Delayed aortic aneurysm enlargement due to endotension after endovascular abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair, because of persistent blood flow within the aneurysm sac, or endoleak. In the absence of detectable endoleak, AAA may still expand, in part because of persistent pressurization within the excluded aneurysm, or endotension. We report three patients who underwent successful endovascular AAA repair in whom postoperative surveillance showed aneurysm regression, yet delayed AAA enlargement without demonstrable endoleak developed in all three patients. Endotension was confirmed in all three patients at elective open conversion. Our study underscores the significance of endotension as a mechanism of delayed aneurysm enlargement after successful endovascular AAA repair.     

Late abdominal aortic aneurysm enlargement after endovascular repair with the Excluder device

OBJECTIVES: Behavior of the abdominal aortic aneurysm (AAA) sac after endovascular abdominal aortic aneurysm repair (EVAR) is graft-dependent. The Excluder endograft has been associated with less sac regression than some other stent grafts. Long-term follow-up has not been reported. METHODS: Between May 1999 and July 2002, 50 patients underwent EVAR with the Excluder bifurcated endoprosthesis. These patients were followed up prospectively with computed tomography (CT) at 1, 6, and 12 months and yearly thereafter. One immediate conversion to open surgery and three deaths occurred within 6 months. One additional patient was lost to follow-up. The remaining 45 patients, 35 men and 10 women, were followed up for at least 1 year, and form the basis for this report. Their mean age was 73 +/- 5.5 years. The minor axis diameter at the largest area of the AAA on CT examination was compared with the baseline measurement at 1 month and to the smallest size previously recorded during follow-up. Change in sac size of 5 mm or greater was considered significant. Mean follow-up was 2.7 +/- 1.2 years (range, 1-4 years). Nominal variables were compared with the chi(2) test, and continuous variables with the Student t test. RESULTS: A significant decrease in average AAA sac diameter was observed at 6-month, 1-year, and 2-year follow-up. These differences were lost by the 3-year evaluation, because of delayed sac growth (n = 9) and re-expansion of once shrunken aneurysms (n = 3). The probability of freedom from sac growth or re-expansion at 4 years was only 43%. At last follow-up, sac expansion occurred in the absence of active endoleak in nine patients. Type II endoleak was associated with sac expansion in three patients (P =.003), resulting in one conversion to open surgery after the 4-year follow-up. No graft migrations, AAA ruptures, or aneurysm-related deaths were noted. CONCLUSIONS: Late aneurysm sac growth or re-expansion after EVAR with the Excluder device is common, even in the absence of endoleak. Although the incidence of important clinical sequelae is low at this point, the incidence of aneurysm expansion should be taken into consideration during the risk-benefit assessment before EVAR repair with the Excluder device.     

Symptomatic sac enlargement and rupture due to seroma after open abdominal aortic aneurysm repair with polytetrafluoroethylene graft: Implications for endovascular repair and endotension

OBJECTIVE: We report 5 patients in whom a symptomatic perigraft seroma developed within the aortic sac, without vascular endoleak, after open repair of an abdominal aortic aneurysm (AAA) with a polytetrafluoroethylene (PTFE) graft. We also discuss possible relationships of this phenomenon to endovascular repair of AAAs. PATIENTS AND METHODS: Over 18 years, 1156 patients underwent repair of an AAA by one of the authors (B.M.B.). Of these, 1084 underwent open repair, 256 with PTFE grafts. Five patients in the PTFE group (2.3%) returned at a mean of 4.5 years with acute abdominal or back pain and enlargement of the aortic sac. Mean diameter of the aneurysms was 5.9 cm preoperatively and 8.1 cm at readmission. There was no evidence of vascular endoleak on computed tomography scans, but 1 patient had a retroperitoneal hematoma. RESULTS: Laparotomy in 4 patients disclosed a seroma containing firm rubbery gelatinous material under tension, histologically identified as amorphous eosinophilic material containing thrombus and degenerate blood cells in all cases. Rupture of the sac was confirmed in the patient with a retroperitoneal hematoma. The sac contents were evacuated and the integrity of the underlying grafts and anastomoses was confirmed before sac reduction, with imbricating sutures, and closure was performed. One patient died at 8 months of an unrelated cause; the other 3 patients remain well at mean follow-up of 12 months. The fifth patient received conservative treatment and remains asymptomatic 3 years after acute presentation. CONCLUSIONS: These findings of sac enlargement without vascular endoleak after open AAA repair are reminiscent of sac enlargement in the absence of endoleak after endovascular AAA repair. This has been referred to as endotension. The comparatively benign outcome in 5 patients with symptomatic sac enlargement, including 2 patients with rupture, after open AAA repair provides data to support a circumspect approach to endotension, especially in patients with asymptomatic disease, which has been reported as occurring in almost half of patients who received a PTFE Excluder endograft.     

