Late Complications of Abdominal Aortic Reconstructive Surgery: Roentgen Evaluation WILLIAM M. THOMPSON, M.D.,* IRWIN S. JOHNSRUDE, M.D., DONALD C. JACKSON, M.D., ROBERT A. OLDER, M.D., ANDREW S. WECHSLER, M.D.t
During a 5-year period from 1969 to 1974, 53 (8.5%) of 631 patients developed late complications following abdominal aortic reconstructive surgery. Occlusion was the most frequent complication and occurred in 4%. Others included stenosis, false aneurysm, enteric fistula and infection. Late complications were demonstrated by roentgenographic methods. Angiography was the most valuable roentgen study. It is indicated in all patients suspected of having delayed complications except those with unstable life-threatening hemorrhage. Additional roentgenographic studies including the barium enema and barium meal may help make the diagnosis and exclude other entities. In any patient with an abdominal aortic graft and gastrointestinal bleeding, the diagnosis of an aorto-enteric fistula should be considered until otherwise proven.
D UBOST'S first successful replacement of an abdominal aortic aneurysm with a homograft in 19515 was followed a year later by arterial replacement with prosthetic material. Further advances in operative technique and prosthetic grafts have improved mortality and morbidity in patients who undergo abdominal aortic reconstructive surgery. Results of operation vary with high mortality in acute ruptured aneurysms to low mortality and prolonged graft patency in patients with elective procedures.'-4'8-9'14 Complications of surgery may occur early before the end of normal healing of the vascular procedure. Early complications are related to operation (hemorrhage, infection, and thrombosis) or to problems of associated disease (renal failure, myocardial infarction, stroke and peripheyal ischemia). Late complications occur after the period of hospitalization necessary for adequate recovery from the operation. Late complications are less frequent and are different from those seen early in the postoperative period.14 Submitted for publication June 8, 1976. * Picker Scholar, James Picker Foundation. Department of Surgery, Duke University Medical Center, Durham, North Carolina. '
326
From the Departments of Radiology and Surgery, Duke University Medical Center, Durham, North Carolina
Late complications are a result of three events: 1) defective healing; 2) deterioration of the arterial implant; and 3) degenerative changes of the host artery.14 Since refinement of prosthetic grafts, deterioration of the arterial implant is rare and did not occur in this series. Defective healing may lead to false aneurysm formation with development of vascular-enteric fistulas, encroachment on neighboring organs, and late infection. Degenerative changes in the host artery include aneurysm formation at or near the suture lines, recurrence of intimal atheromatosis in endarterectomized segments, and stenosis of the host artery at suture lines. Radiology plays a major role in the evaluation of late complications but plays only a minor role in the diagnosis of early complications. This study deals with the occurrence and radiological evaluation of late complications in patients undergoing abdominal aortic reconstructive surgery. Methods and Materials
From 1969 to 1974, 712 patients underwent abdominal vascular operations at the Duke University Medical Center and the Durham Veterans Administration Hospital. All available records were reviewed and of the 712, 636 patients had reconstructive procedures of the abdominal aorta and/or iliac arteries. Isolated cases of renal artery stenosis. were excluded. These 636 patients form the basis of this report. Their charts were reviewed for details of previous surgery, late complications, presenting symptoms of
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TABLE 1. Late Complications Folloit,ing Operation fOr Reconstriction of Abdomilial Aortol
Complications False Aneuirysm Type of Operation
Total Primary Operations
Stenosis
For: Occlusive Vascular Disease Prosthesis Endarterectomy
249 19
For: Abdominal Aortic Aneurysms (41 ruptured) Prosthesis
Total *
Occlusion
With Enteric Fistula
Without Fistula
Graft Bed to Bowel Fistula
Infection"
Total
2) 1
16 4
2 -
3
1
2
26 (50%7), 6 (10)6/,)
363
1
5
6
9
1
631
4
25
8
13
2
21 (40%)
2
53
Refers to infection without graft visceral communication or false aneurysm.
late complications, interval from surgery to the onset of the late complications, roentgen findings and outcome. Results Fifty-three of 631 patients developed late complications following abdominal aortic reconstructive sur-
gery. Five additional patients were operated on initially at an outside hospital and referred to our center for treatment of their late complications. Three had bypass grafts and two underwent endarterectomies. Occlusion occurred in two, false aneurysm in one, a late infection in one, and a graft-enteric fistula in one. Excluding these 5 referred patients, the delayed com-
TABLE 2. Interval, Nuember of Vascul/ar Procedtures, Roenttgeni Findings, andl Oitcome ()1 636 Patients
Type of
Complication Stenosis Occlusion
No. 4
27
Average Interval from Primary Operation to Onset of Symptoms (Range)
Number of Vascular Operations
Roentgen Findings
12 mos (9 to 17 mos)
2.25
I-proximal lesion. 3-distal areas of
23 mos
2.7
Occlusion of graft or endarterectomized vessel demonstrated in each case
2-expired 6-amputations
43 mos (9 mos to II yrs)
3.4
24 false aneur-ysms encounter-ed. I false negative angiogram with clotted false aneul-ysm
5-expired
24 mos (I mo to 6 yrs)
2.5
1-erosion into duodenum on UGI.
7-expired
8 mos (7 to 10 mos) 22 mos (9 mos to 4 yrs)
2.0
Outcome
All alive
stenosis
(I mo to 13 yrs) False aneurysm
Proximal without complications Distal (3 infected) Proximal with aortoenteric fistula
Communication from graft bed to intestine (Paraprosthetic enteric fistula) Primary infection
12 8
2
3
no fistula on angiogram 2-extravasation at angiogr-aphy 3 false aneurysm on angiogram 2-not studied
2.6
1-barium extravasation on UGI 1-barium extravasation on BE All angiograms normal. sinogr-am in 2 showed extent of involvement.
Both alive
I-expired
328
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March 1977
4 patients. One patient did not have sufficient symptoms to warrant revision of the stenosis. Operation relieved ischemic symptoms in the other three.
