Analysis and Prevention of Postoperative Complications of Abdominal Aortic Aneurysm Repair in High-Risk Patients_CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Authors：

CHI Kui , ZHAO Jichun

Center of Vascular Surgery and Endovascular Therapy， West China Hospital，Sichuan University， Chengdu 610041， Sichuan Province， China;

Corresponding author：

Keywords：

Abdominal aorta aneurysm; Postoperative complications; High-risk

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Objective 　To study the major postoperative complications of abdominal aortic aneurysm （AAA） repair in high-risk patients， analyze its causes， and suggest the prevention methods.
Methods 　From January 2009 to September 2011， 57 cases of high-risk AAA patients underwent AAA repair in our hospital were analyzed retrospectively. High-risk patients were defined as age≥60 years，the American Society of Anesthesiologists grade three or four，and at least one of complications about heart， lung， and kidney. Major postoperative complications were rated， and preoperative cardiac，pulmonary， and renal condition，anesthesia and surgical impact were taken into account while evaluating the risk factors of major postoperative complications.
Results 　Forty-one of 57 high-risk patients with AAA were repaired by endovascular repair，16 of 57 high-risk patients with AAA were repaired by traditional open surgery. The early mortality （within 30d） was 1.8% （1/57）. The major postoperative complications rate of AAA repair was 19.3% （11/57） in total，and 8.8% （5/57），8.8% （5/57），and 1.8% （1/57） for cardiac complication，pulmonary complication， and acute renal failure，respectively. The patients with coronary heart disease had a higher cardiac complication rate 〔19.0% （4/21） versus 2.8% （1/36），χ2=4.387，P＜0.05〕， while with hypertension had no such effect for that〔10.3% （4/39） versus 5.6% （1/18），χ2=0.340，P＞0.05〕. Patients with abnormal pulmonary function was responsible for postoperative respiratory complications 〔20.0% （4/20） versus 5.6% （1/18）， χ2=4.387， P＜0.05〕， while with chronic obstructive pulmonary disease history was not responsible for that 〔13.2% （5/38） versus 0 （0/19），χ2=2.740，P＞0.05〕．Patients with preoperative renal function was not related to postoperative acute renal failure 〔0 （0/4） versus 1.9% （1/53）， χ2=0.077，P＞0.05〕. Compared with traditional open surgery，endovascular repair could effectively reduce the incidence of postoperative complications 〔12.2% （5/41） versus 37.5% （6/16）， χ2=3.980，P＜0.05〕. The incidence of postoperative respiratory complications in the local anesthesia patients was less than that in the general anesthesia patients 〔0（0/20）versus 19.0% （4/21），χ2=4.221，P＜0.05〕.
Conclusions 　Cardiac and pulmonary complications are commonly seen after AAA repair in high-risk patients．Preoperative cardiac，pulmonary condition，anesthesia and surgical aspects greatly influence the major postoperative complications. Exhaustively assessment of each system before surgery，appropriate anesthesia and surgical options，postoperative active and effective symptomatic，and supportive treatment are the key to reducing the incidence of postoperative complications.

Citation： CHI Kui,ZHAO Jichun,.. Analysis and Prevention of Postoperative Complications of Abdominal Aortic Aneurysm Repair in High-Risk Patients. CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY, 2012, 19(5): 512-516. doi: Copy