Symptomatic seroma after open abdominal aortic aneurysm repair

Seroma following open abdominal aortic aneurysm repair has rarely been described. The majority of cases in the literature have been associated with use of polytetrafluoroethylene grafts. Here, we present a patient with a very large, symptomatic periaortic graft seroma 10 years after conventional (open) repair. The etiology of such seromas is of significant interest in endovascular aortic repair.     

Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.     

Ruptured abdominal aortic aneurysm after endovascular repair

OBJECTIVE: The purpose of this study was to present the experience with aneurysm rupture after deployment of Guidant/EVT (Guidant) endografts and review previously reported cases with other devices. METHODS: Records from Guidant/EVT clinical trials and postmarket approval databases from February 1993 to August 2000 were analyzed to identify patients with rupture and to extract pertinent data. Previously reported cases were obtained with a Medline search. RESULTS: Seven ruptures were found with Guidant/EVT devices. Five of these occurred among the 686 patients in US Food and Drug Administration protocols (group I) who were followed for a mean of 41.8 +/- 21.9 months and limited to the subgroup of 93 first generation tube endografts. Two ruptures occurred in group II (3260 patients after market approval with limited follow-up), specifically in the subgroup of 166 patients who underwent treatment with second generation tube grafts. No ruptures were found in patients with bifurcation or unilateral iliac implants followed for a mean of 37.5 months. All ruptures were caused by distal aortic type I endoleaks on the basis of attachment system fractures (first generation devices only), aortic neck dilatations, persistent primary endoleaks, migration, overlooked imaging abnormalities, refused reintervention, and poor patient selection. The mortality rate was 57% (4/7) overall and was 50% for surgical repair (3/6). A literature search identified 40 additional ruptures related to other devices, for a total of 47. All 44 that were documented with adequate data were caused by endoleaks (26 type I, 2 type II, 11 type III, and 5 source not reported). Other contributing factors were graft module separation and graft wall deterioration. The overall mortality rate for the combined series was 50%, with an operative mortality rate of 41%. CONCLUSION: Postendograft AAA rupture is infrequent, although the true incidence rate is unclear because of inadequate follow-up of individual device designs. Tube endografts should be limited to the rare patient with ideal anatomy, no other alternatives, and at high risk for standard open repair. Prevention of aneurysm rupture requires long-term surveillance with attention to subtle imaging abnormalities and the establishment of reliable follow-up protocols for specific devices. The outcome of postendograft aneurysm rupture is similar to that of rupture without prior endograft therapy.     

Recurrent symptomatic aortic sac seroma after open abdominal aortic aneurysm repair

The expansion of an abdominal aortic aneurysm sac after conventional repair has been rarely described. All cases in the literature have been associated with polytetrafluoroethylene grafts and perigraft seromas. We present a patient with a recurrent, symptomatic periaortic graft seroma after conventional repair. The etiology of this problem along with its potential increasing significance in the endovascular era is reviewed.     

Ischemic complications after endovascular abdominal aortic aneurysm repair

OBJECTIVES: Limb and pelvic ischemia are known complications after endovascular abdominal aortic aneurysm repair (EVAR). The objective of this paper is to present our experience with the incidence, presentation, and management of such complications. METHODS: Over 9 years 311 patients with aortic aneurysms underwent EVAR. A retrospective review identified 28 patients (9.0%) with ischemic complications. RESULTS: Among 28 patients with ischemic complications, 21 had lower extremity ischemia and 7 had pelvic ischemia: colon (n = 4), buttock (n = 2), and spinal cord (n = 2). Of the 21 patients with lower extremity ischemia, 15 had limb occlusions (71.4%), 3 due to embolization (14.7%) and 3 the result of common femoral artery thromboses (14.7%). Limb occlusions were manifested as severe acute arterial ischemia (n = 6), rest pain (n = 3), intermittent claudication (n = 5), and decreased femoral pulse (n = 1). Limb occlusions were managed with thrombectomy and stent placement (n = 4), femorofemoral bypass (n = 7), eventual explantation because of persistent endoleak (n = 1), and expectant management (n = 3). The 3 patients with occlusions managed expectantly all had intermittent claudication, which has subsequently improved. In the 6 patients with lower extremity ischemia due to embolization or common femoral artery injury presentation was acute, and embolectomy was performed, followed by femoral artery endarterectomy and patch angioplasty or placement of an interposition graft. One patient who had a prolonged postoperative course including cardiac arrest subsequently required distal bypass and ultimately above- knee amputation. Among the 7 patients with pelvic ischemia, 2 patients had unilateral hypogastric artery embolization before the original surgery. Among the patients with colonic ischemia, 3 were seen immediately postoperatively, and required colectomy and colostomy. Two patients who required urgent colectomy subsequently had multiple organ failure, and died in the perioperative period. One patient had abdominal pain 1 week after surgery, which was managed with bowel rest, with subsequent improvement. In 2 patients spinal cord ischemia developed immediately after surgery, which resulted in persistent paraplegia. Buttock ischemia developed in 2 patients, 1 of whom required fasciotomy because of gluteal compartment syndrome, and had transient renal failure. CONCLUSIONS: Ischemic complications are not uncommon after EVAR, and may exceed the incidence with open surgical repair. Limb ischemia is most often a result of limb occlusion, and can be successfully managed with standard interventions. Pelvic ischemia often results from atheroembolization despite preservation of hypogastric arterial circulation. Colonic and spinal ischemia are associated with the highest morbidity and mortality.     