Occlusion Six of 27 patients with late occlusions had endarterectomy as their primary operative procedure. The remaining 21 developed occlusion in a portion of their graft. The patients presented with varying degrees of ischemia. Angiography revealed the site of occlusion in each case (Figs. 2 and 3). Knowledge of prior surgical procedures was essential in determining the exact nature of the occlusion (Fig. 3). One of the 27 patients did not have a corrective procedure. She had good collateral circulation, and her symptoms did not warrant surgical treatment. Amputations were performed in 6 patients whose distal circulation could not be restored. Two patients suffering late occlusions expired, one from a bleeding gastric ulcer and the other from sepsis following amputation.
False Aneurysms FIG. 1. An abdominal aortogram in a 55-year-old woman 8 months after implantation of an aorto-femoral graft for occlusive vascular disease. Stenosis (arrow) is demonstrated at the proximal
anastomosis.
Twenty-two patients developed false aneurysms.
false aneurysms. Twenty-to pe Twenty-four false aneurysms occurred In
14 patients who did not have aortoenteric fistulas (Table 2). Two of these were at the proximal anastomosis. Eleven of the 14 patients with false aneurysms had either
plication rate was 8.5%. Table 1 lists the complications in the 631 patients following operation at the Duke University and the Durham Veterans Administration Hospitals. The most common complication was occlusion of the graft or endarterectomized vessel. These were followed in frequency by false aneurysm and graft-enteric fistulas. More complications occured in patients treated for occlusive vascular disease than those treated for abdominal aortic aneurysms. The age range of the patients was from 42 to 80 years, and the ratio of men to women was 6 to one. The interval from operation to onset of symptoms caused by the late complications had a wide range but averaged over 12 months (Table 2). Most of the patients with late complications were operated on more than twice, one undergoing 6 vascular procedures. The radiographic findings are listed in Table 2 for each specific group of complications. Fifteen of the 58 patients expired during the 5-year period.
..
Stenosis Four patients developed stenosis at anastomotic sites. One was at the proximal (Fig. 1), and three at tedtl were at the distal anastomosis. Claudication and signs of vascular insufficiency were present in 3 of the were
nso
FIG. 2. A translumbar aortogram in a 60-year-old man 3 years after an aorto-iliac endarterectomy for occlusive vascular disease. is complete occlusion of the abdominal aorta at the level sThere of the renal arteries. The patient subsequently underwent an
aorto-femoral bypass.
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FIGS. 3a and b. (left) A translumbar aortogram in a 49-year-old woman two years following an aorto-femoral graft for occlusive vascular disease. There is occlusion of the left limb of the graft and stenosis at the distal anastomosis on the right. (right) The diagram shows the relationship of the graft to the patient's patent left iliac artery.
aortoiliac or aorto-femoral grafts. Endartertomy had been performed in two and in one patient the aneurysm was wrapped with Dacron. Obvious clinical signs of infection were present in three of the 14 patients. Nine patients presented with painful expanding masses in the groin or lower abdomen. The two patients with proximal anastomotic false aneurysms developed back pain which prompted their admission and angiographic examinations. Angiograms (Figs. 4 and 5) demonstrated the false aneurysms in all but one patient. The false negative angiogram was obtained in a patient whose false aneurysm was filled with thrombus. Five of the 14 patients expired, four as a result of complications from multiple surgical procedures and one from a dissecting thoracic aortic aneurysm. Eight of the false aneurysms were associated with aorto-enteric fisutlas. All these patients presented with gastrointestinal bleeding of varying degrees. Two of the patients had signs of infection and three had abdominal pain. The average length of symptoms was 21 days, and ranged from one day to two months. The roentgen findings for the 8 patients are listed in Table 2. Angiograms were performed in 6 patients. Obvious extravasation was demonstrated in one (Fig. 8) with subtle extravasation noted in another. False aneurysms were demonstrated by angiography in three patients (Fig. 9). The angiogram in the sixth patient (Fig. 6a) showed only dilatation of the
aorta above the graft without evidence of a fistula. An upper gastrointestinal examination in this patient showed evidence of a large mass eroding the duodenum (Fig. 6b). The findings suggested an aorto-enteric
FIG. 4. A pelvic angiogram in a 60-year-old man 3 years following an aorto-femoral graft for occlusive disease. He developed a tender pulsatile mass in the groin. The aortogram demonstrates a 3 cm false aneurym at the distal anastomosis on the left (arrow).
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FIGS. 5 a and b. Frontal (left) and lateral (right) films from an abdominal aortogram in a 49-year-old man who 8 weeks earlier had an aortic graft implanted for a ruptured abdominal aortic aneurysm. The patient was admitted with an expanding abdominal mass. The aortogram reveals massive extravasation in the retroperitoneum from the distal anastomosis (arrow).
fistula. The upper gastrointestinal studies in two patients were normal but the communication in these patients were from the graft to the jejunum in one and ilium in the other. The diagnosis was made preoperatively in 5 of these 8 patients as the subtle extravasation in one patient was noted in retrospect following surgery. The other patients did not have complete roentgen examination as one patient was taken straight to the operating room. The other was felt to be bleeding from diverticulosis of the colon, however, at operation a false aneurysm with an aorto-ileal fistula was discovered. Seven of the 8 patients expired. The complete details of these patients have been reported previously. 10
Paraprosthetic-enteric Fistula Two patients developed a communication from the intestinal lumen to the prosthetic graft bed. In one patient the graft eroded into the posterior wall of the
duodenum. In the other the iliac limb of the bifurcation graft eroded into the sigmoid colon (Fig. 7). Both of these patients presented with signs of infection and their lesions were demonstrated by barium studies. An angiogram in the patient with the communication to the sigmoid colon was normal. Neither of the patients had false aneurysms at operation. Axillofemoral bypass grafts were performed in both following removal of the original aorta-femoral graft. Primary Infection
Three patients developed late infections of their grafts without other associated abnormalities. All three presented with pulsatile tender groin masses, and in addition, two had draining sinuses. Angiograms were normal in each case (Fig. 9). Sinograms (Fig. 10) revealed the extent of the sinus tracts in two patients. The infected grafts had to be removed in two of the patients, and one subsequenty expired as a result of complications from the infection. In the third patient,
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ps
FIG. 6a. Abdominal aortogram in a 53-year-old man 5 years following resection of an abdominal aortic aneurysm. He was referred to our hospital following the sudden onset of hematemesis. There is marked ectasia and dilatation of the aorta above the patent graft. The filling defect (arrows) represents a large thrombus. Calcification (Ca++) is present in the aortic wall. No fistula is demonstrated. (Reproduced with the permission of the American Journal of Roentgenology. Radium Therapy and Nuclear Medicine. "')
the infection extended only superficially to the graft bed and did not involve the graft. He was managed with local wound care and has not had recurrent infection. Infection was also present in 3 of 14 patients with false aneurysms and was present in all 10 patients with enteric fistulas. Therefore, a total of 16 patients had infection as a late complication. Discussion The incidence of late complications in this series was 8.5%. Our series compares favorably with the 5 to 9% late complication rate reported by others.2'3'79'14'12"6 The presenting symptoms pointed to the specific problem in the majority of patients and were good
FIG. 7. A barium enema in a 59-year-old woman who 7 months previously had an aorto-iliac graft for relief of occlusive vascular disease. She had a two week-history of pain and swelling in the left groin. The enema shows a paraprosthetic-enteric fistula with extravasation of barium from the sigmoid outlining the left iliac limb of the graft (arrows). (Reproduced with the permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.'0)
FIG. 6B. A barium meal reveals a large mass eroding the duodenum felt to represent the aorto-duodenal fistula found at operation. (Reproduced with the permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.')
