Early and mid-term results of endovascular stent grafting for aortic aneurysms]

Early and mid-term clinical results of 28 cases of endovascular stent grafting for descending thoracic aortic aneurysms and 11 cases of abdominal aortic aneurysms are reported. Early clinical results: Among 28 patients (7 true thoracic aortic aneurysms, 3 pseudothoracic aortic aneurysms and 8 acute, 4 subacute, and 6 chronic aortic dissections), two patients (7.1%) with ruptured acute aortic dissection or ruptured infected pseudoaneurysm died in the perioperative period. Two of the remaining 26 patients experienced minor complications. Aneurysmal sacs or false lumens at the descending thoracic aorta were completely thrombosed in the 26 patients. One patient (9.1%) with a ruptured abdominal aneurysm died, and one of the remaining 10 patients had renal and peripheral emboli and peripheral vascular trauma. Inadvertent covering of the renal arteries occurred in another patient. Unless one patient had persistent endoleak, aneurysmal sacs in the 10 surviving patients were thrombosed. Mid-term clinical results: One aortic dissection at a different section of the descending aorta occurred 6 months after stent grafting for aortic dissection, and one patient died of pneumonia 3 months after stent grafting for an abdominal aortic aneurysm. CT scanning 6 months after stent grafting revealed a decrease in maximal aneurysmal size in 3 of 9 patients with true or pseudothoracic aneurysms and in 2 of 5 patients with abdominal aortic aneurysms. Five of 9 patients with stent grafting for acute or subacute dissection showed elimination of the false lumen in the descending thoracic aorta in a CT scan 6 months after grafting. One patient with a true thoracic aneurysm and one patient with an abdominal aortic aneurysm showed an increase in aneurysmal size in a CT scan 2 years and one year after treatment, respectively.     

Extraperitoneal approach for repair of inflammatory abdominal aortic aneurysm

Inflammatory abdominal aortic aneurysms are characterized by dense perianeurysmal fibrosis involving the adjacent organs. Attempts to isolate the aneurysm can lead to operative injuries of these structures, thus increasing the rates of complications and mortality. In the last 12 years 45 patients with inflammatory abdominal aortic aneurysms underwent aneurysm resection at the Department of Vascular Surgery of the University of Rome. The aneurysm was resected through a standard, midline transperitoneal approach in 39 patients, through a thoracophrenolaparotomy in two patients, and through a left-flank extraperitoneal approach in the last four patients. The extraperitoneal approach simplified aneurysm dissection and aortic clamping with no cases of postoperative morbidity or death. In addition, we reviewed the CT scan findings of 12 patients surgically treated for inflammatory abdominal aortic aneurysm. The amount of fibrosis in the anterior wall of the aneurysm was greater than in the left posterolateral aspect (p = 0.008). We conclude that the left-flank extraperitoneal approach is the most anatomically advantageous route for repair of inflammatory abdominal aortic aneurysm.     

Abdominal aortic aneurysm with perianeurysmal fibrosis: experience from 11 Swedish vascular centers

Case records of 2026 patients operated on because of abdominal aortic aneurysms from 11 Swedish Vascular Centers were reviewed and revealed 98 cases (4.8%) of inflammatory abdominal aortic aneurysm. Also included in this case-control study was an analysis of a randomized group of 82 patients from the same centers who had noninflammatory abdominal aortic aneurysms. Four inflammatory aneurysms were ruptured, compared with 16 in the noninflammatory group (p less than 0.01). A higher proportion of patients with inflammatory abdominal aortic aneurysms had symptoms that led to radiographic investigations. The median erythrocyte sedimentation rate was 39 mm versus 19 mm (26% of patients with inflammatory abdominal aortic aneurysms had erythrocyte sedimentation rates greater than 50 mm; p less than 0.001), and the serum creatinine level was increased in 27 and 8 patients (p less than 0.01) in the inflammatory and noninflammatory groups, respectively. Preoperative investigations revealed ureteral obstruction in 19 patients with inflammatory abdominal aortic aneurysms, of whom 12 had preoperative nephrostomy or ureteral catheter placement. At operation, 20 additional patients exhibited fibrosis around one or both ureters. Although ureterolysis was performed in 19 patients, preoperative and postoperative creatinine levels did not differ between these patients and the conservatively treated ones. Duration of surgery (215 vs 218 minutes), intraoperative blood loss (2085 vs 2400 ml) and complications did not differ significantly between the groups. Overall operative (30-day) mortality was equal (11% vs 12%) but was increased for patients undergoing elective surgery for inflammatory abdominal aortic aneurysms (9% vs 0%; p = 0.03).(ABSTRACT TRUNCATED AT 250 WORDS)     

Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms

Emergency surgery is the only effective treatment of ruptured abdominal aortic aneurysms, even though morbidity and mortality rates remain high. We have studied the feasibility of left retroperitoneal aortic exposure in these cases in an effort to reduce postoperative complications. Over a 33 month period, 29 patients underwent emergency surgery for either a ruptured or symptomatic infrarenal abdominal aortic aneurysm. Of 13 patients with ruptured aneurysms, 4 underwent repair through a midline transperitoneal approach (3 deaths) whereas the remaining 9 were repaired through the retroperitoneal exposure (1 death). Supraceliac aortic clamping through the same incision prior to aneurysm exposure maintained hemodynamic integrity. The remaining 16 patients with symptomatic aneurysms were all treated through the retroperitoneal exposure (3 deaths). In the retroperitoneal groups, the cause of death was cardiac in two patients, hypertensive stroke in one, and necrotizing pancreatitis in one. Morbidity consisted of prolonged intubation, respiratory distress syndrome, and thrombophlebitis in one patient each and acute tubular necrosis in two patients. We believe that the left retroperitoneal approach is a useful option in the emergent treatment of abdominal aortic aneurysms.     

Inflammatory solitary iliac artery aneurysms: a report of two cases

Inflammatory abdominal aortic aneurysms are associated with atherosclerosis, which are characterized by specific clinical manifestation. We treated two patients with unilateral solitary iliac artery aneurysms with perianeurysmal fibrosis which compressed the ureter resulting in ipsilateral hydronephrosis. After the iliac artery aneurysm was repaired with a prosthetic graft, the hydronephrosis resolved. Microscopically, there was clear evidence of atherosclerosis in one case. There was a characteristic inflammatory reaction around the adventitia in both aneurysms. Localized iliac perianeurysmal fibrosis has not been particularly described. The clinicopathologic similarities between these cases and inflammatory abdominal aortic aneurysms suggest the same pathogenesis.     

Technical aspects in the management of abdominal aortic aneurysms

During the past decade, resection of abdominal aortic aneurysms has become common. The technical aspects of the operation are now relatively standardized and simplified. With concomitant improvements in anesthesia and intensive care, the operative mortality for elective resection of these aneurysms has declined progressively; several centres report an operative mortality of less than 5%. The author considers the following principles important in managing patients with abdominal aortic aneurysms: (a) simplicity and limited dissection are critical features of the operative technique; (b) tubular grafts should be used whenever possible; (c) selected patients should be transferred to the intensive care unit preoperatively for "fine-tuning" of the cardiovascular system; (d) patients should be monitored intraoperatively and postoperatively; (e) the surgeon should be aware of special problems such as horseshoe kidney, venous anomalies, adherent duodenum and the presence of major arteries arising from the aneurysm; (f) ruptured aneurysms should be diagnosed promptly and the patient operated upon without delay. Using these principles, the author's group achieved an operative mortality of only 1.8% in 168 patients with abdominal aortic aneurysms resected electively. However, the operative mortality for their patients with ruptured aortic aneurysms was 50%, a rate that has not changed appreciably over the years.     

