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Management of Non-Infectious Aneurisms of the Sub-Kydney Abdominal Aorta at the CHU/JRA

HF Randrianandrianina¹, ZL Randimbinirina¹*, T Rajaobelison¹, TG Rajaoharimalala¹, RNAL Rakotorahalahy¹, AJC Rakotoarisoa², AML Ravalisoa²

(1) Department of Surgery, Faculty of Medicine of Antananarivo, Antananarivo, Madagascar

(2) Department of Surgery, Faculty of Medicine of Antananarivo, University of Antananarivo, Antananarivo, Madagascar

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Abstract

Introduction: The aim of this study was to describe the principle of the management for non-infectious aneurysm of the sub-kidney abdominal aorta at the university teaching hospital/JRA Ampefiloha.

Materials and methods: It was a retrospective, descriptive study conducted at cardiovascular surgery department of the university teaching hospital/JRA Ampefiloha, for a period of 14 years old (January 2005 to December 2019), including all patients who had an non-infectious aneurysm of the subrenal abdominal aorta at the CHU/JRA Ampefiloha operated on or not.

Results: Sixty-one cases were included, with an mean age of 61.71 years old (from 16 to 82 years old), a male predominance (sex ratio-1.34), high blood pressure, dyslipidemia, active smoking and physical inactivity were the predominant risk factors. The circumstances of discovery were often abdominal pain (52.45%) and a flapping abdominal mass (47.54%). Aortic doppler ultrasound and/or CT angiography allowed the diagnosis and describe the type of aneurysm. Most of them was fusiform in 49 cases (80.32%) and sacciform in 12 cases (19.67%), the majority of which had a diameter of between 50 and 60 mm (36.06%). Thirty-nine patients were operated on (63.93%). Conventional surgery with the flattening of the aneurysm followed by a replacement with a prosthetic graft was our reference technique. Postoperative development was favorable in 82.05% of cases. The mortality rate was 6.56%.

Conclusion: The hospital frequency of an abdominal aortic aneurysm was 1.53% at the university teaching hospital/JRA Ampefiloha. Conventional surgery was our reference technique, saving the lives of our patients.

Keywords: Aneurysm, subrenal abdominal aorta, surgery, prosthesis.

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Article Info: Received 07 Oct 2020;       Review Completed 19 Nov 2020;        Accepted 29 Nov 2020;      Available online 15 Dec 2020

Cite this article as:

Randrianandrianina HF, Randimbinirina ZL, Rajaobelison T, Rajaoharimalala TG, Rakotorahalahy RNAL, Rakotoarisoa AJC, Ravalisoa AML, Management of Non-Infectious Aneurisms of the Sub-Kydney Abdominal Aorta at the CHU/JRA, Journal of Drug Delivery and Therapeutics. 2020; 10(6-s):11-15      http://dx.doi.org/10.22270/jddt.v10i6-s.4604      

*Address for Correspondence:

Dr Randimbinirina Zakarimanana Lucas, Department of Surgery, Faculty of Medicine Antananarivo, Antananarivo, 101, Madagascar

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INTRODUCTION

Aneurysm is defined as a permanent, segmental dilation, with loss of parallelism of the edges ¹ or dilation greater than 50% of the normal diameter of the aortic proximal segment. Aortic aneurysm is subrenal if it is more than 1cm downstream of the origin of the kidney arterie ². Abdominal aortic aneurysm is the most common site of a true arterial aneurysm, mainly affecting the subrenal segment of aorta.  The overall prevalence of abdominal aortic aneurysms was 4.8% according to a 2013 Li meta-analysis ³. It is a serious condition endangering the life-threatening condition in the event of a rupture, with a pre-hospital mortality rate of 9% ⁴. In Madagascar, data on the pathologies of the aneurysm of the sub-kidney abdominal aorta are still scarce. No protocol has been established for his surgical management.

The aim of this study was to describe the principle of the management for non-infectious aneurysm of the subrenal abdominal aorta at the university teaching hospital/JRA Ampefiloha.

Methodology

It was a retrospective, descriptive study conducted in the cardiovascular surgery department of the university teaching hospital/JRA Ampefiloha, for a period of 14 years old from January 2005 to December 2019. We included in this study all patients who presented a pure subrenal abdominal aortic aneurysm confirmed to doppler ultrasound and/or angioscanner of the non-infectious abdominal aorta. Other locations of aneurysm, such as suprarenal abdominal aortic aneurysm, isolated iliac or thoracic aneurysms, infectious aneurysm and incompletes folders have been excluded in this study. Socio-demographic data, discovery circumstances, imaging examinations results (morphology, location and antero-posterior diameter) and therapeutic management were analyzed. The data collected was analyzed with The Epi-info 7.1.3.3 software.