indicators of the underlying complication. The exception to this was in the gorup of patients with enteric fistulas. Here the signs and symptoms were more
332
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Ann. Stirg. * March 1977
FIG. 8. A 77-year-old man who three and one half weeks earlier underwent resection of abdominal aortic aneurysm. He was admitted with massive hematemesis. The aortogram demonstrates extravasation of contrast from the proximal aortic suture line into the duodenum (arrows). (Reproduced with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.10
subtle.15 However in any patient with a previous abdominal aortic graft and gastrotinestinal bleeding or retroperitoneal infection, an aorto-enteric fistula should be considered the diagnosis until otherwise proven.
FIG. 9. An abdominal aortogram performed in a 49-year-old man who 15 months earlier had an aorto-iliac bypass graft for occlusive vascular disease. He was admitted with abdominal pain and intestinal bleeding. A false aneurysm is demonstrated on the aortogram (arrow). No bleeding site is noted. At operation an aorto-duodenal fistula was found. (Reproduced with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.10)
There were not enough patients in any of the groups to develop statistically significant differences in the interval from the patients' initial operation to onset of symptoms. Excluding a few cases, they were all quite similar (Table 2). Occlusion accounted for 4% of the delayed complications. In many patients, late occlusion and/or stenosis is related to progression of the occlusive vascular disease rather than to complications related to operation.8 Normally, following vascular reconstructive surgery, a small amount of thrombus forms at the suture line, but it resorbs in 10-20 days. If thrombus persists or develops later and becomes organized, intimal thickening and luminal narrowing occur at the anastomosis.4'10 Stenosis may progress to occlusion. Late graft occlusions occr less frequently when the graft replaces vessels with aneurysms or localized trauma than when it replaces primary
occlusive disease. Infection in the operative site is one of the most serious complications in patients undergoing arterial reconstructive surgery. Sixteen patients in our series (3%) had infections. This compares with 1.9o incidence reported by Szilagyi et al.'3 The commonest site of infection in patients following aorto-femoral bypass grafts is in the groin.8'13 Infection may lead to thrombosis. Graft infection may also cause disturbance in healing and suture line failure, leading to hemorrhage, false aneurysm, and rupture at the anastomosis. The state and degree of infection determines the clinical course of this complication and which radiological findings may be present. The angiograms may be normal (Fig. 10), or show false aneurysms (Figs. 4, 5 and 9). With longstanding infections, graft
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333
and ureters17 have been reported as late complications. Recently we encountered a massive fistula from the aortic graft to the inferior vena cava. We did not encounter deterioration of any arterial grafts. 14 Dacron grafts were used exclusively to reconstruct the aorta and iliac vessels. The porous nature of
FIG. 10. A right posterior pelvic arteriogram in a 53-year-old man 3 years following a right ilio-femoral graft. There was a pulsatile inflamed mass in the right groin. The arteriogram is normal. An infected graft was removed.
this material permits a capillary and fibroblastic ingrowth to form a lining on its internal surface. This pseudointima is composed of elastic and connective tissue, smooth muscle cells, capillaries and arterioles.10 It is not as firmly attached as normal arterial intima and may be disrupted during a percutaneous puncture (Fig. 12). The roentgenologic approach to evaluating patients with delayed complications of reconstructive surgery is dictated by the clinical manifestations. Angiography was the primary roentgen procedure contributing to diagnosis of the late complications (Table 2). It is indicated in all cases except in patients with lifethreatening hemorrhage, especially those with unstable vital signs despite transfusions. The angiographic approach was dependent upon the available vessel. Since the majority of patients had grafts, the left axillary and translumbar approaches were used in most cases. A translumbar angiogram is contraindicated if the proximal anastomosis is thought to be infected.
cutaneous fistulas or graft-enteric fistulas may be
demonstrated (Figs. 6, 7, 8 and 1 1). Dilatation of the anastomotic site implies a false aneurysm, and this may occur because of infection. Defective healing disruption of the suture line, weakening of the adjacent arterial wall, and localized endarterectomy may also cause false aneurysms.4"4 False aneurysm at the suture line of the graft was the most healing defect in the large series14 and accounted for 6% of the delayed complications. False aneurysm was the second most common complication in the present series. Distinction of false aneuryms from true aneurysms beyond the anastomosis may be impossible. Surgical repair is required in any event to prevent fistualization and/or rupture. The same factors responsible for formation of false aneurysms may lead to late rupture of the false aneurysm into the retroperitoneum. There are other late complications that have been reported but they did not occur in our series. Retroperitoneal hemorrhage has been reported as a late complication.6 We chose to include our two cases with massive hemorrhage into the retroperitoneum under false aneurysms since the hemorrhage appeared confined (Fig. 7). Ischemia of the colon, which usually occurs in the early postoperative period, has been reported as late as three weeks after surgery.18 common
Septic embolization'7 and obstruction of both bowel'4
FIG. 11. A sinogram on a 55-year-old woman with an infected aorto-femoral graft two years following operation for occlusive vascular disease. The patient's angiogram was normal, the sinogram demonstrates an obvious graft cutaneous fistula. The graft was subsequently removed.
