Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair

PURPOSE: Retroperitoneal iliac procedures can enable successful endovascular repair of abdominal aortic aneurysm (AAA) in patients who otherwise would not be anatomically eligible. The purpose of this study was to determine perioperative outcome with adjunctive retroperitoneal procedures compared with standard bilateral femoral exposure. METHODS: Between August 1997 and November 2002, 164 patients underwent elective endovascular AAA repair at a single university medical center. Anatomic, demographic, and early postoperative outcome data gathered prospectively were analyzed. Thirty-two patients (20%) underwent 38 separate adjunctive retroperitoneal procedures. Indications included small external iliac arteries (16 of 32 patients; 50%) and concomitant iliac aneurysm that precluded fixation of the endograft limbs in the common iliac arteries (16 of 32 patients; 50%). The 38 procedures consisted of 8 iliac conduits only, 14 iliac conduits with iliofemoral bypass grafts, and 16 hypogastric revascularization procedures. Data for the study patients were compared with data for 132 patients who underwent endovascular AAA repair through femoral incisions. Primary end points were hospital length of stay, and early morbidity and mortality. RESULTS: Retroperitoneal procedures enabled an additional 14% of patients with AAA to undergo endovascular techniques. However, there was a significantly higher proportion of women and patients at high risk for anesthesia (American Society of Anesthesiologists class IV or higher) in the group who underwent retroperitoneal procedures. On average, retroperitoneal procedures were associated with 2.6-fold greater blood loss, 82% longer procedure time, 1.5 days additional hospital stay, and 1.8-fold higher rate of perioperative complications, compared with endovascular AAA repair with femoral exposure alone. In contrast, early mortality was similar in the two groups. CONCLUSION: Adjunctive retroperitoneal procedures during endovascular AAA repair are associated with increased risk for complications and longer hospital length of stay, compared with AAA repair with standard femoral exposure only. They do not, however, increase early mortality, even in patients at high risk, and enable a larger subset of patients with AAA to undergo endovascular repair.     

Open abdominal aortic aneurysm repair in octogenarians before and after the adoption of endovascular grafting procedures

OBJECTIVE: This study evaluated (1) elective open abdominal aortic aneurysm repair (OAR) in patients aged > or =80 years before and after stent graft devices for endovascular aneurysm repair (EVAR) became commercially available and (2) the effect on perioperative (30-day) outcome of the anatomic constraints that led to EVAR being excluded for many of them. METHODS: A review was conducted on the records of 111 patients aged > or =80 years who underwent elective OAR during a 14-year period at the University of Padua School of Medicine. Patients were separated into two groups: group 1 (n = 65) had OAR before and group 2 (n = 46) after an EVAR program was adopted at the medical school in mid-2000. Perioperative death and morbidity, location of proximal aortic clamp, management of the left renal vein, associated iliac aneurysmal or occlusive diseases, the type of surgical reconstruction, operating time, and lengths of stay in the intensive care unit and the hospital were recorded. All the data were compared between the two groups. RESULTS: Retroperitoneal approach, suprarenal clamping, left renal vein division, and longer operating room time were statistically more common in group 2 (36.9% vs 12.3%, P = .002; 15.2% vs 3.1%, P = .032; 23.9% vs 7.7%, P = .026; and 117 +/- 8 min vs 95 +/-7 min, P < .001, respectively). Although group 2 had significantly more iliac aneurysms (52.1% vs 32.3%; P = .036), the number of bifurcated reconstructions was comparable. The overall perioperative mortality rate was 1.8% (2 of 111), and the figures for groups 1 and 2 were comparable (3.1% vs 0%; P = .510). No deaths were cardiac related. Group 2 had a significantly higher incidence of kidney failure (8.7% vs 0%; P = .027). Kaplan-Meier analysis showed an overall 3-, 5-, and 10-year survival rate of 80.6%, 67.2%, and 59.4%, respectively, with a 3- and 5-year survival rate comparable between groups 1 and 2 (77.8% and 66.7% vs 87.8% and 45.8%, respectively; log-rank test, P = .921). CONCLUSIONS: Octogenarians can tolerate OAR with acceptable rates of perioperative mortality and morbidity. Although the complexity of OAR has increased significantly in the era of EVAR, the perioperative outcome has not changed.     

Hand-assisted laparoscopic abdominal aortic aneurysm repair.