Inflammatory abdominal aortic aneurysms: a thirty-year review

The operative records of 2816 patients undergoing repair for abdominal aortic aneurysm (AAA) from 1955 to 1985 were reviewed. Inflammatory aortic or iliac aneurysms were present in 127 patients (4.5%), 123 men and four women. Most patients were heavy smokers (92.1%). Clinical evidence of peripheral arterial occlusive disease and coronary artery disease was found in 26.6% and 39.4%, respectively. Additional aneurysms occurred in half of the patients; iliac aneurysms were the most common (55 patients), followed by thoracic or thoracoabdominal (17 patients), femoral (16 patients), and popliteal aneurysms (10 patients). Ultrasound and computed tomography suggested the diagnosis in 13.5% and 50%, respectively; angiography was not helpful. Excretory urographic findings of medial ureteral displacement or obstruction suggested the diagnosis in 31.4%. The aneurysm was repaired in 126 patients. Only one patient experienced acute aneurysm rupture, but eight patients had chronic contained leakage. When compared with patients who have ordinary atherosclerotic aneurysms, patients with inflammatory aneurysms are significantly more likely to have an elevated erythrocyte sedimentation rate (ESR, 73% vs. 33%, p less than 0.0001); weight loss (20.5% vs. 10%, p less than 0.05); symptoms (66% vs. 20%, p less than 0.0001); and an increased operative mortality rate (7.9% vs. 2.4%, p less than 0.002). The triad of chronic abdominal pain, weight loss, and elevated ESR in a patient with an abdominal aortic aneurysm is highly suggestive of an inflammatory aneurysm and may be beneficial in the preoperative preparation of the patient for aneurysm repair.     

Factors Affecting the Regression of Surgically Replaced Abdominal Aortic Aneurysms

Purpose After endovascular therapy for abdominal aortic aneurysms, aneurysm sac shrinkage is considered to be the best marker of successful treatment. Such shrinkage, however, is infrequent and the rate of shrinkage is variable because of endoleaks. To investigate the factors that influence such contraction, the aneurysm sac regression after a conventional surgical replacement of the abdominal aortic aneurysm in an inclusion fashion was studied. Methods Abdominal aortic aneurysms that measured 5 cm in diameter or larger were studied in 35 patients who underwent surgical replacement. The aneurysm sac was closed anterior to the prosthesis. Of the 35 cases, 4 aneurysms were inflammatory and 10 had aneurysm wall circumferential calcification of greater than 40%. Computed tomography was performed preoperatively, and at 1 week, and then 3 months postoperatively. Results The maximum major and minor diameters of the aneurysmal sac decreased significantly from 1 week to 3 months after surgery (major diameter: 49 ± 12 to 32 ± 8 mm and minor diameter: 39 ± 10 to 26 ± 7 mm). In inflammatory aneurysms, the maximum major and minor diameters were significantly larger at 3 months postoperatively, in comparison to nonspecific aneurysms. Among the 31 patients with nonspecific aneurysms, the maximum major diameter was significantly larger in those with aneurysmal calcification of greater than 40% of its circumference at 3 months postoperatively, in comparison to noncalcified aneurysms. Conclusions The surgically repaired abdominal aortic aneurysm contraction tends to develop over 3 months, and inflammation, thickening, and calcification of the aneurysm wall are all considered to influence the regression of the aneurysm.     

Giant size abdominal aortic aneurysm repair using open proximal anastomosis under hypothermic circulatory arrest: a report of two cases

Hypothermic total circulatory arrest and open proximal anastomosis techniques are not commonly used in abdominal or juxtarenal abdominal aortic aneurysm repair. Proximal aortic clamping is usually adequate for surgical repair of abdominal aortic pathologies. We present two cases of giant-sized abdominal aortic aneurysms, one was juxtarenal and one was a Crawford type IV thoracoabdominal aneurysm, that were repaired by using open proximal anastomosis under hypothermic total circulatory arrest and a transabdominal approach. This technique may be useful for both thoracoabdominal and large abdominal aortic aneurysms because it offers the opportunity to not clamp the aorta and operate in bloodless surgical field.     