334
Ann. Stag. * March 1977
THOMPSON AND OTHERS
in delineating late complications of aortic reconstruction. Since barium examination was of high diagnostic specificity but for lesions of low occurrence, angiography is the initial procedure of choice except in the presence of exsanguinating hemorrhage. Demonstration of a false aneurysm in the presence of gastrointestinal bleeding appears to be of adequate specificity to mandate operation in any patient with prior aortic reconstructive operation. Additionally this knowledge allows construction of extra anatomic bypass grafts prior to abdominal exploration thereby facilitating control of aortic bleeding while maintaining peripheral perfusion. References FIGS. 12a and b. This 55-year-old woman had an abdominal aortic graft removed because of infection. She had a 95% stenosis of the left subclavian artery and bilateral axillo-femoral grafts. Patency in the left graft could only be studied by direct puncture of the axillo-femoral graft. The diagram (left) shows the complicated vascular situation. Note the pseudointimal flap raised by the direct graft puncture (arrows). The graft occluded 3 hours following the study and had to be replaced.
It is best to avoid puncturing grafts, but in two patients, this was the only approach available. One patient's graft subsequently occluded (Fig. 12), and the other suffered no complications. Barium studies may help establish a diagnosis of enteric fistula.13 They will also help exclude other causes for symptoms that may be unrelated to the abdominal aortic graft. If a cutaneous fistula is present, a sinogram may help determine the extent of the graft infection (Fig. 10). The diagnostic value of ultrasound in patients with abdominal aortic aneurysm is well known.11 Although not used in our group of patients, ultrasound has been used subsequently in a number of patients following their abdominal aortic operations. False aneurysms and retroperitoneal hematomas have been shown by ultrasound when the angiograms were normal. Ultrasound should prove to be a useful diagnostic technique in patients suspected of having late complications following abdominal aortic reconstructive surgery. The highest mortality in the 6 groups of patients was encountered in the 8 patients with graft-enteric fistulas (90%). There were 8 other patients who died. The major cause of death in 5 was infection of the graft or amputated extremity. The 3 remaining deaths occurred from unrelated causes. Those complications which do not include aorto-enteric fistula or infection are, as a rule, successfully treated with low mortality and a high rate of patent grafts.7'12"14 These patient experiences confirm the safety and diagnostic accuracy of roentgenographic techniques
1. Chiariello, L., Reul, G. J., Jr., Wukasch, D. C., et al.: Ruptured Abdominal Aortic Aneurysm. Am. J. Surg., 128:735, 1974. 2. Crawford, E. S., DeBakey, M. E., Morris, G. C., et al.: Evaluation of Late Failures After Reconstructive Operations for Occlusive Lesions of the Aorta and Iliac, Femoral, and Popliteal Arteries. Surgery, 47:79, 1960. 3. DeBakey, M. E., Crawford, E. S., Cooley, D. A., et al.: Aneurysm of Abdominal Aorta. Ann. Surg., 160:622, 1964. 4. Downs, A. R.: Aorto-Illiac Occlusive Disease. Surg. Clin. North Am., 54: 195, 1974. 5. Dubost, C., Allary, M., and Oeconomos, N.: Resection of an Aneurysm of the Abdominal Aorta: Re-Establishment of the Continuity by a Preserved Human Arterial Graft with Result After Five Months. Arch. Surg., 64:405, 1952. 6. Humphries, A. W., Young, J. R., de Wolfe, V. G., and LeFevre, F. A.: Complications of Abdominal Aortic Surgery. Arch. Surg., 86:43, 1963. 7. Imparato, A. M., Sanoudos, G., Epstein, H. Y., et al.: Results in 96 Aortoiliac Reconstructive Procedures: Preoperative Angiographic and Functional Classifications Used as Prognostic Guides. Surgery, 68:610, 1970. 8. Javid, H. X., Julian, 0. C., Dye, W. S., et al.: Complications of Abdominal Aortic Graft. Arch. Surg., 85:142, 1962. 9. Kouchoukos, N. T., Levy, J. F., Balfour, J. E., et al.: Operative Therapy for Aortoiliac Arterial Occlusive Disease. Arch. Surg., 96:628, 1968. 10. Krippaehne, W. W.: Arterial Substitutes, In Davis-Christopher's Textbook of Surgery, 10th Edition: Sabiston, D. C., Jr. (ed). Philadelphia, W. B. Saunders Company, 1972; pp. 1642-1650. 11. Lee, R. L., Walls, W. J., Martin, N. L., et al.: A Practical Approach to the Diagnosis of Abdominal Aortic Aneurysms. Surgery, 78:195, 1975. 12. Moore, W. S., Cafferata, H. T., Hall, A. P., et al.: In Defense of Grafts Across the Inguinal Ligament: An Evaluation of Early and Late Results of Aorto-Femoral Bypass Grafts. Ann. Surg., 168:207, 1968. 13. Szilagyi, D. E., Smith, R. F., Elliott, J. R., et al.: Infection in Arterial Reconstruction with Synthetic Grafts. Ann. Surg., 176:321, 1972. 14. Szilagyi, D. E., Smith, R. D., Elliot, J. P., et al.: Secondary Arterial Repair. Arch. Surg., 110:485, 1975. 15. Thompson, W. M., Jackson, D. C., and Johnsrude, I. S.: Aorto-Enteric and Paraprosthetic-Enteric Fistulas: Roentgen Findings. Am. J. Roentgenol. Radium Ther. Nucl. Med., In Press. 127:235, 1976. 16. Waibel, P. P. and Dunant, J. H.: Late Results of Aorto-Iliac Reconstructive Surgery. J. Cardiovasc. Surg., 14:492, 1973. 17. Willwerth, B. M. and Waldhausen, J. A.: Infection of Arterial Prostheses. Surg. Gynecol. Obstet., 139:446, 1974. 18. Young, J. R., Humphries, A. W., de Wolfe, V. G., and Le Fevre, F. A.: Complications of Abdominal Aortic Surgery. Arch. Surg., 86:51, 1963.
