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April 1998 - Papers of the Month
1. May J et al (Sydney, Australia). Concurrent
comparison of endoluminal versus open repair in the
treatment of AAAs: Analysis of 303 patients by life table
method. J Vasc Surg 1998; 27: 213-21.
Purpose - "...to compare the outcome of consecutive
patients with AAA treated concurrently by open operation
(OR) and endoluminal intervention (ER) by the same
surgeons during a defined interval" (May 92-May 96).
Methods - 303 consecutive patients who underwent elective
repair; OR in 195 and ER in 108. "The decision to
perform ER was based on comorbidities that precluded OP
(48) and patient choice (60)."
Results - Peri-operative mortality = 5.6% for OR and 5.6%
for ER. "No significant difference was seen in survival
rate between ER and OR when analyzed by the log-rank
test." "The rate of graft failure, however, was
significanly higher in ER than in OR."
Conclusion - "This study suggests that ER is safe...,
despite 44% of the ER group being rejected as unfit for
OR." ER "results in shorter LOS, shorter length of ICU
stay, and less blood loss..." "Patients who opt for
endoluminal method of repair should be made aware that
the minimally invasive technique carries the disadvantage
of a higher failure rate."
Comment by mdt: Well, as that noted vascular surgeon
John Porter once said, "Live for today." With more or
less similar up-front mortality risks, the choice is
between a shorter hospital stay (with a greater risk of
long-term complications) and a more difficult post-
operative period (with fewer chances of problems later).
2. Lobato AC & Leao PP (Sao Paulo, Brazil). Predictive
factors for rupture of thoracoabdominal aortic aneurysm.
J Vasc Surg 1998; 27: 446-53.
Methods & Results - 31 patients with TAA were followed
for a median period of 47 months. Five underwent
elective repair; 6 died of unrelated causes; 9 ruptured;
and 11 reached the end of the study without rupture or
surgery.
Conclusion - The authors "recommend elective repair for
a fit patient with asymptomatic TAA with an initial AP
diameter of 50 mm only when there is an annual growth
rate of at least 10 mm." "Patients with an initial AP
diameter of 60 mm and an annual growth rate of 6 mm
should undergo surgical treatment..." "These guidlines
for elective repair of TAA are based on the results of a
relatively small series and have to be carefully
individualized for each patient."
Comment by mdt: Nicely done. The natural history of AAA
has been subject to much more extensive analysis than
TAA. This study is a step toward better knowledge of the
TAA.
3. Hirose H, et al (Nagasaki, Japan). Genetic risk
factor for AAA: HLA-DR2(15), A Japanese study. J Vasc
Surg 1998; 27: 500-3.
Purpose - "These experiments were carried out to
determine whether the same HLA DR types that have been
reported to be associated with AAA in a mixed North
American population are similarly associated with AAA in
a more homogeneous group of patients in Japan."
Methods and Results - 46 AAA and 50 Control patients;
DR2(15) detected in 27 patients with AAA and 14 controls
(p<0.005).
Conclusion - These results suggest that "DR2(15) has an
important role as a genetic factor for AAA in Japanese
patients, as previously reported in a mixed North
American population".
Comment by mdt: Hitoshi Hirose (who goes by "Gene") was
a student in my laboratory when we reported that DR2
might be a susceptibility gene for AAA at the NY Academy
of Sciences Symposium in 1996. When he returned to
Japan, he carried out a study of the Japanese population
referred to the vascular clinic at Nagasaki; and of
course the senior author of this paper is happy to note
that one of the same alleles has come up as a risk
factor.