В.Княжев, Д.Големанов

Knyazhev V., Golemanov D.

SATURELESS ANASTOMOSIS IN ABDOMINAL AORTIC ANEURYSMS.

SOMEWHERE BETWEEN OPEN SURGERY AND ENDOVASCULAR TECHNIQUE

Vascular Surgery Clinic, MBAL “St.Anna”,

Medical University

Varna, Bulgaria

Background: The rapid advance of the endovascular treatment in cases of abdominal aortic aneurysms is undoubted. In spite of this, a number of complications reported in the last few years give a proof of the imperfection of the contemporary stent-prostheses. What is more, they can’t be used in cases of juxtarenal aneurysms, stenotic or significantly deviated iliac and subclavian arteries, etc. And if in case of failure during elected operation one can proceed to open surgery, the waste of time for unsuccessful attempts to lead in the stent-prosthesis in patients with ruptured aneurysm (sometimes under the circumstances of the simple resources of some health centres) can bring along dramatic results. Does this conclusion mean unpreventable use of only conventional reconstructions in such cases or there is a possibility for their improvement?

Aims: It’s the use of the invented and submitted by us device for intralumenal sutureless connection between the aorta and the artificial vascular graft, which allows maximum reduction of the aortic cross-clamping time. The device is a wide and thin titanium ring of special shape, ensuring its reliable fixing by ligatures to the aortic and graft walls.

Material and methods: For the period 1993-2003 we used this technique in 58 cases (53 men, 5 women) of abdominal aortic aneurysm, 27 of them elected operations and 31 ruptured. The age was 58 to 86 years (68.8 mean), aneurysm size - 5.5 to 12.3 cm.

Of all patients with ruptured aneurysms 18 were in hemorrhagic shock, 25 with prolonged anuria.

All patients except three had high blood pressure, 12 had medical history of heart attack or cerebral stroke.

Diagnosis was specified by Duplex-Doppler scanning and in planned surgery also by computed (incl. spiral) tomography. The aneurysm in 15 cases was juxtarenal with a neck less than 1 cm. The access was laparotomia. Sutureless technique was used in all 58 cases for the proximal anastomosis and in 12 – for the distal. In a case of aneurysm of the aorta and both iliac arteries all three anastomoses were completed successfully by the sutureless technique. Straight graft was used in 42 cases, bifurcated – in 16 (10 patients with iliac arteries anastomoses).

Results: Creation of sutureless proximal anastomosis needed in 52 patients 4 to 6 min, in six – 9 to 18 min. The duration of the aortic cross-clamping was 10 to 42 min (25.6 mean). Not one case of suprarenal cross-clamping necessitated kidney protection. Blood loss during planned surgery was 310 to 780 ml (420 mean), in emergency – 600 to 1350 ml (860 mean). Average surgical time was 165 to 212 and 135 to 285 min respectively. Acute renal failure was registered in the early postoperative period in 7 patients but was affected by medication.

There was no mortality after elected surgery. In the group of the ruptured aneurysms the results were as follows: intraoperative mortality – 0%; early postoperative mortality (to the 48^th hour) – 16.1% (5 patients); hospital mortality (to the 30^th day) – 9.7% (3 patients); total – 25.7% (8 patients).

In a period of 6 months to 11 years complications such as thrombosis, stent migration, aortic cut through or infection were not registered. 10 patients died 2 to 8 years after the operation because of other diseases.

Conclusion: The use of the device for sutureless connection between the aorta and the vascular graft reduces the aortic cross-clamping time to 20-50 min, shortens the operation itself and reduces the blood loss, which decreases the postoperative mortality. The use of this technique is appropriate in cases of high risk patients and when there is rupture of the aortic aneurysm.

Key Words: Aortic aneurysm, sutureless technique for vascular anastomoses.