Great vessel management for endovascular exclusion of aortic arch aneurysms and dissections.

OBJECTIVES: To evaluate a recent approach for the endovascular repair of thoracic aortic aneurysms and dissections involving the aortic arch in high risk patients (HRP). METHODS: Amongst 102 thoracic aortic aneurysms and dissections, we treated 25 patients for aortic arch endovascular exclusion after transposition of the great vessels, of which 14 (56%) had thoracic aortic arch aneurysms and 11 type A and B chronic aortic dissections. Total transpositions were done in 15 cases (60%) and hemi-arch transpositions in 10. We then used Talent, Excluder and Zenith endografts in 12, seven and six cases, respectively. RESULTS: Surgical transpositions were complicated by one minor stroke, which worsened to a major stroke (4%) after endovascular exclusion. After endovascular exclusions, two patients (8%) died from catheterization related complications. One patient had a delayed minor stroke (4%). The successful exclusion rate was 92%. During follow-up (15+/-5.8 months), one patient (4%) developed unilateral limb palsy, successfully treated by CSF drainage. The late exclusion rate remained 92%. No stent-related complications were seen. CONCLUSIONS: Transposition of supra-aortic vessels allows the endovascular exclusion of the aortic arch in HRP. Aortic endografting after surgical transposition proved to be feasible and offers good mid-term results. Specialized surgical centers with both endovascular and surgical expertise are required to treat these patients.     

Endovascular Repair of a Saccular Infrarenal Aortic Aneurysm in a Liver Transplant Patient

Saccular infrarenal aortic aneurysms are rare lesions that usually require prompt surgical repair. In clinical situations where morbidity and mortality associated with open aortic surgery appear to be prohibitively high, an endovascular approach may serve as a life-saving alternative. We report successful endovascular repair of a symptomatic saccular infrarenal aortic aneurysm in a complicated liver transplant patient.     

Mycotic aneurysm of the abdominal aorta with retroperitoneal abscess: successful endovascular repair

Mycotic aortic aneurysms are rare. Improved diagnostic procedures, appropriate antibiotic treatment, and safe surgical techniques have reduced the high mortality associated with bacterial aortitis. However, definite evidence-based conclusions with regard to the surgical strategy cannot be drawn from the data available in the published literature. We report successful endovascular repair of a mycotic abdominal aortic aneurysm. Endovascular treatment may offer a benefit, especially in critically ill patients.     

Combined open and endovascular repair of a syphilitic aortic aneurysm

The use of endovascular stent grafts in the repair of thoracic aortic aneurysms has provided an alternative means of treatment, particularly in the high-risk patient who may not tolerate conventional open repair. The combination of conventional surgery and endovascular repair may allow for successful treatment in patients with anatomy unsuitable for repair entirely by endovascular means alone. We present the case of a patient with a syphilitic thoracic aortic aneurysm involving the aortic arch and descending thoracic aorta. He underwent a staged repair with an elephant trunk reconstruction of the aortic arch followed by endovascular repair of the descending thoracic aorta. This is the first reported case of the repair of a syphilitic aneurysm by means of endovascular techniques.     

Ruptured abdominal aortic aneurysm: endovascular program development and results

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.     

Endovascular Reconstruction of a New Aortoiliac Bifurcation to Manage a Ruptured Thoracoabdominal Pseudoaneurysm in a Marfan Patient

Abstract Traditional open surgical repair for aortic rupture from a thoracoabdominal pseudoaneurysm is associated with a high morbidity and mortality. The use of advanced intravascular imaging and endovascular techniques permits selection and customizing endoluminal graft components to treat such catastrophic events in high‐risk surgical patients. We report the successful management of a ruptured thoracoabdominal pseudoaneurysm with an endovascular approach.     

Successful treatment for infected aortic aneurysm using endovascular aneurysm repairs as a bridge to delayed open surgery

Management of infected aortic aneurysms, which can be life-threatening, remains challenging. Open surgical treatments, including debridement of the infected aorta and the surrounding tissue and either in situ reconstruction or extra-anatomic bypass covering with omentum or muscle flap, are the mainstay of therapy. However, increasing advances in technology have made endovascular treatment of infected aneurysms feasible. The present study describes the first clinical report of successful treatment of an infected aneurysm using endovascular techniques in the acute phase, followed by delayed open surgery.     

Inflammatory abdominal aortic aneurysm treated by endovascular stent grafting: a case report

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.     