1.	Dubost C， Allary M， Oeconomos N. Resection of an aneurysm of the abdominal aorta：reestablishment of the continuity by a preserved arterial graft， with result after five months [J]. Arch Surg， 1952， 64(3)：405-408.
2.	Wahlgren CM， Malmstedt J. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients：results from the Swedish Vascular Registry [J]. J Vasc Surg， 2008， 48(6)：1382-1388.
3.	Dindo D， Demartines N， Clavien PA. Classification of surgical complications：a new proposal with evaluation in a cohort of 6 336 patients and results of a survey [J]. Ann Surg， 2004，240(2)：205-213.
4.	Allaqaband S， Mortada ME， Tumuluri R， et al. Endovascular stent graft repair of abdominal aortic aneurysms in high-risk patients：a single center experience [J]. J Interv Cardiol， 2004，17(2)：71-79.
5.	Parodi JC， Palmaz JC， Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms [J]. Ann Vasc Surg， 1991， 5(6)：491-499.
6.	AbuRahma AF， Campbell J， Stone PA， et al. The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients [J]. J Vasc Surg， 2009， 50(4)：738-748.
7.	Schouten O， van Waning VH， Kertai MD， et al. Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass [J].Am J Cardiol， 2005， 96(6)：861-866.
8.	Drury D， Michaels JA， Jones L， et al. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm [J]. Br J Surg， 2005， 92(8)：937-946.
9.	Greenberg RK， Sternbergh WC 3rd， Makaroun M， et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms [J].J Vasc Surg， 2009， 50(4)：730-737.
10.	Lovegrove RE， Javid M， Magee TR， et al. A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm [J]. Br J Surg， 2008， 95(6)：677-684.
11.	Sajid MS， Desai M， Haider Z， et al. Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair：a systematic review [J]. Asian J Surg， 2008， 31(3)：119-123.
12.	Richardson JD， Main KA. Repair of abdominal aortic aneurysms. A statewide experience [J]. Arch Surg， 1991， 126(5)：614-616.
13.	Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part Ⅱ：variables predicting morbidity and mortality [J]．J Vasc Surg， 1989， 9(3)：437-447.
14.	Huber TS， McGorray SP， Carlton LC， et al. Intraoperative autologous transfusion during elective infrarenal aortic reconstruction：a decision analysis model [J]. J Vasc Surg， 1997， 25(6)：984-993.
15.	JCS Joint Working Group. Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery (JCS 2008) — digest version [J]. Circ J， 2011， 75(4)：989-1009.
16.	Fleisher LA， Beckman JA， Brown KA， et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery：focused update on perioperative beta-blocker therapy — a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) [J]. Anesth Analg， 2007， 104(1)：15-26.
17.	Kahn RA， Moskowitz DM， Marin M， et al. Anesthetic considerations for endovascular aortic repair [J]. Mt Sinai J Med，2002， 69(1-2)：57-67.
18.	Vemuri C， Wainess RM， Dimick JB， et al. Effect of increasing patient age on complication rates following intact abdominal aortic aneurysm repair in the United States [J]. J Surg Res， 2004，118(1)：26-31.
19.	Szostek M， Krepski K， Ma?ek AK， et al. Complication risk after abdominal aortic aneurysm operations [J]. Pol Merkur Lekarski，1999， 7(40)：172-174.
20.	Geisbüsch P， Leszczynsky M， Kotelis D， et al. Open versus endovascular repair of acute aortic transections — a nonrandomized single-center analysis [J]. Langenbecks Arch Surg，2009， 394(6)：1101-1107.
21.	黄建华，刘光强，符洋，等. 腹主动脉瘤手术切除与腔内治疗疗效的比较 [J]. 中国普通外科杂志， 2008， 17(6)：542-545.
22.	Walsh SR， Bhutta H， Tang TY， et al. Anaesthetic specialisation leads to improved early- and medium-term survival following major vascular surgery [J]. Eur J Vasc Endovasc Surg， 2010，39(6)：719-725.
23.	Bonfreschi V， Giuliani E， Malagnino FC， et al. Analgesia during abdominal aortic aneurysm endovascular repair：remifentanil vs. fentanyl-midazolam — a randomized controlled trial [J].Eur J Anaesthesiol， 2009， 26(9)：782-787.
24.	Ruppert V， Leurs LJ， Steckmeier B， et al. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair：an analysis based on Eurostar data [J]. J Vasc Surg， 2006， 44(1)：16-21.
25.	Verhoeven EG， Cinã CS， Tielliu IJ， et al. Local anesthesia for endovascular abdominal aortic aneurysm repair [J]. J Vasc Surg， 2005， 42(3)：402-402.
26.	De Virgilio C， Romero L， Donayre C， et al. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia：a comparison of cardiopulmonary morbidity and mortality rates [J]. J Vasc Surg， 2002， 36(5)：988-991.
27.	Sugino S， Omote K， Kawamata M， et al. Anesthetic management of endovascular repair for aortic abdominal aneurysm in a patient with severe chronic obstructive pulmonary disease [J].Masui， 2006， 55(12)：1480-1483.
28.	Sadat U， Cooper DG， Gillard JH， et al. Impact of the type of anesthesia on outcome after elective endovascular aortic aneurysm repair：literature review [J]. Vascular， 2008， 16(6)：340-345.
29.	Parras Maldonado MT， Ramos Lozano R， García Saura PL， et al. Endovascular treatment of a ruptured abdominal aorta aneurysm with local anesthesia， sedation and analgesia [J]. Rev Esp Anestesiol Reanim， 2009， 56(3)：193-194.
30.	Lippmann M， Lingam K， Rubin S， et al. Anesthesia for endovascular repair of abdominal and thoracic aortic aneurysms：a review article [J]. J Cardiovasc Surg (Torino)， 2003， 44(3)：443-451.
31.	Bettex DA， Lachat M， Pfammatter T， et al. To compare general，epidural and local anaesthesia for endovascular aneurysm repair (EVAR) [J]. Eur J Vasc Endovasc Surg， 2001， 21(2)：179-184.

