Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.     

Endoluminal grafting of abdominal aortic aneurysms: experience with the Talent endoluminal stent graft

The aim of this study was to evaluate the Talent endoluminal stent graft (TESG) in treating abdominal aortic aneurysms (AAA). The TESG is a polyester-covered nitinol endograft (proximal diameters 20–38 mm and iliac limb diameters 8–22 mm). Twenty-two men were treated with the TESG via bilateral femoral arteriotomies. Pre-implantation, coil embolization of various vessels arising from the aneurysm was performed in 6 patients. Plain radiographs and spiral CT angiograms (CTA) were carried out at 7 days, 3, 6, and 12 months following TESG implantation or re-intervention. Median aortic and iliac diameters were 27 mm (range 20–34 mm) and 14 mm (range 10–19 mm). The corresponding graft diameters were 30 mm (range 24–38 mm) and 14 mm (range 12–20 mm). No patient was rejected purely on the basis of too large aortic or iliac diameters. Eight patients required custom-made grafts. Graft implantation was successful in all patients. There were no blood transfusions, distal embolic episodes, or conversions to open surgery. Re-intervention was necessary in 1 patient. Complications included one fatal myocardial infarction, one inguinal hematoma, and two superficial wound infections. The aneurysm thrombosed completely following implantation in 14 patients and at 3 or 6 months in 4 other patients. One patient with endoleak is awaiting his 3-month control and 2 patients show tiny endoleaks but reduction of aneurysm size. The mean aneurysm size decreased significantly from 58 ± 10 to 53 ± 13 mm (p < 0.0005). Due to the large sizes available and the option of custom-made grafts, the TESG helps widen the spectrum of patients who can be treated with endoluminal grafting. The treatment is associated with a significant reduction in aneurysm size. Received: 30 March 1999; Revised: 6 July 1999; Accepted: 23 August 1999     

MR angiography vs CT angiography in the follow-up of nitinol stent grafts in endoluminally treated aortic aneurysms

Our objective was to evaluate the accuracy of contrast-enhanced 3D MR angiography (MRA) in the follow-up of patients with endoluminally treated aortic aneurysms and correlate these findings with uni- or biphasic CT angiography (CTA). Forty MR angiograms in 32 patients with implanted aortic nitinol stent grafts were compared to CTA. Twenty-two MR examinations were correlated with arterial-phase CTA (uniphasic), and 18 MR examinations were correlated with biphasic CTA. Uniphasic CTA demonstrated three type-1/type-3 endoleaks and four reperfusion (type-2) endoleaks. In addition, MRA depicted two type-2 reperfusion endoleaks that were missed by CTA. Using biphasic CTA, two type-1/type-3 endoleaks and three reperfusion (type-2) endoleaks were detected; of those, delayed scanning detected three reperfusion (type-2) endoleaks missed during arterial-phase CTA. In addition to the findings by CTA, MRA depicted another type-2 reperfusion endoleak. Magnetic resonance angiography is at least as sensitive as uni- or biphasic CTA for detecting endoleaks and may consequently offer advantages in patients with contraindications to iodinated contrast agents.     

腹主动脉瘤腔内隔绝术中内漏动物模型的建立

目的：建立近似人体的腹主动脉瘤（AAA）腔内隔绝术（EVE）后内漏的实验动物模型。方法：采用6只犬 ，以牛颈静脉间置法或前壁补片的方法形成保留腰动脉的肾下型AAA，经髂动脉行AAA EVE，术中采用修剪人造血管和改变支架附着点的方法形成内漏。结果：血管造影示6只犬动脉瘤形态良好，5只犬形成了即时性内漏，内漏来自近端返流，也有近端返流。结论：通过移植物释放位置的变化可以模拟出与人体EVE后相似的即时性内漏，以供血流动力学和治疗研究。     

