Open surgery for abdominal aortic aneurysms at the present stage
AbstractBackground. Currently, open operation of aortic prosthetic repair for abdominal aortic aneurysms remains one of the main methods of treatment, making it possible to achieve sustainable. However, the approaches to obligatorily performing separate stages of the perioperative management and separate stages of the operation itself seem far from being standardized.
Objective. The purpose of this study was to work out a specific, obligatory-to-perform technology of open prosthetic repair for an abdominal aortic aneurysm, to be associated with both a minimal rate of intraoperative complications and long-term favorable postoperative outcomes.
Patients and methods. Our single-center retrospective and prospective cohort study included a total of 284 elective patients presenting with an abdominal aortic aneurysm and subjected to open prosthetic repair. Depending on the technology of managing the perioperative period and the technical aspects of surgery, the patients were divided into two groups. Group 1 (retrospective) comprised 89 patients with abdominal aortic aneurysms treated by elective AAA repair according to the generally accepted intrasaccular method known as endoaneurysmorrhaphy. There was no unified strategy of the perioperative management and performing separate stages of the operation in patients of this group. Group 2 (prospective) was composed of 195 patients with abdominal aortic aneurysms, who underwent elective prosthetic repair according to the worked-out technique with aneurysmal sac reduction. The perioperative management and compulsory-to-perform separate stages of the operation were standardized.
Results. Statistically significant differences were obtained for the frequency of cardiac (p<0.001) and respiratory complications (p=0.009), as well as acute renal damage (p=0.007). Also, a statistically significant difference was observed between the two groups in the volume of intraoperative blood loss (p<0.001). The remote results were followed-up for 14 years. The frequency of reoperations amounted to 2.7%, accounting for either stent-branch thrombosis or the development of an aneurysm of the distal graft-femoral anastomosis. No aneurysms of the proximal anastomosis were revealed.
The operation of open repair for abdominal aortic aneurysms remains one of the main methods of treatment. Strictly complying with the clear-cut technology of the intraoperative management and performing the stages of the operation itself made it possible to statistically significantly decrease the volume of intraoperative blood loss, the amount of required transfusion of blood substitutes, postoperative complications, and to increase freedom from reoperation in the remote period.
Funding. The study had no financial support.
Conflict of interest. The authors declare no conflicts of interest.
Authors’ contribution. Study conception and design – Vachev A.N.; data collection and handling – Vachev A.N., Chernovalov D.A., Dmitriev O.V., Italiyantsev A.Yu., Kozin I.I., Gryaznova D.A., Kutsenko V.V., Andreeva Yu.V., Akhmedkhanova S.N.; statistical processing – Chernovalov D.A., Kozin I.I.; draft manuscript preparation – Chernovalov D.A., Kozin I.I.; manuscript revision – Vachev A.N.
For citation: Vachev A.N., Chernovalov D.A., Dmitriev O.V., Italiyantsev A.Yu., Kozin I.I., Gryaznova D.A., Kutsenko V.V., Andreeva Yu.V., Akhmedkhanova S.N. Open surgery for abdominal aortic aneurysms at the present stage. Angiology and Vascular Surgery. Journal named after Academician A.V. Pokrovsky. 2024; 30 (1): 41–52. DOI: https://doi.org/10.33029/1027-6661-2024-30-1-41-52
Keywords: abdominal aortic aneurysm; aortic prosthetic reconstruction; endoprosthetic aortic repair; aneurysmal sac reduction; open aortic surgery
References
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26. Jenkins M.P. Standard EVAR Can Be Used in Most Challenging Necks: Against the Motion. European Journal of Vascular and Endovascular Surgery. 2021; 62 (5): 680–681. DOI: https://doi.org/10.1016/j.ejvs.2021.07.020
Частота дыхательных осложнений зависит от исходного состояния больного, длительности ИВЛ [11, 12]. Курильщиками были 83,8% больных, вошедших в данное исследование, 57% больных имели ХОБЛ той или иной степени выраженности. Переход к тактике начала операции под эпидуральным блоком и возможность выполнения всей операции без интубации оказались достаточными у 149 (52,5%) больных. Интубация трахеи выполнена 47,5% больных. Статистической разницы в группах по этому показателю не было (p=0,229). Однако невозможно игнорировать статистическое различие по количеству дыхательных осложнений в 1-й и 2-й группах - 29,2 и 15,9% соответственно (р=0,009). Эта разница оказалась сопряжена с продленной ИВЛ (р=0,004) и развитием ателектаза (р=0,013). Важно отметить, что необходимость в продленной ИВЛ возникала у больных с большей интраоперационной кровопотерей и более массивной гемотрансфузией.