During a 5-year period from 1969 to 1974, 53 (8.5%) of 631 patients developed late complications following abdominal aortic reconstructive surgery. Occlusion was the most frequent complication and occurred in 4%. Others included stenosis, false aneurysm, enteric fistula and infection. Late complications were demonstrated by roentgenographic methods. Angiography was the most valuable roentgen study. It is indicated in all patients suspected of having delayed complications except those with unstable life-threatening hemorrhage. Additional roentgenographic studies including the barium enema and barium meal may help make the diagnosis and exclude other entities. In any patient with an abdominal aortic graft and gastrointestinal bleeding, the diagnosis of an aorto-enteric fistula should be considered until otherwise proven.
D UBOST'S first successful replacement of an abdominal aortic aneurysm with a homograft in 19515 was followed a year later by arterial replacement with prosthetic material. Further advances in operative technique and prosthetic grafts have improved mortality and morbidity in patients who undergo abdominal aortic reconstructive surgery. Results of operation vary with high mortality in acute ruptured aneurysms to low mortality and prolonged graft patency in patients with elective procedures.'-4'8-9'14 Complications of surgery may occur early before the end of normal healing of the vascular procedure. Early complications are related to operation (hemorrhage, infection, and thrombosis) or to problems of associated disease (renal failure, myocardial infarction, stroke and peripheyal ischemia). Late complications occur after the period of hospitalization necessary for adequate recovery from the operation. Late complications are less frequent and are different from those seen early in the postoperative period.14 Submitted for publication June 8, 1976. * Picker Scholar, James Picker Foundation. Department of Surgery, Duke University Medical Center, Durham, North Carolina. '
326
From the Departments of Radiology and Surgery, Duke University Medical Center, Durham, North Carolina
Late complications are a result of three events: 1) defective healing; 2) deterioration of the arterial implant; and 3) degenerative changes of the host artery.14 Since refinement of prosthetic grafts, deterioration of the arterial implant is rare and did not occur in this series. Defective healing may lead to false aneurysm formation with development of vascular-enteric fistulas, encroachment on neighboring organs, and late infection. Degenerative changes in the host artery include aneurysm formation at or near the suture lines, recurrence of intimal atheromatosis in endarterectomized segments, and stenosis of the host artery at suture lines. Radiology plays a major role in the evaluation of late complications but plays only a minor role in the diagnosis of early complications. This study deals with the occurrence and radiological evaluation of late complications in patients undergoing abdominal aortic reconstructive surgery. Methods and Materials
From 1969 to 1974, 712 patients underwent abdominal vascular operations at the Duke University Medical Center and the Durham Veterans Administration Hospital. All available records were reviewed and of the 712, 636 patients had reconstructive procedures of the abdominal aorta and/or iliac arteries. Isolated cases of renal artery stenosis. were excluded. These 636 patients form the basis of this report. Their charts were reviewed for details of previous surgery, late complications, presenting symptoms of
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TABLE 1. Late Complications Folloit,ing Operation fOr Reconstriction of Abdomilial Aortol
Complications False Aneuirysm Type of Operation
Total Primary Operations
Stenosis
For: Occlusive Vascular Disease Prosthesis Endarterectomy
249 19
For: Abdominal Aortic Aneurysms (41 ruptured) Prosthesis
Total *
Occlusion
With Enteric Fistula
Without Fistula
Graft Bed to Bowel Fistula
Infection"
Total
2) 1
16 4
2 -
3
1
2
26 (50%7), 6 (10)6/,)
363
1
5
6
9
1
631
4
25
8
13
2
21 (40%)
2
53
Refers to infection without graft visceral communication or false aneurysm.
late complications, interval from surgery to the onset of the late complications, roentgen findings and outcome. Results Fifty-three of 631 patients developed late complications following abdominal aortic reconstructive sur-
gery. Five additional patients were operated on initially at an outside hospital and referred to our center for treatment of their late complications. Three had bypass grafts and two underwent endarterectomies. Occlusion occurred in two, false aneurysm in one, a late infection in one, and a graft-enteric fistula in one. Excluding these 5 referred patients, the delayed com-
TABLE 2. Interval, Nuember of Vascul/ar Procedtures, Roenttgeni Findings, andl Oitcome ()1 636 Patients
Type of
Complication Stenosis Occlusion
No. 4
27
Average Interval from Primary Operation to Onset of Symptoms (Range)
Number of Vascular Operations
Roentgen Findings
12 mos (9 to 17 mos)
2.25
I-proximal lesion. 3-distal areas of
23 mos
2.7
Occlusion of graft or endarterectomized vessel demonstrated in each case
2-expired 6-amputations
43 mos (9 mos to II yrs)
3.4
24 false aneur-ysms encounter-ed. I false negative angiogram with clotted false aneul-ysm
5-expired
24 mos (I mo to 6 yrs)
2.5
1-erosion into duodenum on UGI.
7-expired
8 mos (7 to 10 mos) 22 mos (9 mos to 4 yrs)
2.0
Outcome
All alive
stenosis
(I mo to 13 yrs) False aneurysm
Proximal without complications Distal (3 infected) Proximal with aortoenteric fistula
Communication from graft bed to intestine (Paraprosthetic enteric fistula) Primary infection
12 8
2
3
no fistula on angiogram 2-extravasation at angiogr-aphy 3 false aneurysm on angiogram 2-not studied
2.6
1-barium extravasation on UGI 1-barium extravasation on BE All angiograms normal. sinogr-am in 2 showed extent of involvement.
Both alive
I-expired
328
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4 patients. One patient did not have sufficient symptoms to warrant revision of the stenosis. Operation relieved ischemic symptoms in the other three.
Occlusion Six of 27 patients with late occlusions had endarterectomy as their primary operative procedure. The remaining 21 developed occlusion in a portion of their graft. The patients presented with varying degrees of ischemia. Angiography revealed the site of occlusion in each case (Figs. 2 and 3). Knowledge of prior surgical procedures was essential in determining the exact nature of the occlusion (Fig. 3). One of the 27 patients did not have a corrective procedure. She had good collateral circulation, and her symptoms did not warrant surgical treatment. Amputations were performed in 6 patients whose distal circulation could not be restored. Two patients suffering late occlusions expired, one from a bleeding gastric ulcer and the other from sepsis following amputation.