Inflammatory Aneurysm of the Ascending Aorta: Report of a Case

Inflammatory aortic aneurysms are found most commonly in the infrarenal abdominal aorta. We report the case of a 78-year-old man with an inflammatory aortic aneurysm of the ascending aorta, which is extremely unusual. Surgery revealed that the ascending aorta was adherent to the superior vena cava and pulmonary artery, but a dissection membrane was not found. The wall of the ascending aorta was up to 20 mm thick with perianeurysmal fibrosis. Pathologic examination revealed an inflammatory aneurysm with adventitia remarkably thickened by fibrotic tissue and infiltrated by lymphocytes and plasma cells. Our search of the literature found only seven other cases of an inflammatory ascending aortic aneurysm. Preoperative diagnosis was very difficult in most of these cases; however, improved scanning techniques using multidetector row computed tomography may allow the differential diagnosis of this clinical entity.     

Simultaneous Operations for Combined Thoracic and Abdominal Aortic Aneurysms

Purpose. To assess whether simultaneous operations are appropriate for combined thoracic and abdominal aortic aneurysms.Methods. Simultaneous operations were performed for combined thoracic and abdominal aortic aneurysms in nine patients. The thoracic aortic aneurysm (TAA) was repaired first, followed by repair of the abdominal aortic aneurysm (AAA). Selective cerebral perfusion was used in eight patients, after the exception of one who underwent replacement of the ascending aorta under hypothermic circulatory arrest. The abdominal organs were perfused during distal anastomosis in surgery for Stanford type A aortic dissection or aortic arch aneurysm; via the femoral artery with an aortic balloon occlusion catheter in one patient, and via an occlusion catheter with a perfusion lumen in two patients.Results. All patients underwent planned simultaneous repair of the AAA. One of the patients who underwent simultaneous replacement of both the descending thoracic and abdominal aorta was left with paraplegia, and one patient died suddenly of massive hemoptysis and melena on the 29th postoperative day. Autopsy revealed that the bleeding had been caused by aorto-broncho-esophageal fistulae. The overall operative mortality was 11%.Conclusions. Simultaneous repair of combined TAA and AAA can be safely performed; however, the risk of paraplegia should be considered, especially with simultaneous repair of concomitant aneurysms of the descending thoracic and abdominal aorta.     

Regression of perianeurysmal fibrosis and ureteral dilation following endovascular repair of inflammatory abdominal aortic aneurysm

An inflammatory component to abdominal aortic aneurysms (AAA) is thought to occur in approximately 5% of cases. Accompanying ureteral entrapment may be involved in 20% of these. Transabdominal repair of inflammatory AAA with ureterolysis may result in increased complications. Many authorities have recommended a retroperitoneal approach to decrease dissection. Similarly, an endovascular approach has been utilized. We report here the results of a patient with an inflammatory AAA with bilateral ureteral obstruction successfully treated with endovascular stent graft repair and bilateral ureteral stents with exclusion of the aneurysm and resolution of hydronephrosis.     

Management and Course of Hydronephrosis Secondary to Inflammatory Aneurysms of the Abdominal Aorta

The objective of this study was to evaluate the management and course of obstructive uropathy secondary to inflammatory aneurysms. From January 1981 to December 2000 a total of 52 patients underwent surgical intervention for inflammatory aneurysms of the abdominal aorta. Eleven of these cases (21%) had obstructive uropathy, which was bilateral in five cases. Preoperative drainage of the urinary tract was done in five ureters in three patients with four double J catheters and one percutaneous nephrostomy; surgical ureterolysis was also carried out in one case. Endoaneurysmorraphy and placement of an aortic graft were performed in all 11 patients. Operative mortality was zero. There was no recurrence of hydronephrosis in seven patients during a mean follow-up of 55 months. Three patients were lost to follow-up and one died. When compared with 41 inflammatory aneurysms in which hydronephrosis did not develop, there were statistically significant differences with respect to lumbar pain and renal insufficiency. The ureter is a structure adjacent to the aorta that is trapped by fibrosis in 21% of patients with inflammatory abdominal aortic aneurysms. The natural tendency of the periaortic fibrosis is to remit following surgery to correct the aneurysm. This results in spontaneous remission of the hydronephrosis, making routine intraoperative manipulation of the ureter unnecessary.     

