Acute Renal Failure Complicating Ruptured Abdominal Aortic Aneurysm Surendra K. Chawla, MD; Hassan Najafi, MD; Todd S. Ing, MD; William S. Hushang Javid, MD; James A. Hunter, MD; Marshall D. Goldin, MD; Cyrus

Ruptured abdominal aortic aneurysm complicated by renal failure is associated with a mortality greater than 90%. Aggressive management, which included the early use of hemodialysis, was employed. Between 1970 and 1973, a total of 43 patients had surgery for proved ruptured abdominal aortic aneurysm. Fourteen patients developed acute and fixed renal failure. Nine of these 14 patients had undergone hemodialysis with treatments beginning as early as the second postoperative day and lasting as long as ten weeks. There were six survivors, with a hospital mortality of 33%. This represents an improvement in survival compared with our earlier experience where the mortality in this type of patient was 93%. Early use of hemodialysis in the postoperative management of patients with acute renal failure complicating ruptured abdominal aortic aneurysm is recommended. abdominal aortic aneurysm is one of the most in vascular surgery. In critical from 19 centers with a collective review of 756 from four to patient populations 117, the operative mor¬ tality ranged from 34%' to 85%,2 with a mean of 56%. When ruptured abdominal aortic aneurysm is complicated by acute renal failure, this mortality approximates 90%, with very few patients surviving an otherwise seemingly successful operation.38 In our earlier report of 107 con¬ secutive patients operated on for ruptured abdominal aor¬ tic aneurysm, there were 15 patients with associated acute renal failure. Only one patient survived, a hospital mortal¬ ity of 93%.4 The extremely lethal nature of this combina¬ tion suggested the need for a more aggressive manage¬ ment and, consequently, the decision was made to explore

Ruptured surgical emergencies patients


for publication Jan 10, 1975. From the Department of Cardiovascular-Thoracic Surgery, Rush-Presbyterian-St. Luke's Medical Center, Chicago. Read before the 82nd annual meeting of the Western Surgical Association, San Francisco, Nov 21, 1974. Reprint requests to 1725 W Harrison St, Chicago, IL 60612 (Dr. Najafi).

Dye, MD; Serry, MD

feasibility of early application of hemodialysis. This modality of treatment was considered in every instance and, when appropriate, has been utilized in the postopera¬ tive management of patients since January 1970. To ex¬ amine the value of hemodialysis under these circum¬ stances, the records of all patients operated on for ruptured abdominal aortic aneurysm during the ensuing four-year period have been reviewed. These observations the

form the basis for this report.


During a four-year period beginning January 1970, a total of 43 patients, all transferred from other institutions, underwent sur¬ gery for ruptured abdominal aortic aneurysm at Rush-Presby¬ terian-St. Luke's Medical Center. Eleven patients died, either dur¬ ing the operation or shortly after surgery. The causes of death in this group consisted of bleeding, irreversible shock, cardiac fail¬ ure, and ventricular arrhythmias. Of the 32 patients who survived beyond 48 hours, 14 developed postoperative renal failure. These 14 patients were all men ranging in age from 48 to 87 years, with a mean age of 66 years. Seven patients were in profound shock preoperatively, refractory to usual resuscitative measures. Six pa¬ tients were severely oliguric for many hours prior to the oper¬ ation. In four patients the aorta was clamped above the renal ar¬ teries during operation to control bleeding. The exact duration of aortic cross clamping could not be determined from the records. The duration of operations, however, ranged from Zlk to 7 hours, with a mean of 4M; hours. An average of 8 liters of blood was given during operation. The urine output was carefully monitored dur¬ ing operation and ranged from none to as high as 800 ml/hr. Pa¬ tients showing evidence of oliguria (less than 20 ml/hr) were treated with estimated volume replacement, using both crystal¬ loids and colloids (mannitol as much as 25 gm intravenously) and diuretics (usually furosemide, up to 500 mg intravenously). Fail¬ ure of the urinary volume to increase was interpreted as impend¬ ing renal failure. Once the presence of this complication was es¬ tablished, either because of sustained oliguria or anuria, or