False Aneurysms FIG. 1. An abdominal aortogram in a 55-year-old woman 8 months after implantation of an aorto-femoral graft for occlusive vascular disease. Stenosis (arrow) is demonstrated at the proximal
anastomosis.
Twenty-two patients developed false aneurysms.
false aneurysms. Twenty-to pe Twenty-four false aneurysms occurred In
14 patients who did not have aortoenteric fistulas (Table 2). Two of these were at the proximal anastomosis. Eleven of the 14 patients with false aneurysms had either
plication rate was 8.5%. Table 1 lists the complications in the 631 patients following operation at the Duke University and the Durham Veterans Administration Hospitals. The most common complication was occlusion of the graft or endarterectomized vessel. These were followed in frequency by false aneurysm and graft-enteric fistulas. More complications occured in patients treated for occlusive vascular disease than those treated for abdominal aortic aneurysms. The age range of the patients was from 42 to 80 years, and the ratio of men to women was 6 to one. The interval from operation to onset of symptoms caused by the late complications had a wide range but averaged over 12 months (Table 2). Most of the patients with late complications were operated on more than twice, one undergoing 6 vascular procedures. The radiographic findings are listed in Table 2 for each specific group of complications. Fifteen of the 58 patients expired during the 5-year period.
..
Stenosis Four patients developed stenosis at anastomotic sites. One was at the proximal (Fig. 1), and three at tedtl were at the distal anastomosis. Claudication and signs of vascular insufficiency were present in 3 of the were
nso
FIG. 2. A translumbar aortogram in a 60-year-old man 3 years after an aorto-iliac endarterectomy for occlusive vascular disease. is complete occlusion of the abdominal aorta at the level sThere of the renal arteries. The patient subsequently underwent an
aorto-femoral bypass.
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FIGS. 3a and b. (left) A translumbar aortogram in a 49-year-old woman two years following an aorto-femoral graft for occlusive vascular disease. There is occlusion of the left limb of the graft and stenosis at the distal anastomosis on the right. (right) The diagram shows the relationship of the graft to the patient's patent left iliac artery.
aortoiliac or aorto-femoral grafts. Endartertomy had been performed in two and in one patient the aneurysm was wrapped with Dacron. Obvious clinical signs of infection were present in three of the 14 patients. Nine patients presented with painful expanding masses in the groin or lower abdomen. The two patients with proximal anastomotic false aneurysms developed back pain which prompted their admission and angiographic examinations. Angiograms (Figs. 4 and 5) demonstrated the false aneurysms in all but one patient. The false negative angiogram was obtained in a patient whose false aneurysm was filled with thrombus. Five of the 14 patients expired, four as a result of complications from multiple surgical procedures and one from a dissecting thoracic aortic aneurysm. Eight of the false aneurysms were associated with aorto-enteric fisutlas. All these patients presented with gastrointestinal bleeding of varying degrees. Two of the patients had signs of infection and three had abdominal pain. The average length of symptoms was 21 days, and ranged from one day to two months. The roentgen findings for the 8 patients are listed in Table 2. Angiograms were performed in 6 patients. Obvious extravasation was demonstrated in one (Fig. 8) with subtle extravasation noted in another. False aneurysms were demonstrated by angiography in three patients (Fig. 9). The angiogram in the sixth patient (Fig. 6a) showed only dilatation of the
aorta above the graft without evidence of a fistula. An upper gastrointestinal examination in this patient showed evidence of a large mass eroding the duodenum (Fig. 6b). The findings suggested an aorto-enteric
FIG. 4. A pelvic angiogram in a 60-year-old man 3 years following an aorto-femoral graft for occlusive disease. He developed a tender pulsatile mass in the groin. The aortogram demonstrates a 3 cm false aneurym at the distal anastomosis on the left (arrow).
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FIGS. 5 a and b. Frontal (left) and lateral (right) films from an abdominal aortogram in a 49-year-old man who 8 weeks earlier had an aortic graft implanted for a ruptured abdominal aortic aneurysm. The patient was admitted with an expanding abdominal mass. The aortogram reveals massive extravasation in the retroperitoneum from the distal anastomosis (arrow).
fistula. The upper gastrointestinal studies in two patients were normal but the communication in these patients were from the graft to the jejunum in one and ilium in the other. The diagnosis was made preoperatively in 5 of these 8 patients as the subtle extravasation in one patient was noted in retrospect following surgery. The other patients did not have complete roentgen examination as one patient was taken straight to the operating room. The other was felt to be bleeding from diverticulosis of the colon, however, at operation a false aneurysm with an aorto-ileal fistula was discovered. Seven of the 8 patients expired. The complete details of these patients have been reported previously. 10
Paraprosthetic-enteric Fistula Two patients developed a communication from the intestinal lumen to the prosthetic graft bed. In one patient the graft eroded into the posterior wall of the
duodenum. In the other the iliac limb of the bifurcation graft eroded into the sigmoid colon (Fig. 7). Both of these patients presented with signs of infection and their lesions were demonstrated by barium studies. An angiogram in the patient with the communication to the sigmoid colon was normal. Neither of the patients had false aneurysms at operation. Axillofemoral bypass grafts were performed in both following removal of the original aorta-femoral graft. Primary Infection
Three patients developed late infections of their grafts without other associated abnormalities. All three presented with pulsatile tender groin masses, and in addition, two had draining sinuses. Angiograms were normal in each case (Fig. 9). Sinograms (Fig. 10) revealed the extent of the sinus tracts in two patients. The infected grafts had to be removed in two of the patients, and one subsequenty expired as a result of complications from the infection. In the third patient,
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ps
FIG. 6a. Abdominal aortogram in a 53-year-old man 5 years following resection of an abdominal aortic aneurysm. He was referred to our hospital following the sudden onset of hematemesis. There is marked ectasia and dilatation of the aorta above the patent graft. The filling defect (arrows) represents a large thrombus. Calcification (Ca++) is present in the aortic wall. No fistula is demonstrated. (Reproduced with the permission of the American Journal of Roentgenology. Radium Therapy and Nuclear Medicine. "')
the infection extended only superficially to the graft bed and did not involve the graft. He was managed with local wound care and has not had recurrent infection. Infection was also present in 3 of 14 patients with false aneurysms and was present in all 10 patients with enteric fistulas. Therefore, a total of 16 patients had infection as a late complication. Discussion The incidence of late complications in this series was 8.5%. Our series compares favorably with the 5 to 9% late complication rate reported by others.2'3'79'14'12"6 The presenting symptoms pointed to the specific problem in the majority of patients and were good
FIG. 7. A barium enema in a 59-year-old woman who 7 months previously had an aorto-iliac graft for relief of occlusive vascular disease. She had a two week-history of pain and swelling in the left groin. The enema shows a paraprosthetic-enteric fistula with extravasation of barium from the sigmoid outlining the left iliac limb of the graft (arrows). (Reproduced with the permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.'0)
FIG. 6B. A barium meal reveals a large mass eroding the duodenum felt to represent the aorto-duodenal fistula found at operation. (Reproduced with the permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.')