RESULTS

Sixty-one cases were collected among the 3974 admissions during this study period, giving a hospital frequency of 1.53%. A male predominance was observed with 35 men and 26 women giving a sex ratio of 1.34. The mean age was 61.71 years old with extremities of 16 years and 82 years old [Table I].

Table I: Socio-demographic data

The most common risk factors were high blood pressure (81.97%), age over 50 (70.49%), smoking (63.93%), dyslipidemia (57.38%) male gender (57.38%) [Table II].

Table II: Cardiovascular risk factors

The circumstances of discovery were dominated by a flapping abdominal mass (47.54%) (Figure 1) and abdominal pain (52.46%).

Figure 1: Abdominal mass (face)

Aortic doppler ultrasound (97%) and CT angiography of the aorta and limbs arteries (74%) were the most requested follow-up examinations for diagnosis. Subrenal abdominal aortic aneurysms were fusiform in 49 cases (80%) 11 cases (20%), Most of them were had a diameter of between 50 and 60mm (36%). The average diameter of the aneurysm was 57.8cm. These aneurysms are isolated aortic location in 23 cases (38%), aorto-bi-iliac in 35 cases (57%) and aorto-bifemoral in 3 cases (5%) [Table III].

Table III: Diagnosis

Management was surgical in 39 patients (64%) 11 patients (18%). Eight patients had discharged (13%). The prostheses used were aorto-aortic (28%), aorto-bi-iliac (67%) (Figure 3.4), aorto-bifemoral (5%). Protheses type are dominated by dacron (82%) and PTFE (18%).

Figure 2: Subrenal abdominal aortic aneurysm (CHU/JRA)

Figure 3: Aorto bi-iliac prosthetic replacement (CHU/JRA)

The histological studies of the biopsic parts were able to find 95% of atheromatous origin and 5% inflammatory.

Postoperative treatment includes generally, anticoagulants, antibiotic prophylaxis and painkillers (depending on the intensity of the pain). Two patients had died in preoperative conditions awaiting surgical treatment (3.28%). Postoperative development was generally favorable (82.05%). Two patients had died in the first thirty days in postoperative giving a post-operative mortality rate of 5% [Table III].

DISCUSSION

Abdominal aortic aneurysm is an elderly pathology. Its incidence is increasing due to the frequency of cardiovascular risk factors. Hospital prevalence was 1.53% in our series compared to other Western studies as in England with 1.7% ⁵ and in the United States with 2.5% ⁶. Moreover, an Algerian study by Ouarab showed a hospital frequency of 2.2% in Algeria ⁷.

The mean age of discovery of non-infectious aneurysms of the subrenal abdominal aorta varies according to the study. She was 61.71 years old in our study, 64 years old in the Senegalese study of Diengi ⁸ and 70.9 years old in the Gardet study [9. Male predominance in our series (Sex ratio 1.34) was observed in several study series, including Solofomalala (sex ratio-2.7), Stéphane (sex ratio-8) ¹⁰, Ting (sex ratio-5.6) ¹¹ and Khan (sex ratio-6.5) ¹². According to De Carvalho, there is a correlation between gender and the occurrence of abdominal aortic aneurysm ¹³. Indeed, there is a high statistically significant prevalence among the male gender (p-0.001) ¹³.

Atherosclerosis is the main etiology of abdominal aortic aneurysm, apart from rare etiologies. The main risk factors are age over 65 years old, male gender, smoking, family history of abdominal aortic aneurysm, history of coronary heart disease, high blood pressure, peripheral arterial disease and anterior myocardial infarction ¹⁴. The prevalence of high blood pressure, smoking and diabetes in modifiable risk factors is similar to the study of Becker ¹⁵ and Ouarab ⁷ in view of the prevalence of these risk factors (Table V). Some cardiovascular risk factors are blamed for abdominal aortic aneurysm rupture including a history of heart or kidney transplantation, female gender, high average blood pressure, wide initial diameter of abdominal aortic aneurysm, and smoking ¹⁶.

The circumstances of discovery range from abdominal mass palpation to painful abdominal syndrome, or even cardiovascular collapse associated with aneurysmal rupture. For symptomatic forms, abdominal pain is the main telltale sign of abdominal aortic aneurysm, usually motivating the request for paraclinical examination. It usually corresponds to the crack of the aneurysmal wall or the aneurysmal rupture. The frequency of acute abdominal pain varies according to the study: 52% in our series, 45% in the Rinckenbach study ¹⁷ and 22% in Carvalho's study ¹³. For asymptomatic forms, the presence of a pulsatile abdominal mass is suggestive of AAA. The abdominal mass frequency observed in our series was identical in the De Carvalho study (47%) ¹³ The presence of asymptomatic forms justifies routine screening of AAA in subjects over the age of 60 with several cardiovascular risk factors.

