Abdominal Aortic Aneurysms
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DOCTOR OF MEDICAL SCIENCE DANISH MEDICAL BULLETIN Abdominal aortic aneurysms Screening and prognosis Jes Sanddal Lindholt This review has been accepted as a thesis together with seven previously published papers by University of Aarhus June 2010 and VII: Lindholt JS. Relatively high pulmonary and defended on 5th of November 2010 cardiovascular mortality rates in screening-detected aneurysmal patients without previous hospital Official opponents: Torsten Toftegaard Nielsen and Torben Jørgensen admissions. Correspondence: Department of Vascular Surgery, Viborg Hospital, Eur J Vasc Endovasc Surg. 2007;33:94-9. Postbox 130, DK-8800 Viborg ACKNOWLEDGEMENTS E-mail: [email protected] The Danish National Research Council, the Danish Heart Foundation, the Foundation of Rosa and Asta (12)B4219 Dan Med Bull 2010;57: Jensen, and later the Foundation of Research in The present thesis is based on the following Western Denmark and Viborg County are thanked for published papers, which will be referred to in the text financial support by their Roman numerals: HISTORIC VIEW OF THE MANAGEMENT OF AAA I. Lindholt JS, Juul S, Fasting H, Henneberg EW. Screening for AAA: single centre randomised One could say that abdominal aortic aneurysm controlled trial. BMJ 2005;330:750-754. (AAA) surgery began with the first attempts to control bleeding vessels by ligation. The great surgeon of II. Lindholt JS, Juul S, Henneberg EW. High-risk and ancient India, Sushruta (approx. 800-600 BC), was the Low-risk Screening for AAA Both Reduce Aneurysm- first to ligate bleeding vessels with hemp fibres[2]. related Mortality. A Stratified Analysis from a Single- However, Antyllus, a second-century surgeon from centre Randomised Screening Trial. Eur J Vasc ancient Greece, was the first to describe the anatomy Endovasc Surg. 2007;34:53-8. and treatment of aneurysms. He described two sorts of aneurysmal lesions: those originating from a local III. Lindholt JS, Sørensen J, Søgaard R, Henneberg arterial dilatation, which were cylindrical, and those EW. Benefit and cost effectiveness analysis of screening arising from trauma, which were rounded. He precisely for AAA based on 14 years results from a single-centre described proximal and distal ligation and even randomised controlled trial. Br J Surg 2010; accepted evacuation of the aneurismal sac[3], a technique which was to be forgotten for 17 centuries until Astley IV: Lindholt JS. Aneurysmal wall calcification Cooper in 1817 ligated the aortic bifurcation in a 38- predicts natural history of small AAA. Atherosclerosis year-old man named Charles Hudson due to a 2008; 197;673-678 ruptured iliac aneurysm. Cooper knew the presence of the aneurysm and described it as having been steadily V. Lindholt JS, Jorgensen B, Shi GP, Henneberg EW. increasing during the last year and doubled in size 3 Relationships between activators and inhibitors of days before surgery. Shortly after admission, the plasminogen, and the progression of small AAA. Eur J aneurysm ruptured through the skin. Cooper made a Vasc Endovasc Surg. 2003;25:546-51. transperitoneal incision and placed a silk ligature just above the aortic bifurcation, while Hudson was still in VI: Lindholt JS, Stovring J, Ostergaard L, bed. Hudson appeared remarkably well the following Urbonavicius S, Henneberg EW, Honore day, but died 40 hours postoperatively[4]. More than B, Vorum H. Serum antibodies against Chlamydia 100 years later, Rudolph Matas performed the first pneumoniae outer membrane protein cross-react with successful ligation of the aorta in April 1923. The patient the heavy chain of immunoglobulin in the wall of was a 28-year-old woman with a ruptured syphilitic abdominal aortic aneurysms. Circulation. aneurysm at the aortic bifurcation. She survived and 2004;109:2097-102 lived 17 months before dying of tuberculosis[5]. Nevertheless, ligation never became a gold standard of treatment due to discouraging results. DANISH MEDICAL BULLETIN 1 Probably inspired by this first aortobiiliac bypass, the first repair of an AAA was also performed in Paris shortly after. In March 1951, Charles Dubost used a 14-cm-long preserved thoracic aorta from a young accident victim to replace an AAA in a 50 year-old man. Through a thoracoabdominal incision, the homograft was anastomosed to the aorta and the right common iliac artery, and the left common iliac artery was anastomosed end-to-side to the homograft[9] [Figure 1]. The patient survived and lived for another 8 years before dying of myocardial infarction in his home in Brittany. Dubost was a pioneer in several fields; the same year he attempted the first renal transplantation – probably without consent from the donor of the kidney - a just guillotined criminal! He encouraged one of his pupils, Alain Carpentier, to develop a prosthetic heart valve, and in 1968 Carpentier implanted the first artificial heart valve in humans at his institution. The same year, Dubost