Ergebnisse der stentgestützten Aortenrekonstruktion im Rupturstadium

ZusammenfassungStudienziel Untersuchungen über den Stellenwert der notfallmäßigen endovaskulären Behandlung von Patienten mit gedeckten Rupturen im Bereich der Aorta descendens sowie im infrarenalen Aortenabschnitt.Studiendesign. Prospektive, nichtrandomisierte Studie in einer Universitätsklinik.Material und Methoden Im Zeitraum zwischen 1995 und 2003 wurde bei insgesamt 338 Patienten eine stentgestützte aortale Rekonstruktion durchgeführt. 274 Eingriffe erfolgten elektiv (81%). In 64 Fällen (19%) wurde die endovaskuläre Versorgung notfallmäßig im Stadium der Ruptur durchgeführt. Bei 29 Patienten handelte es sich um ein gedeckt rupturiertes infrarenales Aortenaneurysma, bei 11 Patienten um ein rupturiertes Aneurysma im Bereich der Aorta descendens, bei 3 Patienten um eine Ruptur eines thorakoabdominalen Aortenaneurysmas, bei 5 Patienten um eine Ruptur im ersten Segment der Aorta descendens bei akuter Typ-B Dissektion und bei weiteren 16 Patienten um eine traumatische thorakale Aortenruptur loco typico. Die Diagnose wurde bei allen 64 Patienten jeweils durch eine präoperative Spiral-CT-Untersuchung gesichert.Ergebnisse Der rupturierte Aortenabschnitt konnte bei 62 Patienten endovaskulär sicher versorgt werden. Eine primäre Konversion zum offenen Eingriff wurde bei 2 Patienten (3,1%) notwendig. Die postoperative 30-Tage-Letalität betrug bei 7 Todesfällen 10,9%. Keiner der Patienten entwickelte postoperativ ein vorübergehendes oder dauerhaftes neurologisches Defizit. Bei 8 Patienten (12,5%) waren Zweiteingriffe zum Verschluss primärer Endoleaks erforderlich und 6 Patienten (9,3%) bedurften eines zweiten chirurgischen oder kombinierten endovaskulären und offenchirurgischen Vorgehens. Die mittlere Nachbeobachtungszeit (Follow-up) betrug 37 Monate (1–93).Schlussfolgerung Unsere Ergebnisse zeigen, dass die stentgestützte Rekonstruktion bei Patienten mit rupturierten Aortenläsionen technisch durchführbar ist und diese Technik zudem mit einer ausreichenden Sicherheit angewandt werden kann. Angesichts der im Vergleich zum offenen Vorgehen reduzierten Morbidität und Letalität stellt das endovaskuläre stentgestützte Verfahren bei Patienten, die anatomisch und pathomorphologisch für eine Stentbehandlung geeignet erscheinen, ein alternatives, viel versprechendes Behandlungskonzept dar. Unsere Ergebnisse lassen zudem vermuten, dass bei rupturiertem mykotischem Aneurysma bzw. bei aortobronchialen und aortointestinalen Fisteln die endovaskuläre Therapie nur als "Bridging"-Maßnahme angewandt werden sollte.

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Results of stent graft repair of ruptured aortic lesions

Objectives To evaluate endovascular repair in ruptured aortic lesions.Design Prospective nonrandomized study in a university hospital.Material and methods Of 338 endovascular aortic repairs, 64 (19%) procedures were conducted as emergencies (29 ruptured infrarenal aortic aneurysms, 11 ruptured descending thoracic aortic aneurysms, 3 ruptured thoracoabdominal aortic aneurysm, 5 patients with descending aortic rupture due to acute type B dissection, and 16 patients with acute descending aortic transection). Preoperative spiral computed tomography was performed in each patient, and based on these findings the feasibility of endovascular treatment and appropriate size of stent grafts were determined.Results Endovascular operations were completed successfully in 96.8% (62 patients). The primary conversion rate to open repair was 3.1% (two patients). The 30-day mortality rate was 10.9% (seven deaths). In no patient did temporary or permanent paraplegia result. Of the primary endoleaks, 12.5% (eight patients) required additional intervention and 9.3% (six patients) required secondary surgical procedures. The mean follow-up was 37 months (1–93 months); three deaths occurred within 3 months after stent graft placement. Six patients (9.3%) required secondary conversion to open repair.Conclusion Endoluminal treatment of ruptured aortic lesions is feasible and safe and may offer the best means of therapy in selected cases. Compared with open repair, endoluminal treatment holds tremendous potential in terms of reduced morbidity and mortality and confers protection against secondary aortic rupture. Continued surveillance is essential.