1. Dubost C， Allary M， Oeconomos N. Resection of an aneurysm of the abdominal aorta：reestablishment of the continuity by a preserved arterial graft， with result after five months [J]. Arch Surg， 1952， 64(3)：405-408.
2. Wahlgren CM， Malmstedt J. Outcomes of endovascular abdominal aortic aneurysm repair compared with open surgical repair in high-risk patients：results from the Swedish Vascular Registry [J]. J Vasc Surg， 2008， 48(6)：1382-1388.
3. Dindo D， Demartines N， Clavien PA. Classification of surgical complications：a new proposal with evaluation in a cohort of 6 336 patients and results of a survey [J]. Ann Surg， 2004，240(2)：205-213.
4. Allaqaband S， Mortada ME， Tumuluri R， et al. Endovascular stent graft repair of abdominal aortic aneurysms in high-risk patients：a single center experience [J]. J Interv Cardiol， 2004，17(2)：71-79.
5. Parodi JC， Palmaz JC， Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms [J]. Ann Vasc Surg， 1991， 5(6)：491-499.
6. AbuRahma AF， Campbell J， Stone PA， et al. The correlation of aortic neck length to early and late outcomes in endovascular aneurysm repair patients [J]. J Vasc Surg， 2009， 50(4)：738-748.
7. Schouten O， van Waning VH， Kertai MD， et al. Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass [J].Am J Cardiol， 2005， 96(6)：861-866.
8. Drury D， Michaels JA， Jones L， et al. Systematic review of recent evidence for the safety and efficacy of elective endovascular repair in the management of infrarenal abdominal aortic aneurysm [J]. Br J Surg， 2005， 92(8)：937-946.
9. Greenberg RK， Sternbergh WC 3rd， Makaroun M， et al. Intermediate results of a United States multicenter trial of fenestrated endograft repair for juxtarenal abdominal aortic aneurysms [J].J Vasc Surg， 2009， 50(4)：730-737.
10. Lovegrove RE， Javid M， Magee TR， et al. A meta-analysis of 21 178 patients undergoing open or endovascular repair of abdominal aortic aneurysm [J]. Br J Surg， 2008， 95(6)：677-684.
11. Sajid MS， Desai M， Haider Z， et al. Endovascular aortic aneurysm repair (EVAR) has significantly lower perioperative mortality in comparison to open repair：a systematic review [J]. Asian J Surg， 2008， 31(3)：119-123.
12. Richardson JD， Main KA. Repair of abdominal aortic aneurysms. A statewide experience [J]. Arch Surg， 1991， 126(5)：614-616.
13. Johnston KW. Multicenter prospective study of nonruptured abdominal aortic aneurysm. Part Ⅱ：variables predicting morbidity and mortality [J]．J Vasc Surg， 1989， 9(3)：437-447.
14. Huber TS， McGorray SP， Carlton LC， et al. Intraoperative autologous transfusion during elective infrarenal aortic reconstruction：a decision analysis model [J]. J Vasc Surg， 1997， 25(6)：984-993.
15. JCS Joint Working Group. Guidelines for perioperative cardiovascular evaluation and management for noncardiac surgery (JCS 2008) — digest version [J]. Circ J， 2011， 75(4)：989-1009.
16. Fleisher LA， Beckman JA， Brown KA， et al. ACC/AHA 2006 guideline update on perioperative cardiovascular evaluation for noncardiac surgery：focused update on perioperative beta-blocker therapy — a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2002 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery) [J]. Anesth Analg， 2007， 104(1)：15-26.