Secondary interventions after endovascular abdominal aortic aneurysm repair

BACKGROUND: One adverse outcome of endovascular abdominal aortic aneurysm (AAA) repair (EVAR) is a significantly increased incidence of secondary interventions (SIs) required compared with traditional open aortic repair. We present a consecutive series of EVARs using a single endograft to identify the incidence and types of SIs performed. METHODS: From February 1, 2000, to January 31, 2005, we repaired 136 AAAs with the Zenith (Cook, Bloomington, Indiana) endograft. All patients met the same strict anatomic inclusion and exclusion criteria. Follow-up lasted from 1.5 to 61 months (median 36). The indications for SI group A were procedural and technical errors, for group B were aortic morphology, and for group C were device failures. RESULTS: Twenty-one SIs were required in 17 of 136 patients (12.5%). Three patients required multiple interventions. Nine patients were in group A, four were in group B, and six were in group C. All but 4 patients required SIs for late (>30 days) complications. CONCLUSIONS: Although it is a viable alternative to open aortic repair, EVAR is associated with a significantly higher rate of SIs. To maintain the efficacy of EVAR, patients must be followed-up in a vigilant graft surveillance protocol for life.     

Multicenter trial of the PowerLink bifurcated system for endovascular aortic aneurysm repair

PURPOSE: The purpose of this study was to assess the results of abdominal aortic aneurysm repair with the PowerLink bifurcated endovascular graft (Endologix, Inc, Irvine, Calif). METHOD: Twelve centers used the PowerLink bifurcated system for elective endovascular aneurysm repair in 118 patients recruited during a 16-month interval and followed for a 25-month interval (mean follow-up, 16 months) as part of a pivotal US Food and Drug Administration trial. Stent grafts were oversized by 10% to 20% relative to computed tomographic scan-based diameter measurements. All repairs were performed in the operating room through one surgically exposed femoral artery and a contralateral 9F sheath percutaneously placed. Results were assessed with contrast-enhanced computed tomography and plain abdominal radiography at 1, 6, and 12 months after surgery. RESULTS: Three failed insertions and one late conversion for endoleak remediation occurred, resulting in four conversions (3.3%) to open surgery. Of the failed insertions, two were from a faulty delivery system design, which was corrected. No failures occurred after the modification. One perioperative death (0.8%) occurred that was not device related. Eight late deaths were from unrelated causes, and one was from complications after reoperation for treatment of an endoleak. Endoleaks were noted in 19 patients (16%) at the time of the endograft procedure: 12 resolved spontaneously, four resolved with secondary interventions (three type I, one type II), and three underwent observation, yielding a 30-day endoleak rate of 5.9%. Two graft limb thromboses (0.8%) were seen. One graft migration (0.8%) was of no clinical significance. No ruptures or wire fractures were found. The mean aneurysm diameter was reduced from 51 mm (preoperative) to 45 mm (12 months; P <.0001). CONCLUSION: The PowerLink system appears to be safe and effectively protects patients from abdominal aortic aneurysm rupture over the short to medium term. The low endoleak rate is superior to that reported for other devices. The graft and stent materials have thus far been free from failure and fatigue. The sutureless stent and endoskeleton design confer a number of unique advantages and challenges. Careful follow-up over the longer term is necessary to assure the durability of these results.     

Laparoscopic pancreaticoduodenectomy after endovascular repair for abdominal aortic aneurysm