Endovascular treatment of aortic dissections and thoracic aortic aneurysms

Diseases of the thoracic aorta pose a significant challenge to the surgeon because of the complexity of the disease and the characteristics of the patient population. Frequent comorbidities and increasing age account for mortality rates between 5% and 20% for surgical repair of descending thoracic aortic aneurysms and in excess of 50% for Stanford type B aortic dissections, when complicated by preoperative end-organ ischemia. Endovascular techniques of fenestration, stenting, and stent-grafting have emerged as viable alternatives to conventional surgery in these patients. The authors review their experience using endovascular stent-grafts in the treatment of 103 patients with descending thoracic aortic aneurysms and 19 patients with acute aortic dissections. Fenestration and stenting are also addressed as adjuvant therapies in the treatment of complicated aortic dissections. Actuarial survival for aneurysms was 81% +/- 5% at 1 year and 73% +/- 5% at 2 years. Stent-grafting for acute aortic dissections achieved instant relief of symptoms in 71% of cases with an early procedural mortality of 16%, and endovascular revascularization of ischemic beds was achieved in 93% +/- 4% of cases of peripheral or visceral ischemia. The authors' experience supports the use of endovascular techniques in the treatment of thoracic aortic pathologic conditions. Longer follow-up and results of ongoing trials that use newer devices will help define the indications for their future use.     

Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.     

Endovascular repair of a proximal aortic arch aneurysm: a novel approach of supra-aortic debranching with antegrade endograft deployment via an anterior thoracotomy approach

Although open surgical repair continues to be the standard therapy for thoracic aortic aneurysms, endovascular intervention has evolved into an acceptable strategy for patients who have prohibitive risks for conventional surgical treatments. Aortic arch aneurysm, in particular, is associated with substantial surgery-related morbidities, yet is typically not suitable for endovascular intervention. We describe a combined technique of supra-aortic trunk debranching through an anterior thoracotomy followed by endovascular repair of a large proximal arch aneurysm in an 82 year-old man 8 years after an ascending aortic aneurysm repair.     

Endovascular repair of para-anastomotic aneurysms of the aorta and iliac arteries: preferred treatment for a complex problem

PURPOSE: Standard surgical repair of para-anastamotic aneurysms (PAAs) of the abdominal and thoracic aorta and the iliac arteries has been associated with high morbidity and mortality rates. We reviewed our continuing experience with endovascular repair of these lesions to determine whether this approach is favorable and durable. METHODS: All patients with PAAs of the aorta or iliac arteries who underwent endovascular treatment of their lesions between August 1993 and July 1999 were prospectively followed up, and data on age, previous aortic pathology and surgery, size of PAA, time to diagnosis, and symptoms at presentation were recorded. Preoperative, intraoperative, and postoperative imaging studies were analyzed. All patients had endovascular stent-grafts placed under digital fluoroscopic guidance in the operating room. Data on intraoperative and postoperative complications, mortality, and endoleaks were reviewed. RESULTS: From August 1993 to July 1999, 28 patients (20 men, 8 women) had 35 PAAs of the aorta or iliac arteries. There were 5 thoracic aortic, 12 abdominal aortic, and 18 iliac artery PAAs. Three patients had a contained rupture of their PAA. All patients who had originally undergone reconstruction for occlusive disease had lesions consistent with false aneurysms, whereas 73% of the aortic or iliac PAAs in patients originally treated for aneurysm disease appeared to be true aneurysms. Thirty-four of 35 PAAs were successfully excluded with stent-grafts (97%). There was one death at 30 days (3.6%) in a patient who was successfully treated endovascularly for a contained rupture of a thoracic PAA. There were four major postoperative complications (14.2%) in the 28 patients who were treated. One patient had continued perfusion of a thoracic aortic PAA (type I endoleak). The in-hospital length of stay after endovascular repair of PAA was 4 days (range, 1-18 days). The mean follow-up period was 21 months (range, 1-68 months). CONCLUSION: Endovascular repair of aortic and iliac artery PAAs is technically feasible and provides a high rate of lesion exclusion. Morbidity and mortality rates appear lower than those reported for open surgical repair. These patients can typically be discharged by the second postoperative day. Endovascular therapy for stable ruptured PAAs can be successfully performed and should be considered as an option only when appropriate devices and expertise are available. For uncomplicated PAAs of the aorta and iliac arteries, endovascular therapy may be more favorable than surgical repair.     

Endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome

Ehlers-Danlos syndrome is a connective tissue disorder caused by abnormal collagen synthesis. Vascular complications, including aneurysm formation and spontaneous arterial perforations, are difficult to manage surgically and result in significant operative mortality due to blood vessel fragility. We describe the first reported successful endovascular abdominal aortic aneurysm repair in a patient with Ehlers-Danlos syndrome. We discuss the advantages endovascular surgery offers over open surgery in these patients. We believe that endovascular repair of abdominal aortic aneurysms preferentially over open repair merits consideration in patients with Ehlers-Danlos syndrome.     

