LETTERS TO T H E E D I T O R S 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,
The value o f computed tomography in the management o f symptomatic abdominal aortic aneurysms To the Editors: The use of CT scanning in the diagnosis of ruptured abdominal ao~xic aneurysms has been controversial because the patients die in the CT suite. While the results presented by Kvilekval et al. (J VAse SURG 1990;12:28-33) are very commendable and reflect an outstanding vascular service, "~e article as such must be considered dangerous, and I fear it will lead to unnecessary delays in the hands of physicians in the emergency rooms who are less skilled at assessing symptomatic abdominal aortic aneurysms than is the group from Stonybrook. The diagnosis of a ruptured abdominal aortic aneurysm is a clinial diagnosis that rarely requires CT scanning. There is no question that a careful medical evaluation and stabilization prior to operations on these patients will lead to a decreased mortality and a smoother postoperative course; however, in my opinion, the stabilization should take place in the operating room with all services on sharp alert. The CT scan should be used only for the occasional patient in whom one is seeking an excuse not to operate on a symptomatic abdominal aortic aneurysm. I worry that this article will become a guiding light for emergency room physicians as they shift patients around in the busy emergency rooms, trying to buy a little time here and there. I also worry that young residents who are prone to order too many tests will use this article as a crutch as they order a CT scan and an ultrasound in the middle of the :night over the telephone while they steal a minute or two more of sleep. Not every patient who goes to the operating room has to have a CT scan before getting there. The diagnosis of ruptured abdominal aortic aneurysm remains at clinical diagnosis, and any delay in all but the very best of hands is dangerous. Jean-Ren~ Dupont, MD Suite 101 CCMC Professional Bldg. Division of Vascular Surgery Crozer Chester Medical Center and Hahneman University Fifteenth St. and Upland Ave. Chester, PA 19013
Reply To the Editors: Thank you for the opportunity to respond to the comments o f Dr. Dupont concerning our article, '~Fhe Value of Computed Tomography in the Management of Syrup-
tomatic Abdominal Aortic Aneurysms" (J VASC SURG 1990;12:28-33). We agree with Dr. Dupont that the care of a patient with a symptomatic abdominal aortic aneurysm should not be relegated to either the emergency room physician or the most junior member of the team. Indeed, as our report states, not every patient must have a CT scan before going to the operating room. There is no question that those patients who are hemodynamically unstable should be taken for surgery without delay. There is, however, a group of patients (in our study, 69% [65/95]) who are stable enough to undergo an emergency CT scan. It is in these patients that the CT scan can be beneficial, not simply in identifying who among them must go immediately to the operating room or who among them may be optimized before undergoing repair; the c r scan also helps to define the intraabdominal anatomy, including the extent of the aneurysm, any congenital anomalies, or other cause(s) of abdominal pain. In both subgroups, we found that surgery benefited from the additional information and that no increase in mortality resuited for the time delay imposed by the scan. Given the value of the CT findings, which allow the surgeon to modify the approach, if necessary, or to beware of venous anomalies, our recommendation of a preoperative CT scan in the hemodynamically stable patient is justified. Again, we agree that these patients must be carefully and expeditiously managed by an experienced surgeon, both during the evaluation and in transit, with the operating room ready. Kara Kvilekval, MD Vascular Division Department of Surgery, Health Sciences Center State University of New York at Stony Brook Stony Brook NY 11794-8191
Postischemic cell membrane dysfunction To the Editors: Ischemia/reperfusion injury presents a challenge vascular surgeons have to deal with not only in peripheral vascular procedures. We conducted a study to evaluate ischemia/reperfusion injury mediated by oxygen free radicals in aortic surgery. In 25 patients with thoracoabdominal and suprarenal aortic aneurysms blood samples were taken at time points before and during ischemia, during reperfusion, and on the first day after surgery. Plasma
351
The value o f computed tomography in the management o f symptomatic abdominal aortic aneurysms To the Editors: The use of CT scanning in the diagnosis of ruptured abdominal ao~xic aneurysms has been controversial because the patients die in the CT suite. While the results presented by Kvilekval et al. (J VAse SURG 1990;12:28-33) are very commendable and reflect an outstanding vascular service, "~e article as such must be considered dangerous, and I fear it will lead to unnecessary delays in the hands of physicians in the emergency rooms who are less skilled at assessing symptomatic abdominal aortic aneurysms than is the group from Stonybrook. The diagnosis of a ruptured abdominal aortic aneurysm is a clinial diagnosis that rarely requires CT scanning. There is no question that a careful medical evaluation and stabilization prior to operations on these patients will lead to a decreased mortality and a smoother postoperative course; however, in my opinion, the stabilization should take place in the operating room with all services on sharp alert. The CT scan should be used only for the occasional patient in whom one is seeking an excuse not to operate on a symptomatic abdominal aortic aneurysm. I worry that this article will become a guiding light for emergency room physicians as they shift patients around in the busy emergency rooms, trying to buy a little time here and there. I also worry that young residents who are prone to order too many tests will use this article as a crutch as they order a CT scan and an ultrasound in the middle of the :night over the telephone while they steal a minute or two more of sleep. Not every patient who goes to the operating room has to have a CT scan before getting there. The diagnosis of ruptured abdominal aortic aneurysm remains at clinical diagnosis, and any delay in all but the very best of hands is dangerous. Jean-Ren~ Dupont, MD Suite 101 CCMC Professional Bldg. Division of Vascular Surgery Crozer Chester Medical Center and Hahneman University Fifteenth St. and Upland Ave. Chester, PA 19013
Reply To the Editors: Thank you for the opportunity to respond to the comments o f Dr. Dupont concerning our article, '~Fhe Value of Computed Tomography in the Management of Syrup-
tomatic Abdominal Aortic Aneurysms" (J VASC SURG 1990;12:28-33). We agree with Dr. Dupont that the care of a patient with a symptomatic abdominal aortic aneurysm should not be relegated to either the emergency room physician or the most junior member of the team. Indeed, as our report states, not every patient must have a CT scan before going to the operating room. There is no question that those patients who are hemodynamically unstable should be taken for surgery without delay. There is, however, a group of patients (in our study, 69% [65/95]) who are stable enough to undergo an emergency CT scan. It is in these patients that the CT scan can be beneficial, not simply in identifying who among them must go immediately to the operating room or who among them may be optimized before undergoing repair; the c r scan also helps to define the intraabdominal anatomy, including the extent of the aneurysm, any congenital anomalies, or other cause(s) of abdominal pain. In both subgroups, we found that surgery benefited from the additional information and that no increase in mortality resuited for the time delay imposed by the scan. Given the value of the CT findings, which allow the surgeon to modify the approach, if necessary, or to beware of venous anomalies, our recommendation of a preoperative CT scan in the hemodynamically stable patient is justified. Again, we agree that these patients must be carefully and expeditiously managed by an experienced surgeon, both during the evaluation and in transit, with the operating room ready. Kara Kvilekval, MD Vascular Division Department of Surgery, Health Sciences Center State University of New York at Stony Brook Stony Brook NY 11794-8191
Postischemic cell membrane dysfunction To the Editors: Ischemia/reperfusion injury presents a challenge vascular surgeons have to deal with not only in peripheral vascular procedures. We conducted a study to evaluate ischemia/reperfusion injury mediated by oxygen free radicals in aortic surgery. In 25 patients with thoracoabdominal and suprarenal aortic aneurysms blood samples were taken at time points before and during ischemia, during reperfusion, and on the first day after surgery. Plasma
351