Hand-assisted laparoscopic aneurysm resection enables the surgeon to use his tactile senses while performing a laparoscopic aneurysm repair. Even more complex procedures that involve suprarenal clamping of the aorta can be performed by using this laparoscopically assisted approach. Twenty-nine laparoscopic patients were compared with a control group of 19 patients who were operated on conventionally. Transperitoneal hand-assisted laparoscopic aneurysm resection with a tube graft or a bifurcated graft was performed. The anastomosis was sutured with conventional instruments using the mini-incision as an access. The time for laparoscopy did not exceed 40 minutes. The incidence of complications did not vary between groups. The mean operating time was 135 minutes in the conventional group versus 180 minutes in the minimal invasive group. Intensive care stay and postoperative hospital stay were significantly shorter after the laparoscopic procedure. An oral diet was resumed significantly earlier, and the time until complete recovery was shortened in the miniaccess group. Hand-assisted laparoscopic aneurysm resection can be performed safely with operating times almost as expeditiously as in open surgery. Because it can be offered to the majority of patients with aortic disease, the technique described has distinct advantages over a total laparoscopic approach and a less steep learning curve.     

Laparoscopically assisted abdominal aortic aneurysm repair.

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. However, the application of laparoscopic techniques to intraabdominal vascular procedures has now progressed from the animal laboratory to the clinical arena. Initial experience with laparoscopically assisted aortic bypasses for occlusive disease has led to the development of procedures for aneurysmal disease. This article reviews the current clinical experience in the evolving technique of laparoscopically assisted abdominal aortic aneurysm repair.     

Totally laparoscopic abdominal aortic aneurysm repair.

Current experience with totally laparoscopic aortic aneurysm repair is reviewed with particular attention to the techniques of surgery. Vascular surgery has been slow to enter the field of minimally invasive surgery because of the unique difficulties of managing arterial anatomy with minimal access techniques. Laparoscopic instrumentation has undergone a stunning evolution, and surgeon experience with minimally invasive surgery has grown exponentially. This dramatic revolution has allowed several groups to perform laparoscopic aortic vascular surgery. The surgical approach that each group has taken has varied. The approaches have included both laparoscopically assisted and totally laparoscopic aortic surgery with both transperitoneal and retroperitoneal approaches to the aorta. A review of these varied techniques will be discussed and include our experience with totally laparoscopic aortic surgery. This experience includes both transperitoneal and retroperitoneal approaches to infrarenal aortic aneurysms. An extended discussion of our surgical technique for aneurysm bypass is included. Patient selection, patient positioning, and trocar placement are described. The pattern of surgery for both techniques is enumerated, and postoperative care is discussed. However, the world experience with minimally invasive vascular surgery remains small, therefore a wider acceptance will require a prospective, randomized trial that shows an equally as safe surgical approach as provided open vascular surgery. With its acceptance, minimally invasive vascular surgery should show the patient benefits that befall minimally invasive surgery patients.     

Laparoscopic-assisted abdominal aortic aneurysm repair

Since the advent of laparoscopy, the sweeping changes seen in general surgery have not been paralleled in vascular surgery. There have been case reports of laparoscopic-assisted aortobifemoral bypass for occlusive disease. Because aneurysmal disease comprises the majority of aortic surgery, we pursued animal and cadaveric feasibility studies for laparoscopic-assisted abdominal aortic aneurysm (AAA) repair. We present a case report of the first clinical case performed under Institutional Review Board protocol using this technique. The patient was a 62-year-old male with a 6-cm infrarenal AAA. After obtaining a pneumoperitoneum, a modified fish retractor was used to exclude the bowel. Ten 11-mm ports provided access to laparoscopically dissect the neck of the aneurysm and the iliac vessels. Then, a 10-cm minilaparotomy was performed and standard vascular clamps were inserted via the port incisions. Standard aneurysmorraphy was performed with a polytetrafluoroethylene (PTFE) tube graft. Laparoscopy conferred three major benefits: better visualization of the aneurysm neck, less bowel manipulation, and avoidance of hypothermia. This case report illustrates the feasibility of laparoscopic-assisted aneurysm repair. Controlled human studies will define the role of laparoscopy in AAA surgery.     

Complex abdominal aortic aneurysm repair

ascular surgery is a challenging discipline and complex aneurysms can present an entire range of technical difficulties. To overcome these problems good technical skills are mandatory. However, it is also worth remembering a few basic rules: The simplest solution is often the best. All cases need careful planning, including that of the approach. A successful anastomosis requires good aortic tissue. Minimal dissection reduces morbidity.     