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because of substantial and progressive rise in blood urea nitrogen (BUN) and electrolyte imbalance despite large volumes of dilute urine, hemodialysis was instituted. This was accomplished using a peripheral arteriovenous fistula, either between the radial artery and antecubital vein or between the dorsalis pedis artery and the long saphenous vein.' Hemodialysis treatments were performed with an artificial kid¬ ney dialyzer. The therapy was repeated daily or less often in an attempt to prevent the serum BUN value from rising above 70 to 80 mg/100 ml. Other indications for dialysis included hyper¬ kalemia, overhydration, severe metabolic acidosis, and clinical de¬ terioration secondary to uremie state. Judicious regional heparini¬ zation using a slow heparin infusion was utilized8 during the first two weeks postoperatively or in the face of bleeding diathesis. Otherwise, systemic heparinization was used. The dialysis was used in conjunction with the basic medical

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o o rj)

140 120· 10080-8

60·-6 40-4


regimen, which included restricted fluid intake during oliguric phase and unrestricted food, including protein and potassium fol¬ lowing the restoration of gastrointestinal tract motility. Ambula¬ tion was encouraged between dialyses, and the Foley catheter was removed during the oliguric phase. The patients were given prophylactic antibiotics because of the presence of prosthetic grafts. The BUN, creatinine, and serum potassium values, deter¬ mined daily, guided the timing and frequency of the hemodialysis treatments. Electrocardiograms were obtained frequently to de¬ tect myocardial injury and the patients' legs, while in bed, were raised 15° to 20° to promote


return and prevent stasis.


Five patients received supportive therapy without he¬ modialysis, and all died with sustained renal insufficiency


irnuummiiM mumm* Discharged















20· ·2








24 28





40 44



Respiratory Arrest

Arteriovenous Shunt

Fig 1.—Postoperative course of 62-year-old area depicts urine output.

Fig 2.—Postoperative course of 73-year-old area




who received







Internai Shunt

Chronic Dialysis and

hemodialysis treatments (arrows)

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Postoperation Days who received 27 hemodialysis treatments (arrows),


due to bowel necrosis. Shaded




and died


from the


23rd postoperative


as the primary or contributing cause of death. Three of these patients died from infarction of the colon, one from massive upper gastrointestinal tract bleeding, and the re¬ maining one from hyperkalemia. Hemodialysis in this group was either considered too late to be effective or was thought to be contraindicated in the face of other compli¬ cations. Two of these patients conceivably might have been salvaged with hemodialysis. Nine patients were dialyzed and six survived (67%), rep¬ resenting a substantial decrease in hospital mortality as compared to the experience outlined in our earlier report.4 The treatments were started as early as the second post¬ operative day. One patient in the high-risk category for renal failure had an arteriovenous shunt established at the initial operation that was used for dialysis several days later. The treatments were initiated within one week from the operation in all patients who ultimately sur¬ vived. These patients required hemodialysis either daily or every other day, depending on the clinical response and the rate of rise of BUN and serum creatinine values. One patient required only one treatment, resulting in the gradual fall in BUN level. Eight patients required be¬ tween 8 and 30 treatments. Two patients were discharged from the hospital on a long-term hemodialysis program. The clinical course of one of the latter patients is depicted in Fig 1. He was a 62-year-old man transferred to our hos¬ pital with a ruptured abdominal aortic aneurysm and taken directly to the operating room. He suffered hypoten¬ sion when the abdominal cavity was entered and suprare¬ nal clamping of the abdominal aorta was required for ten minutes. During a seven-hour operating period, he had a urine output of 800 ml. The decrease in urine output over the next 24 hours was managed with crystalloids, colloids, and furosemide (up to 300 mg intravenously every three hours). He remained oliguric and required an arterio¬ venous shunt on the second postoperative day. Hemodialy¬ sis was instituted to keep the BUN value below 70 to 80 mg/100 ml. His hospital course was complicated by res¬ piratory arrest and urinary and abdominal wound infec¬ tions. A percutaneous renal biopsy specimen showed evidence of acute tubular necrosis. A permanent arterio¬ venous fistula was created, and the patient was dis¬ charged on a long-term outpatient dialysis program. Of the three patients who were dialyzed and who died, in each instance major complications other than renal fail¬ ure, at least in part, contributed to their death. One pa¬ tient (a 60-year-old man) developed high output renal fail¬ ure with a rate of rise of the BUN level up to 40 mg/day. He was managed on conservative treatment for four days, when an arteriovenous shunt was established. The patient received only one dialysis treatment, but died the next day from massive gastrointestinal tract bleeding. Post¬ mortem examination revealed pulmonary edema, acute bronchopneumonia, and gastric erosions. A second pa¬ tient, a 77-year-old man, showed a rate of rise of BUN value up to 30 mg/day. Because of his extremely pre¬ carious condition, he was managed on conservative treat¬ ment. An arteriovenous fistula was created on the 33rd postoperative day, with full realization of his irreversible

