Traumatic abdominal aortic injury treated by endovascular stent placement

Traumatic injury of the abdominal aorta is rare and potentially lethal. The authors present the case of a restrained passenger who was involved in a high-speed, head-on motor vehicle accident. On arrival in the emergency department, the patient complained of abdominal pain, was tachycardic and had a large ecchymoses on his right flank and lower abdominal wall. Computed tomography (CT) angiography (CTA) of the abdomen revealed a degloving injury to the abdominal wall, small bowel injury, and a distal abdominal aortic injury with a small amount of retroperitoneal hemorrhage. The patient underwent surgical repair of bowel injuries and the anterior abdominal wall. Because of risk of peritoneal soiling, open repair of the aorta was not attempted. The interventional radiology and vascular surgery services performed an endovascular repair of the aortic injury using a bifurcated endograft.     

Gallstone abscess: a delayed complication of spilled gallstone after laparoscopic cholecystectomy

Laparoscopic cholecystectomy has become the preferred method of treatment of cholelithiasis since its inception in 1987. Although overall complication rate is less than that of traditional approach, two operative complications of laparoscopic cholecystectomy have been frequently described in the literature. One is the bile duct injury or leak and the other one spillage of stones resulting in delayed abscess formation (Horton and Florence, Am J Surg 175:375–379, 1998; Frola et al., BJR 72:201–203, 1999). The incidence of abscess is very rare (approximately 0.3%). The location of the subsequent abscess and the inflammatory masses containing stones or stone fragments is generally in the abdominal wall, subhepatic space, or the retroperitoneum below the subhepatic space but can occur anywhere in the abdomen, right thorax, at trocar site, and at incisional hernia (Zehetner et al., Am J Surg 193:73–78, 2007; Offiah et al., BJR 75:393–394, 2002; Morrin et al., AJR 174:1441–1445, 2000). We report here a case of abscess formation due to spilled stone occurring 6 months post-laparoscopic-cholecystectomy. The diagnosis was suggested by ultrasound examination and was further confirmed by computed tomography scan of the abdomen.     

Terminal ileal micro-perforation from an ingested fish bone incidentally diagnosed with 111In-leukocyte scintigraphy in an asymptomatic patient

¹¹¹In-leukocyte scintigraphy has generally been considered a sensitive diagnostic test for the evaluation of infectious or inflammatory processes in the abdomen due to a lack of normal physiologic bowel activity. Herein we present a case of a patient status post endovascular repair of an abdominal aortic aneurysm for which an ¹¹¹In-leukocyte scan was ordered to assess for graft infection. Planar imaging revealed an abnormal focus of radiotracer activity in the right lower quadrant of the abdomen. A SPECT-CT obtained to further delineate the anatomic location of abnormal activity showed abnormal leukocyte activity localizing to the terminal ileum secondary to a micro-perforation from an ingested fishbone. This case underscores the principle that in the absence of known intra-abdominal pathology, ¹¹¹In-leukocyte activity in the abdomen should always be considered abnormal, and that further evaluation with dedicated cross-sectional imaging should be performed to assist with the localization of abnormal activity.     

Salmonella spondylodiscitis associated with a mycotic abdominal aortic aneurysm and paravertebral abscess

Each year, 1.4 million people in the United States are infected with Salmonella (Beneson et al. [23] Am J Med, 110:60–63, 2001). The most common clinical presentation of Salmonella infection is gastroenteritis which is usually self-limited, lasting between one to four days (Black et al. [24] N Engl J Med, 261:811–816, 1960). Although most infections are mild-to-moderate, serious disease, and death does occur (Voetsch et al. [25] CID, 38:S127–S132, 2004). A rare but increasing number of patients present with Salmonellosis spondylodiscitis resulting from contiguous spread of infection from the adjacent abdominal aorta. Concurrent infection of these structures exacerbates morbidity, necessitating an elevated clinical suspicion in patients with appropriate risk factors, clinical signs and symptoms. Furthermore, an overall mortality rate of 67% makes mycotic abdominal aortic aneurysms highly lethal (Gonda et al. [26] Radiology, 168:343–346, 1988). Thus, early diagnosis is crucial, allowing for prompt antibiotic and surgical management. Laboratory and imaging tests obtained at the initial suspicion for infection of the spine and aorta facilitates diagnosis while minimizing or preventing more serious complications like paresis and aortic rupture. We present a patient with a mycotic abdominal aortic aneurysm infected with Salmonella enteritides that spread to the adjacent lumbar vertebra and left psoas muscle.     