Two morphological examinations were requested in our series, ranging from a simple abdominal ultrasound to CT angiography of the abdominal aorta. In our series, abdominal ultrasound was used to diagnose eighteen patients (no.61). According to Liisberg, abdominal ultrasound offers moderate sensitivity ranging from 57.1% to 70.4% and high specificity ranging from 99.2% to 99.6% ¹⁸. In addition, the abdominal computed tomography can detect an aneurysm of the abdominal aorta. Forty-five of our patients (74%) had performed an CT angiography of the abdominal aorta in our study. According to Claridge, the detection rate of an abdominal aortic aneurysm on routine abdominal computed tomography was 5.8% ¹⁹. However, aortic doppler ultrasound (97% in our series) and aortic CT angiography (74% in our series) are the key examinations of pretherapeutic diagnosis and evaluation, measuring its diameter, morphology, the presence of intra-sacular thrombus, the association with the iliac or femoral artery and especially the measurement of the distance between the aneurysm collar from the distal edge of the renal artery ²⁰. The use of doppler ultrasound on the diagnostic in our series was (96.7%) higher than in the De Carvalho study (3.9%) ¹³.

Evaluation of the diameter of the abdominal aorta is essential for the diagnosis and surgical treatment. The average diameter of the aneurysm sac measured in our series (57.8cm) is similar to the study of Belarbi (56cm) ¹⁵ and Muehling (55cm) ²¹, significantly higher than the Carvalho study (39cm) ¹³.

Literature says, the majority of aneurysms of the abdominal aorta is fusiform (80%). Our study agrees with this literature data with 80.3% fusiform aneurysm and 19.7% sacciform form. De Carvalho's study showed 96.3% fusiform aneurysm and 3.7% sacciform aneurysm ¹³.

The association of aortic aneurysm to the iliac or femoral artery is not exceptional. However, the rate of association with iliac or femoral arteries varied depending on the study our study showed 37.7% aorto-aortic aneurysm, 57.4% aorto-bi-iliac aneurysm and 4.9% aorto-ilio-femoral aneurysm. The Carvalho study showed 13.2% association between aortic aneurysm to the iliac artery ¹³. In addition, Rinckenbach's study showed 52% aorto-aortic aneurysm, 28% aorto-bi-iliac aneurysm and 18% aorto-bifemorale aneurysm ¹⁷.

Without treatment, the natural evolution of subrenal abdominal aortic aneurysm is done towards the gradual size increase. However, the probability of rupture depends on several factors such as the size of the aneurysm (5.5cm), the rate of expansion (1cm/year), the morphology of the aneurysm and the genus ²².

The management of subrenal abdominal aortic aneurysm is medical and surgical. In 2019, the recommendation of the European Society for Vascular Surgery (ESVS) calls for quitting smoking and taking medication, including statins associated with conversion enzyme inhibitors and platelet anti-aggregate ²³, controlling other modifiable cardiovascular risk factors is important to slow the expansion of aneurysm. Surgical indication arises in front of a symptomatic aneurysm and an aneurysm with a diameter greater than 5.5cm ^{22, 24}, the goal of the treatment is to prevent aneurysmal rupture given the serious morbidity and mortality. In our study, therapeutic management was surgical in 63.93% and medical in 18.03%. Conventional surgery by flattening graft remained our preferred technic, while in advanced countries endovascular surgery (EVAR) have an important role in the treatment of abdominal aortic aneurysm. The high cost of surgical consumables, especially prostheses, could explain the high rate (13%) of discharge in our series. In our study, prosthetic replacement was 28.2% aorto-aortic, 66.7% aorto-bi-iliac and 5.1% aorto-bifemoral. On the other hand, Rinckenbach's study of grafting flattening found 52% aorto-aortic prosthesis, 28% aorto-bi-iliac and 18% aorto-bifemoral ¹⁷.

According to the etiology, atheromatous origin is the most common (95%) related to cardiovascular risk factors. Three to 10% of AAA are inflammatory. Takayashu's disease, Behçet's disease and, unusually, Horton's disease are mentioned. They represent a particular clinical entity whose diagnostic arguments are based primarily on clinical context, AAA imaging and the histological study of biopsy exhibits ^27,28,29

Postoperative evolution was favorable to 82% in our series and 58% in the Belarbi study ¹⁵. The early postoperative mortality rate in our series was 5.1%, this mortality rate was close to the other studies 4.9% the Fairman study ²⁵, 16% in the Belarbi study ¹⁵.

CONCLUSION

Subrenal abdominal aortic aneurysm is a serious and fatal condition for complications, hence the need for routine screening for elder people with cardiovascular risk factors to avoid it. Medical treatment relies primarily on the control of cardiovascular risk factors, and surgery remains the only treatment for aneurysms with antero-posterior diameter greater than 50 mm. Elsewhere, the endovascular technique is booming and yielding better results.

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