Endovascular abdominal aortic aneurysm repair

Around two-thirds of abdominal aortic aneurysms (AAA) are incidentaldiscoveries during the investigation of backache, hip pain orurinary tract complaints. They are much more common in men thanwomen (5:1) and account for 2% of all deaths in men aged >60yr. Open surgical repair of the aneurysm is considered as thestandard, traditional method of treatment. Surgery is recommendedwhen the AAA exceeds 55 mm in anteroposterior diameter as measuredby ultrasound scan. The risk of spontaneous rupture dependson aneurysm size, ranging from <1% per annum for AAA <55mm diameter to >17% per annum for aneurysms >60 mm diameter.Ninety per cent of AAAs are located distal to the renal arteries. Endovascular repair of an aortic aneurysm using an in-situ prostheticgraft was suggested as a technique in 1969 by Dotter, but wasonly first performed successfully by Parodi and colleagues in1990. Over the last 10 yr, the availability of endovascularstent grafts has provided an alternative treatment for patientswith AAA, especially the elderly with significant co-existingmedical conditions. Endovascular repair is much less invasive.However, it is challenging technically and requires a multidisciplinaryapproach. During endovascular surgery, an aortic stent graft is passedvia the femoral arteries through the aortic lumen to fit tightlyabove and below the AAA. The aim is to exclude the aneurysmsac from the systemic circulation, thereby decreasing or eliminatingthe risk of future rupture. The procedure is performed throughincisions in one or both groins; no laparotomy is required.However, certain anatomical considerations apply.     

腹主动脉瘤腔内治疗现状

1991年,Parodi等发明人工血管内支架（stent graft,SG）并用于临床成功治愈腹主动脉瘤（abdominal aortic aneurvsm,AAA）,此后腹主动脉瘤腔内治疗（endovascular abdominal aortic aneurysm repair,EVAR）取得迅速发展。由于EVAR避免了传统开腹手术创伤大和出血多的缺点,使高龄或伴有心、肺、肝、肾功能不全的患者获得积极治疗的机会。一般来讲,腔内治疗主要是指肾下型腹主动脉瘤。     

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.     

A meta-analysis of 50 years of ruptured abdominal aortic aneurysm repair

BACKGROUND: Operative repair of ruptured abdominal aortic aneurysm (RAAA) is associated with a high mortality rate but reported figures vary widely. The aim of this study was to estimate the operative mortality of RAAA repair and determine how it has changed over time. METHODS: A meta-analysis of all English language literature quoting figures for operative mortality of RAAA repair. RESULTS: The pooled estimate for the overall operative mortality rate of RAAA repair from 1955 to 1998 was 48 (95 per cent confidence interval 46 to 50) per cent. Meta-regression analysis of operative mortality over time demonstrated a constant reduction of approximately 3.5 per cent per decade (1954-1997) with an operative mortality rate estimate for the year 2000 of 41 per cent. Seventy-seven studies reported intraoperative mortality but, while this appears to have remained constant over time, there was evidence of the presence of publication bias in the subgroup of papers reporting this outcome. There was no evidence of publication bias for the overall operative mortality outcome. CONCLUSION: Contrary to the conclusion of recent studies, this paper demonstrates a gradual reduction with time in the operative mortality rate of RAAA repair.     

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应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法对２例病人采用全麻,在动态数字减影血管造影监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生,结论腹主动脉瘤腔内修复术手术创伤小,病人恢复快,跨肾动支架人工     

Percutaneous repair of abdominal aortic aneurysm

OBJECTIVE: Percutaneous treatment of an abdominal aortic aneurysm (AAA) is feasible, but is associated with a unique set of risks. A comparison of Excluder endograft deployment with femoral artery cutdown (FAC) versus percutaneous femoral access (PFA) for treatment of infrarenal AAA was undertaken. METHODS: A single-institution, controlled, retrospective review was carried out in patients who underwent either bilateral FAC or bilateral PFA for endovascular repair of infrarenal AAA with the Gore bifurcated Excluder endograft between March 1999 and November 2003. To November 2000, 35 patients underwent bilateral FAC; since then, 47 patients have undergone bilateral PFA. All have been followed up for at least 30 days. RESULTS: Mean AAA size was 5.7 cm in the FAC group and 6.0 cm in the PFA group. During hospitalization there were six access-related complications in the FAC group; three required early surgical intervention. In the PFA group nine perioperative access-related complications occurred, all consisting of either hemorrhage or arterial occlusion; seven required additional intervention, and were recognized and ameliorated while the patient was still in the operating room. At 30-day follow-up there were no additional access-related complications in the PFA group. There were eight other access-related complications in eight additional patients who underwent FAC. In patients undergoing bilateral PFA total operative time was shorter (PFA 139 minutes vs FAC 169 minutes; P =.002), total in-room anesthesia time was less (PFA 201 minutes vs FAC 225 minutes; P <.008), and use of general anesthesia was reduced (P <.001). No significant differences were observed between groups with respect to estimated blood loss (PFA 459 mL vs FAC 389 mL; P =.851). CONCLUSION: Complete percutaneous treatment of AAA may have some advantages over open femoral artery access, but it is not free from risk. Percutaneous treatment of AAA can be completed successfully in most patients, but should be performed at an institution where conversion to an open procedure can be completed expeditiously if necessary.     

