LETTERS TO THE EDITORS The Editors invite readers to submit letters commenting on the contents of articles that appear in the Journal. Also welcome are brief communications in letter form reporting investigative or clinical observations without extensive documentation and with brief bibliography (five titles or less), not requiring peer review but open to critique by readers. Letters to the Editors should be no more than 500 words in length and they may have to be edited for publication.

Abdominal aortic aneurysm associated with aortic hypoplasia and polycystic kidneys

To the Editors: Patients with abdominal aortic aneurysms (AAAs) may have special clinical problems, such as Marfan and EhlhersDanlos syndromes, intracranial aneurysms, or polycystic kidney disease (PKD). We recently had to treat a patient with an AAA associated with infrarenal aortic hypoplasia and PKD} ,3,s This unusual case was interesting in view of the potential links between the three diseases and the technical problems encountered in the surgical management of the AAA. CASE R E P O R T

The patient was an 83-year-old woman with abdominal pain for several days. Clinical examination and ultrasonograptly related the pain to large polycystic kidneys. The size of the right kidney was estimated to be 20 cm, the size o f the left kidney was 23 cm. The patient was in good health, and hypertension was well controlled (150/80 mm Hg) with medication. The creatinine serum level was 2 mg/dl. Abdominal x-ray films and ultrasonography showed a calcified aneurysm of the abdominal aorta whose size was estimated to be 51 mm in diameter. Digital intravenous subtraction angiography confirmed an anterior sacciform aneurysm of infrarenal aorta associated with an aortic hypoplasia beginning just below the renal arteries. The aneurysm and the hypoplasia did not involve the distal aorta and the iliac arteries. At operation, the aneurysm wall was very thin and totally calcified. The external diameter of the infrarenal aorta was 11 ram. The external diameter of the distal aorta was 20 ram. Renal and iliac arteries were normal. After systemic heparinization the aorta was cross-clamped just below the renal arteries and both common iliac arteries were clamped. The aneurysm was opened and a 12 mm polytetrafluoroethylene graft was sewn in place. Proximal anastomosis was end to end to the infrarenal aorta. Distal anastomosis was end to side to the distal aorta, which had been oversewn. Postoperative course was uneventfial. The patient was dismissed on the tenth postoperative day with a serum creatinine value of 1.2 mg/dl. Pathologic examination o f the aneurysm showed a very thin aortic wall with fibrohyalinosis and few elastic fibers but without atherosclerosis. The aortic wall adjacent to the aneurysm was very thin (1 ram). The intima was thicker than normal with fibrohyalinosis. A subintimal proliferation of myocytes was associated with fragmented elastic fibers. The internal elastic lamina was destroyed in some 504

places. The medial layer was very thin and fibrous with few elastic fibers or smooth muscle cells. Arterial lesions observed in that patient are those usually described in aortic hypoplasia, with a fibroelastic intimal thickening and a very thin and fibrous dystroph~ medial layer. Nevertheless, infrarenal aortic hypoplasia has never been reported before associated with an aneurysm or polycystic kidneys. Numerous theories have been advanced concerning the cause of infrarenal aortic hypoplasia. Whatever the ca~e, aortic hypoplasia may be a contributing factor in the development of atherosclerosis, particularly in women? ,4Atherosclerosis and the stenosis resulting from aortic hypoplasia could then promote the aneurysmal degeneration of the artery. The association of PKD and AAA is rare since only five cases have been reported in the literature? '3'5The first case was reported by Chapman and Hilson i in 1980 who found three patients with PKD and AAA out of a total o f 31 patients undergoing dialysis with PKD. This contrasted with no known aneurysm in patients with other renal disease in their series. Hypertension usually coexists with PKD and this might favor development and rupture of an aneurysm. ~

Polycystic kidneys may grow very large and prevent palpation of AAA, as occured in our case and the three patients reported by Chapman and Hilson I. Abdominal aortic aneurysm may be shown on the abdomen x-ray films as in our case or on the intravenous urogram if the aneurysm walls are calcified. It may be detected incidenta~,f when ultrasonography is done on the kidneys. The possible association of PKD and AAA suggests investigation of PKD patients over 40 years by uflrasonography for possible AAA to know whether that association can be confirmed in larger series.

Olivier Goeau-Brissonniere,~ D , PhD, Jean-Franfois Renier, MD, Franfois Bacourt, MD Department of Surgery H6pital Ambroise Par~ 92104 Boulogne Cedex France REFERENCES 1. Chapman JR, Hilson AJV¢. Polycystic kidneys and abdominal aortic aneurysms. Lancet 1980;1:646-7. 2. De Laurentis DA, Friedmann P, Wolferth CC, Wilson A, Naide D. Atherosclerosis and the hypoplastic aorto-iliac system. Surgery 1978;83:27-37.

Volume 12 Number 4 October 1990

3. Montohu 1, Torras A, Revert L. Polycystic kidneys and abdominal aortic aneurysms. Lancet 1980;i: 1 I33-4. 4. Palmaz JC, Carson SN, Hunter G, Weinshelbaum A. Male hypoplastic infrarenal aorta and premamrc atherosclerosis. Surgery 1983;94:9I-4. 5. Roodvoets AP. Aortic aneurysms in presence of kidney disease. Lancet 1980;1:1413-4.