INTRODUCTIONMost gastroenterological surgeries, even pancreatic surgery, can now be performed laparoscopically. However, the management of concomitant abdominal aortic aneurysm (AAA) and intra-abdominal malignancy is controversial. The performance of endovascular repair (EVAR) for AAA has been increasing; however, there is no report of laparoscopic pancreaticoduodenectomy after EVAR.PRESENTATION OF CASEA pancreatic tumor was detected during follow-up after EVAR for AAA. The enlarging tumor was diagnosed as an intraductal papillary mucinous tumor with a nodule. Laparoscopic pancreaticoduodenectomy was safely performed. After laparoscopic dissection around the pancreas head, an additional incision was made in the upper abdomen, and pancreatic reconstruction was performed through the incision. In spite of grade B pancreatic fistulae, the patient recovered with medical therapy. The pathological diagnosis was intraductal papillary mucinous adenoma with small foci of carcinoma in situ. The patient has been well with neither recurrence of the tumor nor any cardiovascular events for 18 months.DISCUSSIONThe management of concomitant malignancy and AAA is challenging, especially in patients with a pancreatic tumor. The reasons for the rarity of treatment include prognosis, anatomical vicinity, and postoperative complications. EVAR reduces retroperitoneal adhesions. A laparoscopic approach provides a small operative field and decreases mutual interference with AAA. Moreover, reconstruction is performed through an upper abdominal incision apart from the AAA. Hand-sewing provides more reliable stability of the anastomosis.CONCLUSIONThe increasing frequency of performance of EVAR for AAA and subsequent computed tomography may help to detect malignancy. Laparoscopic surgery appears to be a valid approach to malignancy after EVAR.     

Late rupture of abdominal aortic aneurysm after endovascular repair

Objective

The purpose of this study was to compare findings at presentation and surgical outcomes in patients in whom abdominal aortic aneurysms (AAAs) ruptured after endovascular repair and in patients in whom AAAs ruptured before any treatment during a defined period at a single center.

Renal transplantation after endovascular repair of abdominal aortic aneurysm

An increasing number of abdominal aortic aneurysms (AAA) occur in renal failure patients because of strong association between atherosclerosis and chronic kidney disease. Endovascular aneurysm repair (EVAR) has proven to be an effective modality to treat AAA, particularly in patients with renal disease, because of its several advantages over the standard open procedure, including lower morbidity, shorter operative time, and shorter hospital stay. A Medline search showed a single publication on renal transplantation (RT) following EVAR of AAA. In this context, we report our case of successful RT in a patient who had undergone EVAR 2 years prior for a 5.7-cm AAA. No stent-related complications, such as graft occlusion, dislodgement, dissection, or endoleak, were observed in the perioperative period. The transplanted kidney had primary function leading to a stable serum creatinine of 115 micromol/L at 6 months. Although the long-term outcome of RT after endovascular repair of AAA remains unknown, currently available evidence shows favorable outcomes of EVAR in the normal population, in patients with renal diseases, and in RT recipients; hence, RT should not be denied to renal failure patients who have undergone EVAR in the past.     

Endoleak after endovascular repair of abdominal aortic aneurysm.

PURPOSE: We sought to assess the role of endovascular techniques in the management of perigraft flow (endoleak) after endovascular repair of an abdominal aortic aneurysm. METHOD: We performed endovascular repair of abdominal aortic aneurysm in 114 patients, using a variety of Gianturco Z-stent-based prostheses. Results were evaluated with contrast-enhanced computed tomography (CT) at 3 days, 3 months, 6 months, 12 months, and every year after the operation. An endoleak that occurred 3 days after operation led to repeat CT scanning at 2 weeks, followed by angiography and attempted endovascular treatment. RESULTS: Endoleak was seen on the first postoperative CT scan in 21 (18%) patients and was still present at 2 weeks in 14 (12%). On the basis of angiographic localization of the inflow, the endoleak was pure type I in 3 cases, pure type II in 9, and mixed-pattern in 2. Of the 5 type I endoleaks, 3 were proximal and 2 were distal. All five resolved after endovascular implantation of additional stent-grafts, stents, and embolization coils. Although inferior mesenteric artery embolization was successful in 6 of 7 cases and lumbar embolization was successful in 4 of 7, only 1 of 11 primary type II endoleaks was shown to be resolved on CT scanning. There were no type III or type IV endoleaks (through the stent-graft). Endoleak was associated with aneurysm dilation two cases. In both cases, the aneurysm diameter stabilized after coil embolization of the inferior mesenteric artery. There were two secondary (delayed) endoleaks; one type I and one type II. The secondary type I endoleak and the associated aneurysm rupture were treated by use of an additional stent-graft. The secondary type II endoleak was not treated. CONCLUSIONS: Type I endoleaks represent a persistent risk of aneurysm rupture and should be treated promptly by endovascular means. Type II leaks are less dangerous and more difficult to treat, but coil embolization of feeding arteries may be warranted when leakage is associated with aneurysm enlargement.     

Delayed paraplegia after endovascular repair of abdominal aortic aneurysm

Paraplegia is rare after open repair of infrarenal abdominal aortic aneurysm, and only two cases have been reported after endovascular repair, both due to atheroembolism. Incidence of renal failure after endovascular repair of abdominal aortic aneurysm (EVAR) in patients with normal preoperative renal function is about 8.7%, but is much higher in those with preexisting renal impairment, possibly because of administration of nephrotoxic contrast media during EVAR. We report a case in which contrast medium-induced acute renal failure is believed to have led to delayed paraplegia after EVAR.