indicators of the underlying complication. The exception to this was in the gorup of patients with enteric fistulas. Here the signs and symptoms were more
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Ann. Stirg. * March 1977
FIG. 8. A 77-year-old man who three and one half weeks earlier underwent resection of abdominal aortic aneurysm. He was admitted with massive hematemesis. The aortogram demonstrates extravasation of contrast from the proximal aortic suture line into the duodenum (arrows). (Reproduced with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.10
subtle.15 However in any patient with a previous abdominal aortic graft and gastrotinestinal bleeding or retroperitoneal infection, an aorto-enteric fistula should be considered the diagnosis until otherwise proven.
FIG. 9. An abdominal aortogram performed in a 49-year-old man who 15 months earlier had an aorto-iliac bypass graft for occlusive vascular disease. He was admitted with abdominal pain and intestinal bleeding. A false aneurysm is demonstrated on the aortogram (arrow). No bleeding site is noted. At operation an aorto-duodenal fistula was found. (Reproduced with permission of the American Journal of Roentgenology, Radium Therapy and Nuclear Medicine.10)
There were not enough patients in any of the groups to develop statistically significant differences in the interval from the patients' initial operation to onset of symptoms. Excluding a few cases, they were all quite similar (Table 2). Occlusion accounted for 4% of the delayed complications. In many patients, late occlusion and/or stenosis is related to progression of the occlusive vascular disease rather than to complications related to operation.8 Normally, following vascular reconstructive surgery, a small amount of thrombus forms at the suture line, but it resorbs in 10-20 days. If thrombus persists or develops later and becomes organized, intimal thickening and luminal narrowing occur at the anastomosis.4'10 Stenosis may progress to occlusion. Late graft occlusions occr less frequently when the graft replaces vessels with aneurysms or localized trauma than when it replaces primary
occlusive disease. Infection in the operative site is one of the most serious complications in patients undergoing arterial reconstructive surgery. Sixteen patients in our series (3%) had infections. This compares with 1.9o incidence reported by Szilagyi et al.'3 The commonest site of infection in patients following aorto-femoral bypass grafts is in the groin.8'13 Infection may lead to thrombosis. Graft infection may also cause disturbance in healing and suture line failure, leading to hemorrhage, false aneurysm, and rupture at the anastomosis. The state and degree of infection determines the clinical course of this complication and which radiological findings may be present. The angiograms may be normal (Fig. 10), or show false aneurysms (Figs. 4, 5 and 9). With longstanding infections, graft
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and ureters17 have been reported as late complications. Recently we encountered a massive fistula from the aortic graft to the inferior vena cava. We did not encounter deterioration of any arterial grafts. 14 Dacron grafts were used exclusively to reconstruct the aorta and iliac vessels. The porous nature of
FIG. 10. A right posterior pelvic arteriogram in a 53-year-old man 3 years following a right ilio-femoral graft. There was a pulsatile inflamed mass in the right groin. The arteriogram is normal. An infected graft was removed.
this material permits a capillary and fibroblastic ingrowth to form a lining on its internal surface. This pseudointima is composed of elastic and connective tissue, smooth muscle cells, capillaries and arterioles.10 It is not as firmly attached as normal arterial intima and may be disrupted during a percutaneous puncture (Fig. 12). The roentgenologic approach to evaluating patients with delayed complications of reconstructive surgery is dictated by the clinical manifestations. Angiography was the primary roentgen procedure contributing to diagnosis of the late complications (Table 2). It is indicated in all cases except in patients with lifethreatening hemorrhage, especially those with unstable vital signs despite transfusions. The angiographic approach was dependent upon the available vessel. Since the majority of patients had grafts, the left axillary and translumbar approaches were used in most cases. A translumbar angiogram is contraindicated if the proximal anastomosis is thought to be infected.
cutaneous fistulas or graft-enteric fistulas may be
demonstrated (Figs. 6, 7, 8 and 1 1). Dilatation of the anastomotic site implies a false aneurysm, and this may occur because of infection. Defective healing disruption of the suture line, weakening of the adjacent arterial wall, and localized endarterectomy may also cause false aneurysms.4"4 False aneurysm at the suture line of the graft was the most healing defect in the large series14 and accounted for 6% of the delayed complications. False aneurysm was the second most common complication in the present series. Distinction of false aneuryms from true aneurysms beyond the anastomosis may be impossible. Surgical repair is required in any event to prevent fistualization and/or rupture. The same factors responsible for formation of false aneurysms may lead to late rupture of the false aneurysm into the retroperitoneum. There are other late complications that have been reported but they did not occur in our series. Retroperitoneal hemorrhage has been reported as a late complication.6 We chose to include our two cases with massive hemorrhage into the retroperitoneum under false aneurysms since the hemorrhage appeared confined (Fig. 7). Ischemia of the colon, which usually occurs in the early postoperative period, has been reported as late as three weeks after surgery.18 common
Septic embolization'7 and obstruction of both bowel'4
FIG. 11. A sinogram on a 55-year-old woman with an infected aorto-femoral graft two years following operation for occlusive vascular disease. The patient's angiogram was normal, the sinogram demonstrates an obvious graft cutaneous fistula. The graft was subsequently removed.