Feasibility and possibility of Inoue stent graft for thoracic aortic aneurysms

Open surgical repair is a traditional treatment for patients with thoracic aortic aneurysms. Despite recent advances in surgical techniques and anesthetic management, the surgical repair of thoracic aortic aneurysms is still associated with significant mortality and morbidity. Endovascular aneurysm repair of thoracic aortic aneurysms is emerging as an alternative method for repair in selected patients. Although endovascular stent grafting is less invasive than open surgical repair, involvement of branch vessels and precipitous curvature of the aortic arch limits the application of stent grafting. Inoue stent graft system consists of soft nitinol ring-type stent which enables very flexible stent graft, and it can well comply with the precipitous curvature of the aortic arch. The system also provides a stent graft with a side branch to manage the left subclavian artery. This system does not require the surgical revascularization of the left subclavian artery. In this report, we show the feasibility and possibility of Inoue stent graft system to manage the aortic arch aneurysm.     

Operationen an thorakoabdominellen Aortenaneurysmen

Because of the aging population, the incidence of thoracoabdominal aortic aneurysms (TAAAs) will increase in the next decades. These aneurysms constitute a highly lethal disease, therefore requiring treatment to prevent rupture and subsequent death. However, open surgery comprises substantial morbidity (cardiac events, pulmonary complications, renal failure, paraplegia) and mortality, necessitating extensive preoperative risk evaluation. The surgical results of TAAA repair have significantly improved during the last two decades, mainly because of adjunctive measures such as left heart bypass, cerebrospinal fluid drainage, and spinal cord monitoring. Descending thoracic aneurysms are increasingly being treated by means of endovascular techniques. Endovascular repair of TAAAs with side-branch technology has recently begun, and with future technological innovation, this approach will determine future strategies. Meanwhile, hybrid procedures combining open and endovascular techniques will decrease the extent of surgical trauma. Long-term assessment will be necessary to establish the safety and efficacy of endovascular modalities. At present, open surgery is still the gold-standard treatment for TAAA, especially in (relatively) young patients with Marfan syndrome.     

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms

INTRODUCTION: The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome. METHODS: We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test. RESULTS: We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001). CONCLUSION: We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.     

Evaluation of spinal cord ischemia in endovascular stent graft repair and surgical operation of descending thoracic or thoracoabdominal aortic aneurysms

Between October 1996 and June 2003, endovascular stent graft repair was performed in 87 patients with descending thoracic aortic aneurysms, graft replacement was performed in 24 patients with thoracoabdominal aortic aneurysms, and endovascular stent graft repair with concomitant surgical bypass of abdominal visceral arteries was performed in 3 patients with thoracoabdominal aortic aneurysms. The retrievable stent graft was inserted and evoked spinal cord potential were monitored in order to predict spinal cord ischemia for stent graft repair. There was no paraplegia or hospital death, although 3 patients had paraparesis in stent graft repair. Two of the 3 patients with paraparesis made a full neurologic recovery. There were no cases of paraplegia or paraparesis in surgical operations with thoracoabdominal aortic aneurysm. The concomitant surgical procedure was a good technique for patients in whom cardiopulmonary bypass could not be used. Our results of stent graft repair and surgical operation for descending thoracic or thoracoabdominal aortic aneurysms were acceptable. The retrievable stent graft was useful for prediction of spinal cord ischemia before endovascular stent graft repair of descending thoracic or thoracoabdominal aortic aneurysm.     

Achieving cost-effective endoluminal aneurysm repair.

Endovascular repair of abdominal aortic aneurysms has emerged as a viable alternative to open surgical repair. This procedure will be demanded by physicians and patients because of its lower morbidity and faster recovery. However, its eventual role in the management of patients with abdominal aortic aneurysm is likely to be further defined by cost concerns. Currently, endovascular abdominal aortic aneurysm repair is a moving target and thus requires continued analysis of its fiscal impact. Given that it is likely to be a clinically preferable approach, it is important that we explore ways to make it financially viable. Available information on cost of endovascular aneurysm repair is limited; however, cost saving strategies can be developed that will help establish this alternative in the armamentarium of specialists treating patients with abdominal aortic aneurysms.     

Thorakale Aortenaneurysmen

Open surgical repair of thoracic aortic aneurysms can nowadays be performed with low morbidity and mortality rates in specialized cardiovascular centers. In recent years, thoracic endovascular aortic repair (TEVAR) and hybrid aortic procedures have also been established as treatment options for a variety of thoracic aortic lesions, including thoracic aneurysm. However, decision making in choosing between the distinct treatment options in patients with thoracic aortic aneurysms cannot be based on the results of randomized trials. Therefore, the level of evidence is poor and factors, such as the etiology of the aneurysms, comorbidity, anticipated life expectancy, aortic diameter, and morphology (including suitability of landing zones), are of relevance and have to be considered for an individual therapy. This article reviews recent publications on open surgical, endovascular, and hybrid thoracic aortic aneurysms repair.