Endovascular Stent-Graft Repair as a Late Secondary Procedure After Previous Aortic Grafts

Thoracic and abdominal aortic endovascular procedures as alternatives to aortic reoperations were studied in three different cases. An anastomotic aneurysm after previous thoracic aortic graft for coarctation, a second-stage elephant trunk repair (descending thoracic aortic aneurysm), and a secondary aneurysm proximal to a previous abdominal aortic graft were successfully treated with endovascular stent-grafts. During the follow-up period no lethal events or major aortic or graft-related complications were observed, except a type II endoleak in the anastomotic aortic aneurysm case. An endovascular stent-graft can be safely deployed into a previously implanted vascular graft, avoiding repeat surgery.     

多层螺旋CT在腹主动脉瘤腔内隔绝术后的随访价值

目的 分析腹主动脉瘤腔内治疗术后的转归及多层螺旋CT(MSCT)随访价值.方法 回顾性总结2000年3月至2006年12月问193例腹主动脉瘤腔内隔绝术后行MSCT检查的结果,并与术前资料对照.结果 193例中发现支架变形、断裂4例,支架闭塞1例、内漏24例、移植物感染2例;瘤体缩小81例,瘤体增大21例,瘤体无变化91例.结论 MSCT是腹主动脉瘤腔内隔绝术术后随访的首选方法 .     

Renewed endovascular repair for recurrent acute abdominal aortic aneurysm

The aim of the study was to describe the successful endovascular management of a patient who was admitted urgently with a second episode of acute abdominal aortic aneurysm (AAA) 30 months after emergency endovascular abdominal aortic aneurysm repair (eEVAR) for a ruptured AAA. The patient, an 84 year-old male physician, presented with severe acute abdominal and back pain. Contrast-enhanced computer tomography scanning showed type III endoleak owing to complete disconnection of both graft limbs and the prosthetic main body. Treatment consisted of acute stent-grafting with two bridging stent-grafts to seal the endoleak and reline the graft. The patient is alive and well 6 months postoperatively. This case indicates the need for follow-up after eEVAR, but also that complications can be managed endovascularly.     

Helical CT angiography of stent-grafts in abdominal aortic aneurysms: morphologic changes and complications.

Transfemoral placement of an endovascular stent-graft is increasingly be-ing used as an alternative to surgical repair in the treatment of abdominal aortic aneurysm, especially in high-risk patients. However, complications frequently occur after stent-graft placement. Helical computed tomographic (CT) angiography is a fast, minimally invasive procedure that is quickly becoming the imaging modality of choice for assessment of these complications. Thirty-nine patients who were treated for abdominal aortic aneurysm with stent-graft placement underwent helical CT angiography at routinely scheduled follow-up intervals or whenever complications were suspected. The resulting images were evaluated for the presence, extent, and origin of endovascular leaks. In addition, the position, shape, and patency of the stent-grafts were assessed. Findings included both graft-related (n = 4) and non-graft-related (n = 3) leaks, thrombosis of a graft limb (n = 3), distal migration of the stent-graft (n = 5), angulation of bifurcated stent-grafts distal to the main graft (n = 6), shrinkage of the abdominal aortic aneurysm (n = 7), enlargement of the aneurysm with secondary graft-related leaks (n = 2), and an aortoduodenal fistula (n = 1). Helical CT angiography can depict complications that develop after treatment of abdominal aortic aneurysms with endovascular stent-grafts. Long-term follow-up is required to determine the full spectrum and frequency of complications that may develop after initially successful repair.     