downhill course. The patient received only one hemodialy¬ sis treatment and died the next day. The third patient, a 73-year-old man, had a history of previous congestive heart failure and diabetes requiring digoxin and insulin. He was oliguric several hours before arrival to the oper¬ ating room. He required clamping of the suprarenal ab¬ dominal aorta to control bleeding and also clamping of the right renal artery for 30 minutes. He remained anurie during the operative procedure and showed a rate of rise of the BUN level up to 20 mg/day. The hemodialysis treat¬ ments were not started until the tenth postoperative day. He did respond to hemodialysis treatment, but died of massive bowel infarction on the 23rd day after surgery (Fig 2). The clinical summary of the hemodialyzed group of patients is contained in the Table. COMMENT In 1968 we reported on 107 consecutive patients oper¬ ated on for ruptured abdominal aortic aneurysm. The overall mortality was 54%, and of 15 patients with associ¬ ated acute renal failure only one survived surgery, a hos¬ pital mortality greater than 90%. Similar death rates following repair of ruptured abdominal aortic aneurysm complicated by acute renal failure have been reported by other centers.35-6 A large number of early deaths in patients having acute renal failure following surgery for ruptured abdominal aortic aneurysm are due to serious complications unre¬ lated to the kidneys. Such complications usually cause the death of the patient before or despite successful dialysis. It appears that of all patients with ruptured abdominal aortic aneurysm who reach the operating room, approx¬ imately one third die within 48 hours from irreversible shock, generalized bleeding, or myocardial infarction. Of the patients surviving beyond 48 hours, nearly half have a relatively uneventful postoperative course, while the re¬ maining half have a variety of serious complications. Of these, renal failure is probably the most common and emerges as the deciding factor in the ultimate course of surgery. To reduce mortality within the first 48 hours, early diagnosis, better transport systems, prompt control of the proximal part of the aorta, and expeditious oper¬ ation are the most important. To increase survival in pa¬ tients who survive beyond 48 hours, efforts should be di¬ rected at prevention or treatment of complications such as renal failure, which eventually cause the death of the pa¬ tient. Based on this principle, hemodialysis was utilized and the results were as encouraging as those reported by Stenstrom et al.9 An improved survival with hemodialysis has also been achieved in patients suffering acute renal failure secondary to various other surgical causes.1011 The exact pathogenesis of renal insufficiency accom¬ panying ruptured abdominal aortic aneurysm is not yet fully understood. The possible precipitating mechanisms include hypotension, aortic cross clamping, and/or blood pressure fall on release of the aortic clamp. Several hy¬ potheses have been advanced to account for the develop¬ ment of renal insufficiency following clamping of the aorta. These include vasorenal spasms, arteriovenous

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Ruptured Abdominal Aortic Aneurysm: Hemodialyzed Group Age, yr 62 66 61 56 59 65 60 77 73

Preoperative Sex M

Renal Status Anurie Anurie Anurie Anurie Anurie


Preoperative Hypotension Resus¬ During Surgery Symptoms citation Time of Onset of 1


1 day 1 day 1 day Hours 1 day Hours Hours



No Yes* Yes* Yes Yes Yes Yes

No Yes No Yes No Yes Yes

Rate of Rise of Postoperative BUN per Day, Day of Start¬ mg/100 ml ing Dialysis 25 10 20 12 17 28 40 33 30 20 10