Причинами острой ишемии нижних конечностей при операции протезирования аорты чаще всего является эмболия [20]. Всего ишемия нижней конечности развилась у 13 (4,6%) больных, ампутация выполнена 1 (0,3%) больному. С целью уменьшения вероятности эмболии из аневризматического мешка в дистальные отделы при методике его редукции первым этапом мы перевязываем общие подвздошные артерии.
По данным литературы, в отдаленном периоде после операции развитие аневризмы проксимального анастомоза может достигать 12% [21]. В отдаленном периоде спустя 10 лет и более после операции ни у одного из оперированных нами больных не выявлено аневризмы проксимального анастомоза. Мы считаем, что формирование проксимального анастомоза по представленной методике с укреплением этой зоны телескопической манжетой позволяет значительно уменьшить количество аневризм проксимального анастомоза, не связанных с инфекцией протеза, и дает свободу от реопераций.
В выполненном исследовании за 14 лет послеоперационного наблюдения общее количество реопераций составило 2,7%, что следует признать одним из основных параметров, улучшающих качество жизни больных после операции по поводу АБА. При этом у 69% больных, вошедших в данное исследование, длина шейки составляла менее 10 мм. Как правило, при таком размере проксимальной шейки аневризмы она также имеет коническую форму. Это 2 из 5 определенных критериев неблагоприятной проксимальной шейки аневризмы аорты, при наличии которых стандартная процедура эндопротезирования аорты сопряжена с повышенным риском осложнений [22]. А в среднесрочной и долгосрочной перспективе у таких больных после EVAR многократно увеличивается необходимость повторных вмешательств и возрастает смертность от причин, связанных с аортальными событиями. Общее же количество разных реопераций после EVAR достигает 15-20%. Кроме того, все больные должны регулярно проходить контрольные исследования [23-26]. И именно по показателю "свобода от реопераций" открытая хирургия при АБА на современном этапе выглядит предпочтительнее EVAR.
Заключение
Операция открытого протезирования при АБА остается одним из основных методов лечения. Следование четкой технологии периоперационного ведения и выполнения самой операции - один из залогов благоприятного исхода и отсутствия необходимости частых послеоперационных исследований.
Использование для открытой операции у больного с АБА предложенной методики редукции аневризмы и укрепления зоны проксимального анастомоза манжетой в сочетании с ранней целенаправленной коррекцией коагулопатии потребления позволяет статистически значимо уменьшить объем интраоперационной кровопотери, необходимой трансфузии кровезаменителей, послеоперационных осложнений и свободу от реоперации в отдаленном периоде.
Литература
1. National vascular registry 2018 annual report. Available from: http://www.vsqip.org.uk/reports/2018-annual-report/ Accessed on 15 July 2019.
2. Schermerhorn M.L., Buck D.B., O’Malley A.J., et al. Long-term outcomes of abdominal aortic aneurysm in the Medicare population. New England Journal of Medicine. 2015; 373 (4): 328-338. DOI: https://doi.org/10.1056/NEJMoa1405778
3. Patel R., Sweeting M.J., Powell J.T., Greenhagh R.M. EVAR trial investigators. Endovascular versus open repair of abdominal aortic aneurysm in 15-years follow-up of the UK endovascular aneurysm repair trial 1 (EVAR trial 1): a randomized controlled trial. Lancet. 2016; 388 (10058): 2366-2374. DOI: https://doi.org/10.1016/S0140-6736(16)31135-7
4. Aburahma A.F., Campbell J.E., Mousa A.Y., et al. Clinical outcomes for hostile versus favorable aortic neck anatomy in endovascular aortic aneurysm repair using modular devices. Journal of Vascular Surgery. 2011; 54 (1): 13-21. DOI: https://doi.org/10.1016/j.jvs.2010.12.010
5. Patel S.R., Ormesher D.C., Griffin R., et al. Comparison of Open, Standard and Complex Endovascular Aortic Repair Treatments for Juxtarenal/Short Neck Aneurysms: A Systematic Review and Network Meta-Analysis. European Journal of Vascular and Endovascular Surgery. 2022; 63 (5): 696-706. DOI: https://doi.org/10.1016/j.ejvs.2021.12.042
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8. Hoornweg L.L., Storm-Versloot M.N., Ubbink D.T., et al. Meta-analysis on mortality of ruptured abdominal aortic aneurysms. European Journal of Vascular and Endovascular Surgery. 2008; 35 (5): 558-570. DOI: https://doi.org/10.1016/j.ejvs.2007.11.019
9. Karthikesalingam A., Vidal-Diez A., Holt P.J., et al. Thresholds for abdominal aortic aneurysm repair in England and the United States. New England Journal of Medicine. 2016; 375 (21): 2051-2059. DOI: https://doi.org/10.1056/NEJMoa1600931
10. De Freitas S., Hicks C.W., Mouton R., et al. Effects of ischemic preconditioning on abdominal aortic aneurysm repair: a systematic review and meta-analysis. Journal of Surgical Research. 2019; 235: 340-349. DOI: https://doi.org/10.1016/j.jss.2018.09.049
11. Smetana G.W., Lawrence V.A., Cornell J.E. Preoperative pulmonary risk stratification for non-cardiothoracic surgery: review for the American College of physicians. Annals of Internal Medicine. 2006; 144 (8): 581-595. DOI: https://doi.org/10.7326/0003-4819-144-8-200604180-00009
12. Bardia A., Sood A., Mahmood F., et al. Combined epidural-general anesthesia vs general anesthesia alone for elective abdominal aortic aneurysm repair. JAMA Surgery. 2016; 151 (12): 1116-1123. DOI: https://doi.org/10.1001/jamasurg.2016.2733
13. Lee S., Park D., Ju J., et al. Relationship between intraoperative dopamine infusion and postoperative acute kidney injury in patients undergoing open abdominal aorta aneurysm repair. BMC Anesthesiology. 2022; 22 (1): 1-9.
