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PAPERS: Paul E Norman, James B Semmens, Michael M D Lawrence-Brown, and C D'Arcy J Holman Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study BMJ 1998; 317: 852-856 [Abstract] [Full text]

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Surgical complications and outcome

Jack Grogan   (21 October 1998)

Long-term outcome in survivors of abdominal aortic aneurysm repair

A D Kelion   (17 February 1999)

Surgical complications and outcome 21 October 1998
Jack Grogan, Self employed Semi-Retired Send response to journal: Re: Surgical complications and outcome	During my recent surgery for "AAA" (Abdominal Aortic Aneurysm), a clamp slipped off the iliac artery and was not detected until after the aneurysm was incised. This resulted in blood fluid replacement of 11 units during the procedure. I did not see any reference in the Norman article to "surgical complications" in considering variables for 5 year survival rate of "AAA" patients. Are the authors or other readers aware of studies which have considered "surgical complications" as a variable. In reflecting on this question, I considered factors such as anoxia and interrupted blood flow to vital organs and the neuromuscular system, lapse of time while the anomaly was corrected, and effect on total elapsed time required to complete the procedure. My only "competing interest" is that I am a patient.
Long-term outcome in survivors of abdominal aortic aneurysm repair 17 February 1999
A D Kelion Send response to journal: Re: Long-term outcome in survivors of abdominal aortic aneurysm repair	Norman et al have demonstrated encouraging long-term results following abdominal aortic aneurysm (AAA) repair.[1] It is unfortunate however that the authors do not discuss the criteria used to select their patients for elective surgery. Following successful AAA surgery, long-term survival is dependent on the risk of cardiovascular events. If selection for surgery was based upon a low cardiovascular risk, the authors' results would be applicable only to this group and would shed no light on the prognosis for the wider population of patients with AAA. Much emphasis in the literature has been placed on screening methods to identify patients at high risk of perioperative cardiac events. This allows surgery to be avoided or at least deferred until coronary revascularisation has been performed. Several noninvasive imaging modalities have been suggested, including dipyridamole thallium-201 perfusion imaging and dobutamine stress echocardiography.[2] [3] In our institution, stress gated radionuclide ventriculography (RNV) is used to risk-stratify patients with no history of symptomatic cardiac disease prior to AAA repair. Between 1990-1995, 99 patients were studied (mean age 69<plusminus>8 years, 10 women). 81 underwent supine bicycle exercise, 11 drug stress, and 7 rest RNY only. 24 studies were abnormal (resting left ventricular ejection fraction less than 0.40, or failure to rise with stress); 14 patients did not proceed to AAA repair. 6 of the patients with abnormal RNV underwent coronary angiography prior to surgery. leading to CABG in 4. Cardiac events were either definite cardiac death or nonfatal myocardial infarction. Patients were followed up by GP questionnaire (mean 3.4 years, 72 for at least 2 years). Data were analysed using Kaplan-Meier survival curves (P by logrank test) and 2 year survival (P by chi-square test). Onll 1 patient, who had had a normal stress RNV, suffered a perioperative cardiac event. Stress RNV divided patients into low and high risk groups for long-term cardiac outlook (Figure; P=0.003). The 2 year event-rates for patients with normal and abnormal stress RNV results were 3/58 (5%) and 3/14 (21%) respectively (P=0.05), giving a sensitivity of 50% and a specificity of 830X). No clinical or exercise variable was predictive. We conclude that patients with AAA commonly have coronary artery disease. The identification of patients with an unfavourable long-term prognosis is particularly difficult when this process is occult. Noninvasive imaging provides prognostic information for individual patients. This is particularly important when considering surgery on prognostic grounds in asymptomatic patients identified by population screening. References 1 Norman PE, Semmens JB, Lawrence-Brown MMD, Holman CUM. Long term relative survival after surgery for abdominal aortic aneurysm in Western Australia: population based study. BMJ 1998; 317: 852-6. 2 Baron J-F, Mundler O, Bertrand M, Vicaut E, Barre E, Godet G et al. Dipyridamole-thallium scintigraphy and gated radionuclide angiography to assess cardiac risk before abdominal aortic surgery. N Engl J Med 1994; 330: 663-9 3 Poldermans D, Arnese M, Fioretti PM, Salustri A, Boersma E, Thomson IR et al. Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography. J Am Coll Cardiol 1995; 26: 648-53