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The Amplatzer vascular plug for large vessel occlusion in the endovascular management of aneurysms

The Amplatzer vascular plug (AVP) is derived from the Amplatzer device used in correction of cardiac septal defects. We present a large series of the use of the AVP in the endovascular management of aneurysms. Three patients with a combination of aortic and peripheral aneurysms underwent embolisation with the AVP. Plugs with 10–16 mm diameter were used and delivered using introducer/guiding sheaths. A total of 16 internal iliac arteries, 2 common iliac arteries (CIA), 4 subclavian (SCA) arteries, 1 superior mesenteric (SMA) and 1 popliteal artery were embolised. Successful occlusion with the AVP was achieved in 21 out of 24 vessels (87.5%), of which 18 (75%) occluded immediately and 3 (12.5%) were delayed occlusions. The three patients who are considered to have failed to occlude with the AVP required the use of additional embolic agents. At the end of the 17-month follow-up all 24 target vessels had occluded. Two patients developed persistent buttock claudication, and one had a left hemiparesis. The AVP is useful as an adjunctive device in the management of aneurysms. It has a particular role in embolisation of large-diameter vessels with a short implantation zone. The device is safe and easy to use.     

腔内修复术治疗肾下型腹主动脉瘤的内漏防治：附43例报告

目的：总结应用腔内修复术治疗腹主动脉瘤的经验,探讨内漏的防治策略。方法：回顾性分析齐鲁医院及莱钢医院2007年1月—2012年12月接受腔内治疗的43例肾下型腹主动脉瘤患者临床资料,分析内漏的发生原因、预防和处理。结果：术后发生原发性内漏11例,其中I型8例,III型2例;植入分叉型支架发生9例,植入直管型支架发生2例。1例II型因漏血量小未处理;经一期经过球囊扩张、植入支架型血管或裸支架等处理后,除2例I型内漏仍有残留,其余I,III型内漏均消失。39例患者获随访4~50个月,发现迟发性Ib型、II型内漏各2例,继续随访1~2年,未见瘤体明显增大。3例残留原发性内漏自愈,术后半年复发Ia型内漏1例,导致动脉瘤复发破裂而再次接受腔内治疗。结论：内漏的发生与动脉瘤的解剖学条件、移植物缺陷和操作技术有关;防治内漏需要把握好手术适应证、合理选择支架,并有成熟的操作经验。

     

内漏对腹主动脉瘤腔内隔绝术后瘤腔内压力的影响

目的 探讨内漏状态下腹主动脉瘤(AAA)腔内隔绝术(EVE)后瘤腔内压力的变化。方法 通过建立犬AAA EVE后内漏模型，测定内漏存在前后瘤腔内压力的变化。结果 内漏状态下瘤腔内平均动脉压明显升高，而内漏封闭后压力显著下降，且曲线平直。结论 瘤腔内压力曲线可作为评估EVE后瘤壁所受负荷的变化，也可作为判断内漏存在的方法之一。     

腔内栓塞治疗Ⅱ型内瘘

目的探讨腔内栓塞治疗Ⅱ型内瘘的临床价值。方法回顾性分析4例TEVAR或EVAR术后Ⅱ型内瘘患者的腔内栓塞治疗资料。结果 4例患者腔内栓塞治疗的技术成功率及临床成功率均为100%(4/4)。术后均未出现栓塞材料异位栓塞、肠缺血等并发症。结论腔内栓塞治疗Ⅱ型内瘘安全、有效。