Duodenal obstruction after abdominal aortic aneurysm repair.

Duodenal obstruction is a rare post-operative complication of abdominal aortic aneurysm repair. Out of only four previously reported cases, two were post-mortem findings and the other two were managed surgically by gastro-jejunostomy and duodeno-jejunostomy, respectively. We present here two further cases of duodenal obstruction after aneurysm repair, one due to intramural haematoma and the other due to the superior mesenteric artery syndrome. Both cases were managed conservatively with parenteral nutrition and an expectant policy, with a successful outcome in each case.     

Late survival after abdominal aortic aneurysm repair.

OBJECTIVES: This study was undertaken to determine the late survival of patients operated successfully for abdominal aortic aneurysm (AAA) repair, to compare survival data with that of the age- and sex-matched general population, to identify the causes of late death, and to determine the factors influencing late survival. MATERIALS AND METHODS: A total of 187 consecutive patients underwent elective surgical AAA repair between January 1987 and December 1991. There were 11 postoperative deaths (early mortality rate 5.9%). The remaining 176 patients formed the basis of this cohort-based retrospective study. Six patients (3.4%) were lost to follow-up. Mean follow-up was 71 months. RESULTS: A total of 70 patients (39.8%) died during the study period. Coronary artery disease (CAD) and cancer were the two main causes. The survival rate at five years (71.6%) was lower than that of the sex- and age-matched general population (90.6%). Neither arterial hypertension nor CAD had any influence on late survival. In contrast, age and chronic renal failure were predictive variables of late survival. CONCLUSIONS: The life expectancy of patients who undergo successful AAA repair is not as good as that of the age- and sex-matched general population. Late survival depends on the patients' age at the time of surgery and the existence of preoperative chronic renal failure.     

Systematic review and meta-analysis of 12 years of endovascular abdominal aortic aneurysm repair.

BACKGROUND: Endovascular repair (ER) of abdominal aortic aneurysm (AAA) is a new technique, and reported rates of endoleak, conversion to open repair, rupture and mortality vary widely. The aim of this study was to estimate these rates from the published data, and examine how this has changed as more patients have undergone ER. METHODS: A systematic review and meta-analysis of publications identified through searches of the electronic databases EMBASE and Medline. All publications quoting endoleak, conversion to open repair, rupture and mortality rates for a series of patients undergoing ER were included. RESULTS: 163 studies pertaining to 28,862 patients undergoing ER were identified as relevant for the review and meta-analysis. The pooled estimate for operative mortality was 3.3% (95% confidence interval 2.9 to 3.6%). The pooled estimate for type 1 endoleaks was 10.5% (95% confidence interval 9.0 to 12.1%), with an annual rate of 8.4% (95% confidence interval 5.7% to 12.2%). The pooled estimate of type 2,3 and 4 endoleaks was 13.7% (95% confidence interval 12.3 to 15.3%), with an annual rate of 10.2% (95% confidence interval 7.4% to 14.1%). The pooled estimate for primary conversion to open repair was 3.8% (95% confidence interval 3.2 to 4.4%), and for secondary conversion to open repair 3.4% (95% confidence interval 2.8 to 4.2%). The pooled estimate for post-operative rupture was 1.3% (95% confidence interval 1.1 to 1.7%), with an annual rupture rate of 0.6% (95% confidence interval 0.5% to 0.8%). Multivariate meta-regression analysis showed that rates of operative mortality, post-operative rupture and total number of endoleaks all fell significantly (p<0.05) over time. CONCLUSIONS: This study demonstrates a low mortality and a gradual reduction in vascular morbidity and mortality associated with endovascular repair since it was first introduced.     

Urgent abdominal aortic aneurysm repair in patients over the age 80

We present three patients with successful surgical repair of abdominal aortic aneurysms with signs of imminent rupture in octogenarians. The patients presented with evidence of severe left ventricular dysfunction and reduced compliance either before or during surgery. Extremely cautious delivery of fluids and of after-load reducing agents was employed under the guidance of measurements of cardiac output and filling pressures from a pulmonary arterial catheter inserted prior to surgery.