Assessment of Aortic Disease Using Three-Dimensional CT Angiography

The recently developed technique of three-dimensional CT angiography (3D-CTA) was applied to 68 patients with aortic disease. These patients were examined using a unique method of data collection: a helical scanner with continuous tube rotation and continuous table feed. The scanner was used in conjunction with administration of dynamic intravenous contrast material to enhance the vascular image. The group of patients included 35 with aortic dissection, 19 with true thoracic aneurysms, and 14 with abdominal aortic aneurysms. Three-dimensional evaluation was achieved in all patients with no complications. Surgical intervention was used in 45 patients with aortic dissections and aortic aneurysms, and 44 of these patients (98%) survived and were discharged. Preoperative 3D-CTA findings were quite similar to intraoperative findings, and were useful in determining operative procedures. Rapid and accurate assessment of aortic disease was achieved by 3D-CTA. Three-dimensional CT angiography can play an important role in the preoperative assessment of aortic dissections and aortic aneurysms leading to successful surgical treatment. (J Card Surg 1994;9:673–678)     

Results of 256 consecutive abdominal aortic aneurysm repairs using extraperitoneal approach

Two hundred and fifty-six consecutive abdominal aortic aneurysms were repaired using three approaches for extraperitoneal exposure of the aorta and iliac vessels from February 1990 through September 1998. The perioperative mortality rate was 3.1% in 228 elective repairs and 14.3% in 28 ruptured cases. The initial 23 cases were repaired using Sicard's method. The duration of endotracheal intubation was 1.0+/-2.8 h, alimentation initiation was 2.7+/-1.6 days, and narcotic requirements were 1.2+/-1.1 times. Following these initial cases, we employed Williams' method for 192 abdominal aneurysms, however; repeated incisional pain and three cases of deforming bulge led us to avoid dividing muscles. In the last 13 cases, our approach was performed without muscle dividing. The narcotic requirements decreased to 0.3+/-0.7 times. As for postoperative complications, the larger skin incision approach had no shower embolism. However, the shorter skin incision had four cases of shower embolisms, one lymphorrhea and one vascular trauma by the aortic clamp. The extraperitoneal approach offers certain physiologic advantages with minimal disturbance of gastrointestinal and respiratory function. We believe that this method is useful for rapid approach to the proximal aorta in case of emergency. Postoperative wound complications could be prevented via an oblique incision without muscle dividing.     

Surgical treatment of pararenal aortic aneurysms in the elderly

AIM: Until fenestrated endografts will become the standard treatment of pararenal aortic aneurysms, open surgical repair will currently be employed for the repair of this condition. Suprarenal aortic control and larger surgical dissection represent additional technical requirements for the treatment of pararenal aneurysms compared to those of open infrarenal aortic aneurysms, which may be followed by an increased operative mortality and morbidity rate. As this may be especially true when dealing with pararenal aneurysms in an elderly patients' population, we decided to retrospectively review our results of open pararenal aortic aneurysm repair in elderly patients, in order to compare them with those reported in the literature. METHODS: Twenty-one patients over 75 years of age were operated on for pararenal aortic aneurysms in a ten-year period. Exposure of the aorta was obtained by means of a retroperitoneal access, through a left flank incision on the eleventh rib. When dealing with interrenal aortic aneurysm the left renal artery was revascularized with a retrograde bypass arising from the aortic graft, proximally bevelled on the ostium of the right renal artery. RESULTS: Two patients died of acute intestinal ischemia, yielding a postoperative mortality of 9.5%. Nonfatal complications included 2 pleural effusions, a transitory rise in postoperative serum creatinine levels in 3 cases, and one retroperitoneal hematoma. Mean renal ischemia time was 23 min, whereas mean visceral ischemia time was 19 min. Mean inhospital stay was 11 days. CONCLUSION: Pararenal aortic aneurysms in the elderly can be surgically repaired with results that are similar to those obtained in younger patients.     