17. Kahn RA， Moskowitz DM， Marin M， et al. Anesthetic considerations for endovascular aortic repair [J]. Mt Sinai J Med，2002， 69(1-2)：57-67.
18. Vemuri C， Wainess RM， Dimick JB， et al. Effect of increasing patient age on complication rates following intact abdominal aortic aneurysm repair in the United States [J]. J Surg Res， 2004，118(1)：26-31.
19. Szostek M， Krepski K， Ma?ek AK， et al. Complication risk after abdominal aortic aneurysm operations [J]. Pol Merkur Lekarski，1999， 7(40)：172-174.
20. Geisbüsch P， Leszczynsky M， Kotelis D， et al. Open versus endovascular repair of acute aortic transections — a nonrandomized single-center analysis [J]. Langenbecks Arch Surg，2009， 394(6)：1101-1107.
21. 黄建华，刘光强，符洋，等. 腹主动脉瘤手术切除与腔内治疗疗效的比较 [J]. 中国普通外科杂志， 2008， 17(6)：542-545.
22. Walsh SR， Bhutta H， Tang TY， et al. Anaesthetic specialisation leads to improved early- and medium-term survival following major vascular surgery [J]. Eur J Vasc Endovasc Surg， 2010，39(6)：719-725.
23. Bonfreschi V， Giuliani E， Malagnino FC， et al. Analgesia during abdominal aortic aneurysm endovascular repair：remifentanil vs. fentanyl-midazolam — a randomized controlled trial [J].Eur J Anaesthesiol， 2009， 26(9)：782-787.
24. Ruppert V， Leurs LJ， Steckmeier B， et al. Influence of anesthesia type on outcome after endovascular aortic aneurysm repair：an analysis based on Eurostar data [J]. J Vasc Surg， 2006， 44(1)：16-21.
25. Verhoeven EG， Cinã CS， Tielliu IJ， et al. Local anesthesia for endovascular abdominal aortic aneurysm repair [J]. J Vasc Surg， 2005， 42(3)：402-402.
26. De Virgilio C， Romero L， Donayre C， et al. Endovascular abdominal aortic aneurysm repair with general versus local anesthesia：a comparison of cardiopulmonary morbidity and mortality rates [J]. J Vasc Surg， 2002， 36(5)：988-991.
27. Sugino S， Omote K， Kawamata M， et al. Anesthetic management of endovascular repair for aortic abdominal aneurysm in a patient with severe chronic obstructive pulmonary disease [J].Masui， 2006， 55(12)：1480-1483.
28. Sadat U， Cooper DG， Gillard JH， et al. Impact of the type of anesthesia on outcome after elective endovascular aortic aneurysm repair：literature review [J]. Vascular， 2008， 16(6)：340-345.
29. Parras Maldonado MT， Ramos Lozano R， García Saura PL， et al. Endovascular treatment of a ruptured abdominal aorta aneurysm with local anesthesia， sedation and analgesia [J]. Rev Esp Anestesiol Reanim， 2009， 56(3)：193-194.
30. Lippmann M， Lingam K， Rubin S， et al. Anesthesia for endovascular repair of abdominal and thoracic aortic aneurysms：a review article [J]. J Cardiovasc Surg (Torino)， 2003， 44(3)：443-451.
31. Bettex DA， Lachat M， Pfammatter T， et al. To compare general，epidural and local anaesthesia for endovascular aneurysm repair (EVAR) [J]. Eur J Vasc Endovasc Surg， 2001， 21(2)：179-184.

CHINESE JOURNAL OF BASES AND CLINICS IN GENERAL SURGERY

Analysis and Prevention of Postoperative Complications of Abdominal Aortic Aneurysm Repair in High-Risk Patients

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