successfully performed the first European heart transplantation[8]. Dubost´s operation in 1951 chocked the vascular surgical world, and prominent surgeons like DeBakey and Szilagyi rapidly adapted the procedure. However, the enthusiasm of homografts disappeared rapidly due to degenerative changes which made many of them short-lived. From 1948, Arthur Voorhees was donated vinoyn-N cloths for parachutes from the US Air Force to explore the potential of using artificial grafts in animals. However, in 1952 an elderly man was admitted to the Figure 1. Postoperative arteriography of the first AAA resection Columbia Hospital in New York with a ruptured AAA. and vascular reconstruction performed by Dubost[9] The artery bank in New York was empty, so Voorhees rushed to his laboratory one floor above the operation In 1944, Clarence Crafford from Sweden resected theatre and constructed a tube graft of vinoyn-N on his an aortic coarctation in a 12-year-old boy and in a 37- sewing machine, autoclaved it and made a successful year-old man. In both cases, the aorta was repaired implantation. Unfortunately, the patient died with an end-to-end anastomosis, and both patients postoperatively due to myocardial infarction, but recovered well. Reestablishment of the aortic stimulated by the initial success, the group started circulation in humans had now been proven feasible, electively to implant vinoyn-N tubes in humans[10]. In and the next mountain to climb was to bridge large 1954, the group published relatively attractive gaps of aorta[6]. outcomes of 17 AAA resections in humans with In 1948, Gross showed the way by using small implantation of vinoyn-N tubes [11]. preserved arterial grafts in humans with aortic One of the first patients being offered such repair of coarctation, but the real breakthrough happened in an AAA was the famous Nobel-prize taker from 1921, Paris in November 1950, where Jacques Oudot Professor Albert Einstein. Unfortunately, he considered replaced an occluded aortic bifurcation. He used an the operative risk to be too high, and died in New York aortic allograft from a young victim of an accident. of ruptured AAA in 1955[12]. Rapidly, the procedure Persistent ischemia of the right leg forced him to place dispersed world wide, and the first reported operation a second homograft from the left to the right external for AAA was performed in Denmark in 1961[13]. iliac artery. Hereafter, the patient recovered well[7]. In 1970, Charles de Gaulle died due to sudden Such a breakthrough had to be performed by a person rupture of an unknown AAA. This risk of rupture without with a highly developed sense of adventure, and warning symptoms, and the development of portable indeed Oudot was an adventurer; some months before ultrasonographic equipment stimulated in 1984 Alan the operation, he participated in the first Ascent of Scott in the South of England to explore the potential Annapurna in the Himalayas. During the course of this benefits of screening for AAAs[14]. About twenty years expedition, he experimented with intra-arterial later the definitive evidence of benefit was reported by injections of vasodilatators to treat frostbite. him and his colleagues in the randomised Multicentre Unfortunately, he died in 1953 after a fatal crash in his Aneurysms Screening Study [MASS][15] followed by a highly powered sports car on his way to skiing in recommendation for nation-wide screening in the UK Chamonix, only 40 years old[8]. by the National Screening Committee in 2006. In DANISH MEDICAL BULLETIN 2 Denmark, a population screening trial for AAAs started the specific major aims of the present work in this in Viborg in 1994[16][I]. phesis, which were planned to be: The next breakthrough in the battle against AAAs 1. To determine the feasibility of a Danish hospital happened in 1990. After successful animal experiments, based screening programme of 64-73 year old men, Juan Parodi attempted endovascular repair of a their attendance proportion to screening, the human AAA in Buenos Aires using a hand-made tube prevalence and incidence of asymptomatic AAA, and graft[17]. the potential need for interval screening. The incidence In Denmark, the first reported endovascular of ruptured AAA and AAA-related mortality in Danish prosthesis was implanted in 1996 in Viborg[18]. men aged 64-73, and in particular to analyse whether In 1999, the first fenestrated endograft was used to hospital-based mass screening for AAA reduces AAA seal a proximal endoleak[19]. Even today, the use of related mortality after five years. endovascular repair remains controversial because the 2. To assess risk factors for AAA and perform a ends of the stent cannot be securely anchored to the stratified analysis in the above mentioned randomised aortic wall and are thus at risk of leaking with renewed population screening trial for AAA in men, with or risk of rupture. However, in 2005 the first endostapling without hospital diagnoses of chronic obstructive graft was implanted by Takoa Ohki.