Frequency of Dialysis

Total No. of


Alternate days

Daily Daily

27 27


Daily Every 3 to 4 days One One Alternate davs


Follow-Up Survivedt Survived Survived Survived Survived

Survivedt Died Died D:ed

Cardiac arrest preoperatively. t On chronic hemodialysis program. *

in the kidneys, atheromatous emboli, altered pressure conditions in the renal arteries,12 or direct oper¬ ative trauma to renal vessels. The "no reflow cycle" postulated by Flores et al13 may be operative once ischemia is established. These workers have shown by electron microscopic slides that an initial cortical ischemia leads to cellular anoxia with resultant cellular swelling. The swollen cells, by obstructing the microvasculature and limiting the vascular space, cause fur¬ ther impairment of blood flow and thereby aggravation of ischemia. In recent studies by Abbott et al,14 utilizing xenon Xe 133 washout technique, it was concluded that the deleterious changes in renal blood flow distribution were detected in association with aortic occlusion, which was progressive with time and arrested with termination of the occlusion. These were manifested as renal cortical ischemia in the presence of only slight reduction in total renal blood flow. Since renal failure carries a grave prog¬ nosis, every effort should be made to prevent it. Gangre¬ nous extremities should be amputated early. Blood loss should be determined accurately and replaced, vasopres¬ sors should be used with caution, volume should be re¬ stored before the aortic clamp is released to avoid sudden hypotension; and intravenously administered mannitol should be used during and immediately following the op¬ eration to increase renal plasma flow and glomerular fil¬ tration. The operative procedure should proceed expeditiously to avoid prolonged aortic occlusion. The debris should be flushed from the aorta before circulation is reestablished.6 Supportive therapy with ethacrynic acid11 or high doses of furosemide16 should be tried in the early postoperative


when estimated blood volume has been re¬ stored. Inconsistent results have been obtained11 if these agents were used 48 hours after the onset of anuria when well established acute renal failure was already present. The contraindications of the use of hemodialysis were precarious cardiac performance, bowel infarction, nonviable lower extremities, recent myocardial infarction, or established cerebrovascular accident. The presence of ret¬

oliguric phase

roperitoneal hematoma, gastrointestinal tract bleeding, or sepsis were not regarded as contraindications. Judicious use of regional heparinization has eliminated the most common complication, hemorrhage. Hypotension was fre¬ quently noted, but could be easily managed by volume re¬ placement. Other reported major complications of dialysis, such as encephalopathy, convulsions, and cardiac arrhyth¬ mias, were not encountered." The observations evolved from this review encourage the use of hemodialysis in the management of acute renal failure complicating the postoperative course of patients undergoing surgery for ruptured abdominal aortic aneu¬ rysm. To achieve best results, hemodialysis should be in¬ stituted before other complications occur. Construction of an arteriovenous fistula at the completion of the initial op¬ eration for patients most likely to suffer acute renal fail¬ ure following surgery is recommended.

Nonproprietary Name and Trademark of Drug Furosemide—Lasix.

References 1. DeBakey ME, Crawford ES, Cooley DA, et al: Aneurysm of abdominal aorta: Analysis of results of graft replacement therapy one to 11 years after operation. Ann Thorac Surg 160:622-627, 1964. 2. MacVaugh H, Roberts B: Results of resection of abdominal aortic aneurysm. Surg Gynecol Obstet 113:17-23, 1961. 3. David JP, Mark C, Bonneval M: A ten year institutional experience with abdominal aneurysm. Surg Gynecol Obstet 138:591\x=req-\

594, 1974.

4. Graham AL, Najafi H, Dye WS, et al: Ruptured abdominal aortic aneurysm: Surgical management. Arch Surg 97:1024-1031, 1968. 5. Tilney NL, Bailey GL, Morgan AP: Sequential system failure after rupture of abdominal aortic aneurysm: An unresolved problem in postoperative care. Ann Surg 178:117-122, 1973. 6. Wantz GE, Guida PM, Moore SW: Immediate complications

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following abdominal aortic surgery. Surg Clin North Am 44:469\x=req-\ 7. Scribner BH, Magid GJ, Burnell JM: Prophylactic hemodialysis in the management of acute renal failure. Clin Res 8:136,1960. 8. Gordon LA, Simon ER, Rukes JM, et al: Studies in regional heparinization: II. Artificial-kidney hemodialysis without systemic heparinization: Preliminary report of a method using simultaneous infusion of heparin and protamine. N Engl J Med 255:1063, 1956. 9. Stenstrom JD, Ford HS, McKay MI, et al: Ruptured abdominal aortic aneurysm: A ten-year study. Am Surg 38:608-611,1972. 10. Fischer RP, Griffen WO, Resier M, et al: Early dialysis in the treatment of acute renal failure. Surg Gynecol Obstet 123:1019-1023, 1966. 11. Kleinknecht D, Ganeval D: Preventive hemodialysis in acute renal failure: Its effect on mortality and morbidity, in Friedman EA, Haskele E (eds): Proceedings of a Conference on Acute Renal Failure. Washington, DC, NIH Publications, 1973, pp 74-608, 165\x=req-\

481, 1964.

