Eur J VascSurg 8, 750-751 (1994)
Successful Repair of a Ruptured Abdominal Aortic Aneurysm in a Cardiac Transplant Patient R. Chandrasekar, D. M. Nott, L. Enabi, Po L. Harris and A. Bakran
Vascular Surgery Unit, Broadgreen Hospital, Liverpool, U.K.
Introduction Cardiac transplantation is now a well established treatment modality for patients with end stage cardiac disease with recent results suggesting 5-year survival rates of 78%. 1 The commonest cause of graft failure remains recurrent coronary artery disease, 2 however, in order to improve long term survival, attention should also be directed to the diagnosis and treatment of associated diseases. One such condition is aortic aneurysm. Elective repair of abdominal aortic aneurysm both in renal and cardiac transplant patients have been reported. 3' 4 We report the first successful case of repair of a ruptured aortic aneurysm in a cardiac transplant patient.
Case Report A 61-year-old man who had received an orthotopic cardiac transplant 6 years earlier for ischaemic heart disease was admitted with profound hypotension and tachycardia. Physical examination revealed a pulsatile aortic aneurysm with a large left sided tender mass. Prior to this event, a 3.2cm abdominal aortic aneurysm had been diagnosed on ultrasound scan 3 years earlier but no further scans had been performed following this. More recently the patient had undergone coronary angioplasty for recurrent angina and although clinically the abdominal aneurysm had been documented, it was felt that he would not survive elective aneurysm repair. Immunosuppression Was mainPlease address all correspondenceto: D. M. Nott, VascularSurgery Unit, Charing Cross Hospital, Fulham Palace Road, London W6 8RF,U.K.
tained with cyclosporin A (300mg/day) and azathioprine (75mg/day). Laparotomy revealed a large retroperitoneal haematoma secondary to a ruptured 5cm infrarenal aortic aneurysm and in addition both iliac arteries were noted to be aneurysmal. Apart from a brief fall in systolic pressure to 40mm Hg during induction, the blood pressure was maintained at 140mm Hg following cross clamping during which 9.2 1 of colloid and blood were transfused together with a bolus of adrenaline and continuous infusion of dopamine. The aneurysms were repaired with an 18×9 bifurcated double velour graft taken down to both internal and external iliac origins using the inlay technique. Postoperatively a central venous pressure of 20cm water was required to maintain a satisfactory urine output with occasional repeated boluses of diuretics. Immunosuppression was resumed 24hr postoperativel3~ cyclosporin A (300mg/day) and azathioprine (75mg/day) given via a nasogastric tube with t h e addition of methylpredisolone (10mg/day) which was curtailed 7 days following operation. His post operative course was uneventful apart from one episode of heart failure which responded to fluid adjustment and diuretics and he was discharged 5 weeks following the initial insult. He remains well 12 months following the operation.
Discussion Life expectancy after cardiac transplantation has improved steadily with time with cumulative survival rates now in the order of 90% after 1 year and 78% at 5 years. 1 By far the most common indications are end
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Repair of Ruptured AAA
stage ischaemic heart disease a n d dilating cardiom y o p a t h y . 5 Both these c o n d i t i o n s are related to s y s t e m i c atherosclerosis a n d one m a y a s s u m e that as this p o p u l a t i o n of patients s u r v i v e l o n g e r t h e n the extracardiac m a n i f e s t a t i o n s of the disease will b e c o m e m o r e evident. Since 1977, there h a v e b e e n nine cases r e p o r t e d d e a l i n g w i t h aortic a n e u r y s m repair followi n g cardiac transplantation. 