Transperitoneal versus retroperitoneal approach for aortic reconstruction: A randomized 13rospective study To the Editors:

Surgeons who frequently use the retroperitoneal approach for aortic surgery in community hospitals without the same tertiary anesthetic and intensive care unit sul ?ort as major academic centers provide may be confused by the article o f Cambria et al. (J VAse Suv.G 1990; 11:314-25). Ample data exist in comparative studies in the American as well as the European literature that report the advantage of the retroperitoneal approach in decreasing hospitalization, paralytic ileus, and blood loss, even though the mortality is similar with both surgical approaches3 -s In the report by Cambria et al. no statistically significant difference was found between the transperitoneal and retroperitoneal approach in aortic surgery as it refers to multiple intraoperative and postoperative parameters. My confusion whcn interpreting their data is the description by the authors of three maneuvers that are not commonly practiced by most vascular surgeons; "Eighty percent of all patients were anesthetized with a combination of continued epidural narcotics and inhalation agents," "Nasogastric tubes were always removed at the time ofendotracheal intubation and only reinserted if the clinical situation dictated," and "~saatotransfusion is now routine in our practice." Another randomized study by Nevelsteen et al,~ has been published, which addresses the benefits of the retroperitoneal approach over the transabdominal approach for aortic surgery. The results by this surgical group with extensive experience in both the transperitoneal 7 and retroperitoneal 8 approach to aortic surgery demonstrated a statistically significant improvement in pulmonary function parameters in the retroperitoneal group when compared to the transabdominal approach. A randomized mul.ricenter prospective trial addressing the use of a combination of general anesthetic and epidural anesthesia for pain control is needed to demonstrate if these two surgical approaches to aortic surgery are equivalent, as shown in the study by Cambria et al., or if only certain parameters are improved as was demonstrated in the study by Nevelsteen. Manuel Doblas, 21/119

Department of Surgery Hospital "Viegen de la Salud" Av. de Barber s/n Toledo, Spain

Letters to the Editors

505

REFERENCES

1. Rob C. Extraperitoneal approach to the abdominal aorta. Surgery 1963;53:86-89. 2. Helsby R, Moossa R. Aortoiliac reconstruction with special reference to the extraperitoneal approach. Br J Surg 1975; 62:596-600. 3. Willekens FGJ, Widdershoven GMJ, Kirk RS. The retroperitoneal approach to the aortoiliac vessels. Angiolog3~ 1985; 1:31-7. 4. Sicard GA, Freeman MB, VanderWoude JC, Anderson CB. Comparison between the transabdominal and retroperitoneal approach for reconstruction of the infrarenal abdominal aorta. J VAsc SUr,G 1987;5:I9-27. 5. Leather RP, Shah DM, Kaufman JL, Fitzgerald KM, Gahng BB, Feustel PI. Comparative analysis of retroperitoneal and transperitoneal aortic replacement for aneurysm. Surg Gynecol Obstet I989;I68:387-93. 6. Nevelsteen A, Smet G, Weyman S, Depre H, Suy R. Transabdominal or retroperitoneal approach to the aortoiliac track: pulmonary ffmction studies. Eur J Vase Surg 1988;2:229-32. 7. Nevelsteen A, Suy R, Daenen W, Boel A, Stalpaert G. Aortofemoral grafting: factors influencing late results. Surgep,z 1980;88:642-53. 8. Nevelsteen A, Boeckxstaens C, Smet G, Willikens FGJ, Suy R. Extensive aortoiliofemoral endarterectomy with LeVeen placque cracker. J Cardiovasc Surg 1988;29:441-8. Reply To the Editors:

Apparently Dr. DoNas is convinced of the superiority of the retroperitoneal approach over the transperitoneal approach for aotic surgery, yet much of the literature that he cites as "ample data" of the "advantage of the retroperitoneal approach" has been reviewed in our artide) ,s We noted that these reports suffer from the use of historical controls, and in our study we emphasized the necessity for controlling other variables in an era when a number of factors have improved the overall course of patients undergoing elective aortic surgery. Indeed, our study included a retrospectively reviewed group of patients in whom a number of perioperative parameters were significantly different from all randomized patients. Thus the differences were a function of the evolution of the care of the patient undergoing aortic surgery over time, but independent of retroperitoneal versus transperitoneal approach3 I believe wc demonstrated conclusively that there was no significant difference with the two approaches in either perioperative pulmonary dysfunction, length of hospital stay, or blood loss as claimed by Dr. DoNas. There was indeed in our patients, a significant advantage for the retroperitoneal approach with respect to recovery, of gastrointestinal fianction, but the clinical importance of these small differences is doubtful. I would disagree with Dr. DoNas' contention that early discontinuation o f nasogastric suction and autotransfusion are not commonly practiced by vascular surgeons after aortic surgery. With respect to the combined epidural and general anasthesia for aortic surgery this is now routine in our practice although cer-