Reply to Letter to the Editor re : Long-term outcome after inflammatory abdominal aortic aneurysm repair: case-matched study.

We appreciated the interest raised by our article [1] about inflammatory abdominal aortic aneurysms (AAA), as well as the letter of Dr. Tambyraja, who poses three main questions about the contents of our paper. An increased predisposition to graft-related complications in patients submitted to inflammatory AAA repair has not yet been clearly demonstrated either in previous studies or in the abstract published by Tambyraja et al [2]. Certainly definitive statements about the post-surgical long-term results or complications of this uncommon disease should be made cautiously. Nevertheless, although patient survival is the ideal goal to achieve and assess, a thorough evaluation of the fate of the aortic graft should be taken into account to define the true impact of the surgical treatment in this category of patients. In an era of worldwide applied technologies, the simple, yet accurate, clinical evaluation might be imprecise. Postoperative (short- and long-term) graft and aortic features need an instrumental examination (preferably a computerized tomographic [CT] scan) if they are to be evaluated properly. Indeed, in the article by Lindbald et al. [3], only 35/87 (40%) patients who survived surgical repair were submitted to instrumental follow-up (CT, ultrasound [US], urography), and in Niteckis series, 19/29 (66%) had a CT scan or US [4]. Similarly, no mention of postoperative investigations was made by Tambyraja and colleagues [2]. The need for a more detailed instrumental follow-up was well emphasized by Kalman et al [5], who showed a relatively high rate of vascular and graft abnormalities in the post-surgical period, discovered by CT scan, though clinically silent. Graft infections (demonstrated by cultures) were definitely not found in our study, even in the one patient who developed a prosthetic duodenal fistula. In fact, the fistula was observed 3 years after the second repair of an aneurysm involving the aorta at the previous suture line, a repair that was carried out more than 60 months after the first operation. In any case, the absence of proved infections would not be surprising, considering that the mechanism(s) of paraanastomotic aneurysms after inflammatory AAA repair might not be simply related to an infection but also to ischemic and nutritional damage to the aortic wall in this particular disease. Contamination of the graft consequent to the duodenal dissection as the only cause of paraanastomotic aneurysm seems unlikely. Regarding the percentages we reported from Lindblad et al. [3] and Nitecki et al. [4], we related them only to the patients instrumentally (and not simply clinically) evaluated during the follow-up, i. e., 3/35 (8.5%) for Niteckis patients [4] and 1/19 (5.2%) for Lindblads group [3]. Finally, the graft diameter we used for the repair in patients who showed paraanastomotic aneurysms was 20 mm, thus making unreliable the suggestion that the proximal anastomosis was performed below the aneurysmal aortic neck. In conclusion, although we agree about the relatively small sample size (18 patients) of inflammatory AAA, which however was compared with a matched control group of 54 patients (3 ×), we would like to emphasize that the message of our article was mainly to point out the need for accurate instrumental follow-up of repaired inflammatory AAA. Actually the peculiar characteristics of this disease might well predispose to graft and anastomosis alterations, which, in our opinion, should be more precisely assessed by a CT scan than by a clinical evaluation, which in terms of crude survival, is probably deceptive.