Abdominal aortic aneurysms: elective endovascular repair versus conventional surgery--evaluation with evidence-based medicine techniques

PURPOSE: To use evidence-based techniques to compare elective open surgical repair of abdominal aortic aneurysms with endovascular repair by means of stent placement. MATERIALS AND METHODS: A focused clinical question formed the basis of a literature search. Evidence-based criteria were used to appraise and assign a "level of evidence" to retrieved articles. The following data were determined from the best studies: systemic, local, and/or vascular complications; graft failure rates; blood loss; mortality; length of intensive care and/or hospital stay; mid- and long-term outcomes; cost of endovascular repair versus that of surgery; and eligibility for endovascular repair. Absolute risk reductions and/or increases and numbers needed to treat or harm were calculated. RESULTS: The best current evidence came from 22 studies, which showed that there is slight, if any, difference between mortality rates of endovascular repair and surgery. Hospital and/or intensive care stay is shorter, blood loss less, and systemic complications fewer (numbers needed to treat, two to 12) with endovascular repair. Some authors reported a significant increase in local and/or vascular complications with endovascular repair (numbers needed to harm, two to six). Graft failure is significantly more common with endovascular repair (numbers needed to harm, four), and substantive adjunctive interventions are needed. Endovascular repair is more expensive than surgery. CONCLUSION: Elective endovascular repair has short-term benefits compared with surgery. There is slight, if any, difference in mortality. Endovascular repair costs more than surgery. At follow-up, surgical grafts performed better.     

Successful Emergency Stenting of Acute Ruptured False Iliac Aneurysm

A 75-year-old man complaining of acute abdominal pain, 1 month after elective surgical repair of an abdominal aortic aneurysm by an aortabi-iliac bypass graft, was referred and admitted to the emergency room. Imaging by sonography and computed tomography scan revealed a ruptured iliac pseudoaneurysm at the right iliac anastomotic site with associated large retroperitoneal hematoma. We inserted a self-expanding covered Z-stent graft by a transfemoral approach and the iliac anastomotic pseudoaneurysm was successfully excluded. Our case demonstrates the possibilities of an endovascular approach for providing a fast, efficient and less aggravating procedure in order to treat these life-threatening conditions.     

Long-term results after endovascular repair of abdominal aortic aneurysms with the Stentor and Vanguard stent-graft

Purpose: To present a single institution experience of long-term results after endovascular repair of abdominal aortic aneurysms (AAA) with the Stentor and Vanguard stent-grafts.

Material and Methods: Twenty-three patients (20 men, 3 women; mean age 68 years, range 53-81 years) were included in this prospective study. A first generation nitinol stent-graft (Stentor^™) was used in 12 patients and a second generation (Vanguard^™) in 11 patients. Follow-up was performed with magnetic resonance imaging (MRI) with contrast-enhanced MR angiography (CE MRA) at 1, 6, and 12 months, and thereafter annually (median follow-up 3 years; range 8 months to 8 years). A conventional radiograph of the abdomen was also performed. Before secondary intervention the findings on MRI with CE MRA were confirmed with spiral computed tomography (CT) and/or angiography (DSA).

Results: Only one patient (4%) had no complication. Endoleak was found in 15 patients (65%), graft migration in 8 (35%), and graft deformation in 18 (78%). Secondary endovascular repair was required in 7 patients (30%) and 7 (30%) were converted to open repair.

Conclusion: Complications with the Stentor and Vanguard stent-grafts were common. Long-term follow-up of endovascularly repaired AAA is mandatory.     