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in delineating late complications of aortic reconstruction. Since barium examination was of high diagnostic specificity but for lesions of low occurrence, angiography is the initial procedure of choice except in the presence of exsanguinating hemorrhage. Demonstration of a false aneurysm in the presence of gastrointestinal bleeding appears to be of adequate specificity to mandate operation in any patient with prior aortic reconstructive operation. Additionally this knowledge allows construction of extra anatomic bypass grafts prior to abdominal exploration thereby facilitating control of aortic bleeding while maintaining peripheral perfusion. References FIGS. 12a and b. This 55-year-old woman had an abdominal aortic graft removed because of infection. She had a 95% stenosis of the left subclavian artery and bilateral axillo-femoral grafts. Patency in the left graft could only be studied by direct puncture of the axillo-femoral graft. The diagram (left) shows the complicated vascular situation. Note the pseudointimal flap raised by the direct graft puncture (arrows). The graft occluded 3 hours following the study and had to be replaced.
It is best to avoid puncturing grafts, but in two patients, this was the only approach available. One patient's graft subsequently occluded (Fig. 12), and the other suffered no complications. Barium studies may help establish a diagnosis of enteric fistula.13 They will also help exclude other causes for symptoms that may be unrelated to the abdominal aortic graft. If a cutaneous fistula is present, a sinogram may help determine the extent of the graft infection (Fig. 10). The diagnostic value of ultrasound in patients with abdominal aortic aneurysm is well known.11 Although not used in our group of patients, ultrasound has been used subsequently in a number of patients following their abdominal aortic operations. False aneurysms and retroperitoneal hematomas have been shown by ultrasound when the angiograms were normal. Ultrasound should prove to be a useful diagnostic technique in patients suspected of having late complications following abdominal aortic reconstructive surgery. The highest mortality in the 6 groups of patients was encountered in the 8 patients with graft-enteric fistulas (90%). There were 8 other patients who died. The major cause of death in 5 was infection of the graft or amputated extremity. The 3 remaining deaths occurred from unrelated causes. Those complications which do not include aorto-enteric fistula or infection are, as a rule, successfully treated with low mortality and a high rate of patent grafts.7'12"14 These patient experiences confirm the safety and diagnostic accuracy of roentgenographic techniques
1. Chiariello, L., Reul, G. J., Jr., Wukasch, D. C., et al.: Ruptured Abdominal Aortic Aneurysm. Am. J. Surg., 128:735, 1974. 2. Crawford, E. S., DeBakey, M. E., Morris, G. C., et al.: Evaluation of Late Failures After Reconstructive Operations for Occlusive Lesions of the Aorta and Iliac, Femoral, and Popliteal Arteries. Surgery, 47:79, 1960. 3. DeBakey, M. E., Crawford, E. S., Cooley, D. A., et al.: Aneurysm of Abdominal Aorta. Ann. Surg., 160:622, 1964. 4. Downs, A. R.: Aorto-Illiac Occlusive Disease. Surg. Clin. North Am., 54: 195, 1974. 5. Dubost, C., Allary, M., and Oeconomos, N.: Resection of an Aneurysm of the Abdominal Aorta: Re-Establishment of the Continuity by a Preserved Human Arterial Graft with Result After Five Months. Arch. Surg., 64:405, 1952. 6. Humphries, A. W., Young, J. R., de Wolfe, V. G., and LeFevre, F. A.: Complications of Abdominal Aortic Surgery. Arch. Surg., 86:43, 1963. 7. Imparato, A. M., Sanoudos, G., Epstein, H. Y., et al.: Results in 96 Aortoiliac Reconstructive Procedures: Preoperative Angiographic and Functional Classifications Used as Prognostic Guides. Surgery, 68:610, 1970. 8. Javid, H. X., Julian, 0. C., Dye, W. S., et al.: Complications of Abdominal Aortic Graft. Arch. Surg., 85:142, 1962. 9. Kouchoukos, N. T., Levy, J. F., Balfour, J. E., et al.: Operative Therapy for Aortoiliac Arterial Occlusive Disease. Arch. Surg., 96:628, 1968. 10. Krippaehne, W. W.: Arterial Substitutes, In Davis-Christopher's Textbook of Surgery, 10th Edition: Sabiston, D. C., Jr. (ed). Philadelphia, W. B. Saunders Company, 1972; pp. 1642-1650. 11. Lee, R. L., Walls, W. J., Martin, N. L., et al.: A Practical Approach to the Diagnosis of Abdominal Aortic Aneurysms. Surgery, 78:195, 1975. 12. Moore, W. S., Cafferata, H. T., Hall, A. P., et al.: In Defense of Grafts Across the Inguinal Ligament: An Evaluation of Early and Late Results of Aorto-Femoral Bypass Grafts. Ann. Surg., 168:207, 1968. 13. Szilagyi, D. E., Smith, R. F., Elliott, J. R., et al.: Infection in Arterial Reconstruction with Synthetic Grafts. Ann. Surg., 176:321, 1972. 14. Szilagyi, D. E., Smith, R. D., Elliot, J. P., et al.: Secondary Arterial Repair. Arch. Surg., 110:485, 1975. 15. Thompson, W. M., Jackson, D. C., and Johnsrude, I. S.: Aorto-Enteric and Paraprosthetic-Enteric Fistulas: Roentgen Findings. Am. J. Roentgenol. Radium Ther. Nucl. Med., In Press. 127:235, 1976. 16. Waibel, P. P. and Dunant, J. H.: Late Results of Aorto-Iliac Reconstructive Surgery. J. Cardiovasc. Surg., 14:492, 1973. 17. Willwerth, B. M. and Waldhausen, J. A.: Infection of Arterial Prostheses. Surg. Gynecol. Obstet., 139:446, 1974. 18. Young, J. R., Humphries, A. W., de Wolfe, V. G., and Le Fevre, F. A.: Complications of Abdominal Aortic Surgery. Arch. Surg., 86:51, 1963.