Simultaneous repair of arch and abdominal aortic aneurysms

Objective: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. Subjects: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemiarch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. Method: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemiarch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. Results: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. Conclusion: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.     

"Inflammatory aneurysm" of the aorta. Diagnosis, therapy, results

From 1970 to 1987 among 964 patients with aortic aneurysms 52 (5.4%) underwent aortic graft replacement for inflammatory aortic aneurysm. 79.2% were symptomatic, 18.9% ruptured at the time of admission. CT-scan is of main diagnostic value. The perioperative mortality rate was 15.1%. At follow-up (28 months mean) 35 of 38 living patients (92.7%) were examined clinically, by sonography and in most cases by CT-scan. The late complication rate was 20% (n = 7, atrophic kidney 3, anastomotic aneurysms 4). In contrast to abdominal aortic aneurysms inflammatory aneurysms present an elevated morbidity and mortality rate which has to be reduced by exact preoperative diagnosis and modified surgical technique.     

Infective abdominal aortic aneurysm due to Haemophilus influenza identified via the polymerase chain reaction.

Infective abdominal aortic aneurysms due to Haemophilus influenza are rarely reported. We report a case in a 65 year old female presenting with abdominal pain, weight loss, pyrexia and elevated inflammatory markers. The patient was found to have an abdominal aortic aneurysm clinically and on CT scanning. At surgery, an inflammatory aneurysm was successfully repaired using an autogenous vein panel-graft. Tissue samples were analysed using the polymerase chain reaction, identifying H. influenza as the causative organism. H. influenza is a scarcely reported cause of infective aortic aneurysms. The mechanism of infection is unknown. Reference is made to existing reports of such infection.     

Simultaneous repair of arch and abdominal aortic aneurysms. A simple new technique using a temporary bypass graft.

OBJECTIVE: Atherosclerotic aneurysms in the aortic arch are associated with abdominal aortic aneurysms in up to 37% of cases. We have developed a single-stage approach to the repair of both aneurysms using a temporary bypass. SUBJECTS: Since November 1996, 5 patients underwent simultaneous repair of aneurysms in the aortic arch and in the infrarenal abdominal aorta, using a new temporary bypass graft technique. Entire arch replacement with simultaneous abdominal aortic aneurysmectomy was performed in one patient. The other 4 patients underwent distal hemi-arch replacement distal from the orifice of the brachiocephalic artery with simultaneous repair of the abdominal aortic aneurysm. METHOD: For the entire arch replacement procedure, blood flow to all major branches of the aortic arch was established using a bifurcated graft. This graft anastomosed to the ascending aorta was used as the proximal inflow of the temporary bypass graft. For the hemi-arch replacement procedure, the proximal inflow segment of the temporary bypass graft was anastomosed to the brachiocephalic artery. In both cases, the distal outflow segment of the temporary bypass graft was the graft used for repair of the abdominal aortic aneurysm. In order to prevent any clamp injury, Teflon felt was tightly wrapped around the aorta before the clamp was applied. RESULTS: Evaluation of the hemodynamic parameters measured during cross-clamping of the aortic arch revealed stable distal perfusion to the visceral organs and no excessive increase in cardiac afterload. All patients had an uneventful postoperative course and were discharged within 1 month of surgery. CONCLUSION: Our temporary bypass method is recommended for simultaneous replacement of aneurysms in the aortic arch and the abdominal aorta.