4' 6, 7 All of these patients h a d p r e v i o u s l y suffered f r o m ischaemic c a r d i o m y o p a t h y a n d one died f o l l o w i n g repair of a r u p t u r e d aortic a n e u r y s m as a result of c o n t i n u e d acidosis a n d cardiac a r r y t h m i a s . 4 This is the first case r e p o r t of a p a t i e n t w i t h a heart t r a n s p l a n t to s u r v i v e f o l l o w i n g e m e r g e n c y s u r g e r y for a r u p t u r e d aortic a n e u r y s m . This w a s so despite k n o w n recurrent c o r o n a r y a r t e r y disease in his t r a n s p l a n t e d heart. The p r e v a l e n c e of a b d o m i n a l aortic a n e u r y s m s in m e n in their late 60s a n d 70s a p p e a r s to be in the o r d e r of 2% 8 w i t h g r o w t h rates in the o r d e r of 0.4cm p e r year. 9 In a recent report of P i o t r o w s k i et al. 4 r o u t i n e preoperative abdominal ultrasound scanning showed a p r e v a l e n c e of 10.5% w i t h g r o w t h rates of 0.7cm p e r y e a r in patients u n d e r g o i n g cardiac t r a n s p l a n t a t i o n for e n d stage ischaemic heart disease. Possible m e c h a n i s m s for the increased risk of a n e u r y s m f o r m a t i o n in these patients m a y be d u e to increased h a e m o d y n a m i c stress i m p o s e d u p o n an atherosclerotic aorta b y an increased cardiac o u t p u t , s° the h y p e r t e n s i v e effects of c y c l o s p o r i n 11 a n d the increased atherosclerotic tend e n c y of steroids 12 or it m a y s i m p l y be that the risk of cardiac d e a t h has b e e n eliminated in these patients that w o u l d h a v e p o s s i b l y d i e d f r o m cardiac disease h a d the a n e u r y s m b e e n r e p a i r e d or not. Aortic s c a n n i n g s h o u l d be p e r f o r m e d r o u t i n e l y in patients w h o h a v e u n d e r g o n e cardiac t r a n s p l a n t a t i o n a n d clearly a n y detected a n e u r y s m s s h o u l d be offered elective r e p a i r before t h e y rupture. In the light of the
a b o v e case, the risks of aortic s u r g e r y n e e d to be ree v a l u a t e d in the p a t i e n t w i t h a d i s e a s e d heart following cardiac transplantation.
References 1 KRIETTJM, KAYEMR The registry of the International Society for Heart Transplantation: seventh official report - 1990. ] Heart Transplant 1990; 9: 323-330. 2 BALDWINJC, SHUMWAYNE, STINSONEB, BAUMGARTNERWA. Cardiac transplantation. In Operative Surgery and Management. Ed Keen, Wright 1987, pp. 963-969. 3 EVANSG, STANSBYG, HAMILTONG. Aortic aneurysm repair in a renal transplant patient: Preservation of renal function. Eur l Vasc Surg 1991; 5: 479480. 4 PIOTROWSKIJJ, MCINTYREKE, HUNTERGC, SETHIGK, B~RNHARD VMj COPELANDJC. Abdominal aortic aneurysm in the patient undergoing cardiac transplantation. ] Vasc Surg 1991; 14: 460-467. 5 K_aYEMP. The registry of the International Society for Heart Transplantation (editorial). J Heart Transplant 1987; 6: 191-192. 6 lhECHMANW, DYKEC, LE~HM, HANRAHANJ, SZENTPETRYS, SOBEL M. Symptomatic abdominal aortic aneurysms in long term survivors of cardiac transplantation. J Vasc Surg 1990; 11: 475-479. 7 REITZBA, BAUMGARTNERWA, OYERPE, STINSONEB. Abdominal aortic aneurysmectomy in long term cardiac transplant survivors. Arch Surg 1977; 112: 1057-1059. 8 COLLINJ, ARAUJOL, WALTONJ, LINDSELLD. Oxford screening programme for abdominal aortic aneurysm in men aged 65 to 74 years. Lancet 1988; ii: 613-615. 9 BERNSTEINEF, DILLEYRB, GOLDBERGLE. Growth rates of small abdominal aortic aneurysms. Surgery 1976; 80: 765. 10 SZILAGYIDE, ELLIOTJP, SMITHRR. Clinical fate of the patient with asymptomatic abdominal aortic aneurysm and unfit for surgical treatment. Arch Surg 1972; 104: 600-606. 11 OZDOGANE, BONNERN, FITZGERALDM¢MASUMECIF, KHAGHONIA, YACOOBM. Factors influencing the development of hypertension after heart transplantation. J Heart Transplant 1990; 9: 548-553. 12 NASHEL DJ. Is atherosclerosis a complication of long term corticosteroid treatment? Am J Med 1986; 80: 925-929. Accepted 19 April 1993
Eur J Vasc Surg Vol 8, November 1994