	- Unstable angina - Respiratory infection
Mortality, n (%)	0
Median follow-up	85.5 months
Causes of late deaths (n)	- Acute myocardial infarction (n = 1) - Stroke (n = 1)

Discussion

Early atherosclerotic disease may affect patients aged ≤50 years. Manifestations include peripheral vascular disease, ischemic cardiopathy, and stroke.^6-8 Degenerative AAA is rare in young patients, and studies reporting outcomes after surgical treatment of such patients are scarce in the literature.^3,4

In the present study, we reported outcomes after AAA repair in a series of 13 young patients, in a total of 946 patients operated during the study period, accounting for a proportion of 1.4%, similar to the proportion of 1.6% found by Cherr et al.⁴ In our study, we included only patients with infrarenal degenerative AAA. In the study by Muluk et al.,³ in which 26 cases were reported, most patients (n = 20) had this aneurysm type.

It is believed that young patients have larger and more extensive aneurysms and are often more symptomatic than older patients. However, the study by Cherr et al.⁴ did show any differences in these parameters between young and older patients. In the study by Muluk et al.,³ the proportion of symptomatic patients at surgery was 46% in the group of young patients and 6.7% in the control group (p < 0.01). Still in that study, the authors found that aneurysmal involvement of proximal (suprarenal) aorta was three times more common among young patients.³ Despite the non-comparative design of this study, we observed a frequency of symptoms among young patients of 30.8%.

Apparently, the most prevalent risk factors for cardiovascular disease among young patients (hypertension and smoking) are the same reported among older patients. In the study by Cherr et al.,⁴ there were no statistically significant differences among risk factors (ischemic cardiopathy, hypertension, smoking, diabetes mellitus, previous renal failure) between young and older patients. In the study by Mingoli et al.,⁶ on the treatment of aorto-iliac occlusive disease in young patients, the authors found a higher frequency of smoking, hypertension, and dyslipidemia among young patients in comparison with older patients.

In our study there were no deaths, and complications affected only two patients (15.4%). The study by Cherr et al., with 19 patients, included three patients with ruptured AAA (16%) and two patients with suprarenal aneurysm (11%). Mortality rate in that study was 16%, with no statistical difference from the control group (9%).⁴ Complication rate in that same study was 41% among young patients (21% of major complications) and 35% in the control group (9% of major complications). In our study, complication rate was 15.4%.

Due to a good life expectancy among younger patients, we need to obtain good long-term results after surgery. In our study, only two patients died during the median follow-up period of 85.5 months, one patient due to ischemic cardiopathy and one patient due to stroke. In the study by Cherr et al.,⁴ the survival rate of young patients operated within a 3-year period was 73%, comparable to the group of older patients (69%). According to our results, cardiovascular disease manifestations were also the main causes of late death among young patients as reported by other authors.^4,7 According to our results, cardiovascular disease manifestations were also the main causes of late death among young patients as reported by other authors.⁹

Regarding surgical outcomes among young patients with other vascular diseases, Mingoli et al.⁶ and Harris et al.¹⁰ showed similar results in relation to shunt patency and long-term survival among young patients in comparison with older patients submitted to surgical intervention for aorto-iliac and infrainguinal occlusive disease, respectively. In the carotid disease, although younger patients presented higher prevalence of preoperative symptoms, there was no difference concerning survival and restenosis rates between young and older patients after carotid endarterectomy in the study by Martin et al.⁸

In conclusion, the occurrence of AAA is rare in young patients. In our study, there were no perioperative deaths after surgical procedures performed in these patients, with an acceptable complication rate and a good long-term survival. Manifestations of ischemic heart disease and cerebrovascular disease were the main causes of late death in our patients. A strict follow-up program with surveillance and treatment of risk factors for cardiovascular diseases may further improve long-term results after AAA repair in young patients.

References

• 1. Blanchard JF. Epidemiology of abdominal aortic aneurysms. Epidemiol Rev. 1999;21:207-21.
• 2. Pleumeekers HJ, Hoes AW, van der Does E, et al. Aneurysms of the abdominal aorta in older adults: the Rotterdam study. Am J Epidemiol. 1995;142:1291-9.
• 3. Muluk SC, Gertler JP, Brewster DC, et al. Presentation and patterns of aortic aneurysms in young patients. J Vasc Surg. 1994;20:880-6; discussion 887-8.
• 4. Cherr GS, Edwards MS, Craven TE, et al. Survival of young patients after abdominal aortic aneurysm repair. J Vasc Surg. 2002;35:94-9.
• 5. Copeland GP, Jones D, Walters M. POSSUM: a scoring system for surgical audit. Br J Surg. 1991;78:355-60.
• 6. Mingoli A, Sapienza P, Feldhaus RJ, di Marzo L, Burchi C, Cavallaro A. Aortoiliofemoral bypass graft in young adults: long-term results in a series of sixty-eight patients. Surgery. 1997;121:646-53.
• 7. Valentine RJ, Grayburn PA, Eichhorn EJ, Myers SI, Clagett GP. Coronary artery disease is highly prevalent among patients with premature peripheral vascular disease. J Vasc Surg. 1994;19:668-74.
• 8. Martin GH, Allen RC, Noel BL, et al. Carotid endarterectomy in patients less than 50 years old. J Vasc Surg. 1997;26:447-54; discussion 454-5.
• 9. Bonamigo TP, Lucas ML, Erling Jr N. Tratamento cirúrgico dos aneurismas da aorta abdominal: existe diferença nos resultados entre homens e mulheres? J Vasc Bras. 2006;5(2):101-8.
• 10. Harris LM, Peer R, Curl GR, Pillai L, Upson J, Ricotta JJ. Long-term follow-up of patients with early atherosclerosis. J Vasc Surg. 1996;23:576-80; discussion 581.

Publication Dates

• Publication in this collection
  02 Oct 2009
• Date of issue
  June 2009

History

• Accepted
  30 Mar 2009
• Received
  27 Apr 2008