185. 12. Christianson J, Mouridsen HT: Ruptured aneurysm of the abdominal aorta: Factors of importance to operative mortality. Acta Chir Scand 133:111-118, 1967. 13. Flores J, DiBona DR, Beck CH, et al: The role of cell swelling in ischemic renal damage and the protective effect of hypertonic solute. J Clin Invest 51:118, 1972. 14. Abbott WM, Cooper JD, Austen WG: The effect of aortic clamping and declamping on renal blood flow distribution. J Surg Res 14:385-392, 1973. 15. Kaye M: Ethacrynic acid in acute renal failure. Lancet 1:1255, 1968. 16. Cantrovitch F, Locatelli A, Fernandez JC: Furosemide in high doses in the treatment of acute renal failure. Postgrad Med J 47(suppl):13-17, 1971. 17. Teschan PE, Baxter ER, O'Brien TF, et al: Prophylactic hemodialysis in the treatment of acute renal failure. Ann Intern Med 53:992-1016, 1960.

Discussion Roger D. Williams, MD, Fort Lauderdale, Fla: I would like to discuss both of these papers very briefly. Our experience with some 298 patients with aneurysm during the past ten years may be interesting, though quite similar, to both of these recent reports. One hundred fifty-two, or over half, have been over 70 years of age, and surprisingly, the mortality of 37% with ruptured aneurysms has been the same whether they are over or under 70. Elective mortality was twice as high in those patients over 70 years of age, 11% compared with 5%. Since a third of both groups had previous myocardial infarctions and over 40% had substantial hypertension, we have to ascribe this difference probably to the acceptance of a larger number of patients with chronic renal dis¬ ease and severe or substantial pulmonary lesions. It is important to emphasize that not only do we need good re¬ nal dialysis, but we need a good pulmonary function laboratory and good respiratory care if we are going to keep our mortality at reasonable rates. I would like to support the conclusion of Dr. Baker and his asso¬ ciates that observation in elderly patients may be indicated, but in our experience we must caution that roentgenographic examina¬ tion, ultrasound, technetium Tc 99m, and repeated physical exami¬ nations are not always accurate in determining the actual size of aneurysm, and if you are not sure, particularly in obese patients, it may be better to carry out elective operation. We have been a bit more fortunate than Dr. Chawla and his as¬ sociates in that hemodialysis has been available during the whole ten years of this study. One hundred patients with ruptured aneu¬ rysm have been seen, and 61% were over the age of 70. While 71 of these patients were in significant shock, more of them had shock during the operative procedure. There has been renal failure in only 17, and it is interesting that 12 of these 17 actually had preoperative BUN value elevations. Surprisingly, also, we have only had three deaths that we can relate in any way to the renal failure. We ascribe our results not only to the judicious use of fluids and diuretics but, I suspect, to avoidance of further blood loss by very limited dissection, the use of straight grafts in some 72% of our patients, and working intraaneurysmally. These patients just do not tolerate any additional



I agree with the excellent report from Chicago that if renal fail¬ ure is the only major complication, then these patients should sur¬ vive, but would ask the question: have they also seen a substantial increase in the number of postoperative ventral hernias in pa¬ tients who developed uremia? Max R. Gaspar, MD, Long Beach, Calif: In our private series of