14. Wald R., Waikar S.S., Liangos O., et al. Acute renal failure after endovascular vs open repair of abdominal aortic aneurysm. Journal of Vascular Surgery. 2006; 43 (3): 460-466. DOI: https://doi.org/10.1016/j.jvs.2005.11.053
15. Novotny T., Staffa R., Tomandl J., et al. I-lactate kinetics after abdominal aortic surgery and intestinal ischemia - An observational cohort study. International Journal of Surgery. 2022; 98: 106220. DOI: https://doi.org/10.1016/j.ijsu.2021.106220
16. Bjӧrck M., Troeng T., Bergqvist D. Risk factors for intestinal ischaemia after aortoiliac surgery: a combined cohort and case-control study of 2824 operations. European Journal of Vascular and Endovascular Surgery. 1997; 13 (6): 531-539. DOI: https://doi.org/10.1016/s1078-5884(97)80061-5
17. Вачёв А.Н., Грязнова Д.А., Дмитриев О.В. и др. Кардиопротекция при выполнении операции протезирования брюшного отдела аорты при аневризме. Наука и инновации в медицине. 2019; 4 (2): 66-69. DOI: https://doi.org/10.35693/2500-1388-2019-4-2-66-69
18. Вачев А.Н., Труханова И.Г., Гуреев А.Д. Коррекция коагулопатии потребления у пациентов при открытых операциях на брюшном отделе аорты. Ангиология и сосудистая хирургия. 2013; 19 (3): 117-122.
19. Siribumrungwong B., Kurita J., Ueda T., et al. Outcomes of abdominal aortic aneurysm repairs: Endovascular vs open surgical repairs. Asian Journal of Surgery. 2022; 45 (1): 346-352. DOI: https://doi.org/10.1016/j.asjsur.2021.06.015
20. Davidovic L.B., Maksic M., Koncar I., et al. Open repair of AAA in a high volume center. World Journal of Surgery. 2017; 41 (3): 884-891. DOI: https://doi.org/10.1007/s00268-016-3788-3
21. Sachdev U., Baril D.T., Morrissey N.J., et al. Endovascular repair of para-anastomotic aortic aneurysms. Journal of Vascular Surgery. 2007; 46 (4): 636-641. DOI: https://doi.org/10.1016/j.jvs.2007.05.032
22. Marone E.M., Freyrie A., Ruotolo C., et al. Expert Opinion on Hostile Neck Definition in Endovascular Treatment of Abdominal Aortic Aneurysms (a Delphi Consensus). Annals of Vascular Surgery. 2020; 62: 173-182. DOI: https://doi.org/10.1016/j.avsg.2019.05.049
23. Antoniou G.A., Georgiadis G.S., Antoniou S.A., et al. A meta-analysis of outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile and friendly neck anatomy. Journal of Vascular Surgery. 2013; 57 (2): 527-538. DOI: https://doi.org/10.1016/j.jvs.2012.09.050
24. AbuRahma A.F., Yacoub M., Mousa A.Y., et al. Aortic neck anatomic features and predictors of outcomes in endovascular aortic aneurysms following vs not following instructions for use. Journal of the American College of Surgeons. 2016; 222 (4): 579-589. DOI: https://doi.org/10.1016/j.jamcollsurg.2015.12.037
25. Pitoulias G.A., Valdivia A.R., Hahtapornsawan S., et al. Conical neck is strongly associated with proximal failure in standard endovascular aneurysm repair. Journal of Vascular Surgery. 2017; 66 (6): 1686-1695. DOI: https://doi.org/10.1016/j.jvs.2017.03.440
26. Jenkins M.P. Standard EVAR Can Be Used in Most Challenging Necks: Against the Motion. European Journal of Vascular and Endovascular Surgery. 2021; 62 (5): 680-681. DOI: https://doi.org/10.1016/j.ejvs.2021.07.020
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