The contrary position to the nonresective treatment for abdominal aortic aneurysm

Abstract

The operative mortality rate for abdominal aortic aneurysm resection remains high (20% to 66%) for high-risk patients. The high-risk factors are severe cardiac, respiratory, and renal insufficiency and morbid obesity. Those advocating the alternative nonresective treatment of aneurysm thrombosis and axillofemoral bypass grafts have reduced the operative mortality rate to between 0% and 7%. However, in a collective series of 87 patients, there was a mortality rate of 10.3% in the patients with aortic aneurysms treated by the nonresective method and an incidence of reoperation for complications of axillofemoral graft of 31.0%. Many of these patients had subsequent operations and/or radiologic procedures to complete the process of aneurysm thrombosis (23.0%). Because there is an increasing trend toward this method of treatment, we reviewed our experience with the conventional aneurysm resection in a similar group of patients. Of 105 consecutive patients, 19 qualified as high risk. One patient died, resulting in an operative mortality rate of 5.2%. Cerebral, cardiac, and renal morbidity was transient and subsequent operations were not required. Eighteen patients were discharged as well. In the remaining 86 patients, one died, resulting in an operative mortality rate of 1.2%. The mortality rate for the entire series was 1.9%. Indications for the nonresective treatment appear to be increasing by the addition of other risk factors. This trend is of concern. We believe that there are limited indications for the treatment of aortic aneurysms without resection. However, the procedure should not be offered lightly as an alternative form of treatment.

Surgical management of abdominal aortic aneurysm

“…Even though there are advocates for alternative operations such as ligation with axillo-femoral bypass in these patients, these operations have not been proven effective in preventing rupture of the AAAs, although they are associated with a reduced operative mortality. [31][32][33][34] Endovascular grafting of AAAs appears to be a logical and appealing alternative in the treatment of this group of patients but must be considered experimental at this stage and should be assessed against the established treatment of operative repair. [35][36][37][38] For the high-risk patients, the treatment alternatives include watchful waiting (which carries the risk of rupture) and operative repair (with its almost prohibitive operative mortality).…”

Occluding aortic endoluminal stent graft combined with extra-anatomic axillofemoral bypass as alternative management of abdominal aortic aneurysms for patients at high risk with complex anatomic features: A preliminary report

“…This method of treatment has been shown to improve life expectancy, though the overall elective mortality rate is between 2% and 5%. [3][4][5][6] Endoluminal management of AAA has been proposed as an alternative to the standard procedure for patients at high surgical risk. [7][8][9][10] The technique is transarterial placement of an aortic stent graft to exclude completely the aneurysmal sac.…”