330 aneurysm resections, the average age is about 67 years. About two thirds of the patients are over 65; so we are dealing with an older population. Our elective mortality since 1970 has been around 5%, but we have not been able to improve our mortality for ruptured aneurysms; it has stayed at 50%. We use a G suit if the patient is deeply in shock. The abdomen is prepared and draped with sterile towels in the emergency room, and the G suit is ap¬ plied and not removed until the patient is anesthetized, and the in¬ cision then is made immediately. It is a two-edged sword and should be used only in those patients who are deeply in shock. When used in patients not in shock, the blood pressure may fall precipitously when the G suit is removed. In 1958 we published an article stating that all aneurysms over 7 cm in diameter should be resected. Smaller aneurysms occasion¬ ally rupture; so I tend to agree with Dr. Baker's conclusions con¬ cerning resection of aneurysms less than 7.5 cm in diameter. We agree that patients with hypertension are a poor risk. I was sur¬ prised that patients with chronic obstructive pulmonary disease did not do more poorly than they did in his series. This is a very bad risk factor. I thought it was interesting that those with peripheral obstruc¬ tive disease did not do so well. As you know, most people with ab¬ dominal aortic aneurysms tend to have large arteries, but an occa¬ sional patient will also have obstructive disease in the iliac arteries. We recently reported a group of such patients in which the aneurysm thrombosed. It is as lethal as a ruptured aneurysm. This was a very good paper, and I tend to agree with the conclu¬ sions. I would like to ask what is done when a patient has a carotid lesion. Do you deal with the carotid lesion or the aneurysm first? George J. Reul, MD, Houston: We have recently reviewed the last 20 years' experience in the surgical treatment of ruptured ab¬ dominal aneurysm at the Texas Heart Institute. Our results are somewhat more favorable. We have operated on 87 patients, with a mortality of 21%. Recent operative mortality is even lower. Forty percent of the patients were in shock on admission. Most patients had rupture into the free peritoneal cavity. Following surgical repair, 18 patients developed acute renal failure. Five of these patients died because of renal failure early in the series prior to the use of hemodialysis. The other 13 patients also had hemodialysis and were long-term survivors. Early hemo¬ dialysis played an important role in their recovery. In our experience, important factors in the prevention of renal failure following repair of ruptured aortic aneurysm are limita¬ tion of renal ischemie time, avoidance and treatment of hypoten¬ sion, and the use of heparin and mannitol prior to occlusion of the aorta. Another critical factor that has not been stressed is the pre-

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vention of mechanical obstruction of the renal arteries by embolie debris, clot, or technical errors or by previous renal artery occlu¬ sive disease. The renal arteries should be examined and palpated to assess underlying critical renal artery stenosis. The orifices should be examined for clot or debris from the aneurysm and ap¬ propriate flushing should be done. Sutures in the proximal anasto¬ mosis should be carefully placed, avoiding the orifices of the renal arteries. After the anastomosis is completed, palpation of bilat¬ eral renal artery pulses is essential. In some instances, renal ar¬ tery bypass may be necessary. Furthermore, if there is no renal output in the first few hours following surgery, renal artery occlusion should be suspected and an aortogram may show occlusion of the renal arteries. We have recognized this on a few occasions and have performed renal ar¬ tery bypass or embolectomy or both successfully in the immediate

postoperative period.

I would like to ask the authors, then, if these measures were taken and if there was any autopsy evidence of renal artery occlu¬ sion in the patients who died of renal failure? Lee B. Brown, MD, Phoenix, Ariz: I just wanted to ask the au¬ thors of the last paper a question. We all recognize that a certain number of patients with rup¬ tured aneurysm are admitted with so-called contained rupture. They may be seen from 12 to 24 hours after the bleeding episode occurs.

With the very


results that have been

reported today,


managing patients with renal shutdown following aneurysmec¬ tomy, I simply wanted to ask whether the experience alters their judgment in making a decision for operation in patients who may have established renal shutdown with contained rupture of the an¬ eurysm. Dr. Ziffren: We want to thank the discussants. In answer to Dr. Williams, we have found that ultrasound has been very re¬ liable in following the measurement of the patient's aneurysm. As for Dr. Gaspar, we have not used the G suit. It sounds very inter¬ esting. We do operate on patients with carotid lesions before we do the aneurysm. Dr. Dye: I think Dr. Reul has hit on one of the crucial points in the prevention of this complication. We have done renal artery by¬ passes during surgery for ruptured aneurysms but not on very many occasions. I think some of our deaths have occurred in pa¬ tients where attention was not paid to the renal artery at the time of surgery. I am sure this is extremely important. In regard to getting control of the aorta, we also minimize the dissection. 1 think most surgeons' techniques are fairly standard in this respect. Our patient population comes from communities outside Chi¬ cago, since we have so many well-trained vascular surgeons in the city. We are, therefore, faced continually with the problem of pa¬ tients who are delayed for surgery. I have not seen the ventral hernia problem that Dr. Williams re¬


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Acute renal failure complicating ruptured abdominal aortic aneurysm.

Ruptured abdominal aortic aneurysm complicated by renal failure is associated with a mortality greater than 90%. Aggressive management, which included...
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