Endovascular Treatment of Descending Thoracic Aortic Aneurysms with the EndoFit Stent-Graft

Objective To evaluate the mid-term feasibility, efficacy, and durability of descending thoracic aortic aneurysm (DTAA) exclusion using the EndoFit device (LeMaitre Vascular). Methods Twenty-three (23) men (mean age 66 years) with a DTAA were admitted to our department for endovascular repair (21 were ASA III+ and 2 refused open repair) from January 2003 to July 2005. Results Complete aneurysm exclusion was feasible in all subjects (100% technical success). The median follow-up was 18 months (range 8–40 months). A single stent-graft was used in 6 cases. The deployment of a second stent-graft was required in the remaining 17 patients. All endografts were attached proximally, beyond the left subclavian artery, leaving the aortic arch branches intact. No procedure-related deaths have occurred. A distal type I endoleak was detected in 2 cases on the 1 month follow-up CT scan, and was repaired with reintervention and deployment of an extension graft. A nonfatal acute myocardial infarction occurred in 1 patient in the sixth postoperative month. Graft migration, graft infection, paraplegia, cerebral or distal embolization, renal impairment or any other major complications were not observed. Conclusion The treatment of DTAAs using the EndoFit stent-graft is technically feasible. Mid-term results in this series are promising.     

Endovascular Repair of an Anastomotic Leak Following Open Repair of Abdominal Aortic Aneurysm

This report describes the case of an early postoperative anastomotic leak following elective open repair of an infrarenal abdominal aortic aneurysm which was successfully treated by endovascular stent-grafting. A 71-year-old man underwent open tube graft repair of abdominal aortic aneurysm. Twelve days later he presented with a contained leak from the distal anastomosis, which was confirmed on CT scan. This was successfully treated with a bifurcated aortic stent-graft. This case illustrates the usefulness of the endovascular approach for resolving this rare surgical complication of open repair of abdominal aortic aneurysm and the challenges associated with the deployment of such a device within an aortic tube graft. On behalf of the East of Scotland Vascular Network     

Endovascular Repair of Traumatic Rupture of the Thoracic Aorta: Single-Center Experience

Purpose Traumatic rupture of the thoracic aorta secondary to blunt chest trauma is a life-threatening emergency and a common cause of death, usually following violent collisions. The objective of this retrospective report was to evaluate the efficacy of endovascular treatment of thoracic aortic disruptions with a single commercially available stent-graft. Methods Nine men (mean age 29.5 years) were admitted to our institution between January 2003 and January 2006 due to blunt aortic trauma following violent motor vehicle collisions. Plain chest radiography, spiral computed tomography, aortography, and transesophageal echocardiography were used for diagnostic purposes in all cases. All patients were diagnosed with contained extramural thoracic aortic hematomas, secondary to aortic disruption. One patient was also diagnosed with a traumatic thoracic aortic dissection, secondary to blunt trauma. All subjects were poor surgical candidates, due to major injuries such as multiple bone fractures, abdominal hematomas, and pulmonary contusions. All repairs were performed using the EndoFit (LeMaitre Vascular) stent-graft. Results Complete exclusion of the traumatic aortic disruption and pseudoaneurysm was achieved and verified at intraoperative arteriography and on CT scans, within 10 days of the repair in all patients. In 1 case the deployment of a second cuff was necessary due to a secondary endoleak. In 2 cases the left subclavian artery was occluded to achieve adequate graft fixation. No procedure-related deaths have occurred and no cardiac or peripheral vascular complications were observed within the 12 months (range 8–16 months) follow-up. Conclusions This is the first time the EndoFit graft has been utilized in the treatment of thoracic aortic disruptions secondary to chest trauma. The repair of such pathologies is technically feasible and early follow-up results are promising.     

Use of endoluminal stent-grafts in acute aortic rupture

Purpose: To report our experience with stent-graft treatment of acute aortic injuries. Materials and methods: Emergent stent-graft placement was considered in patients with acute aortic rupture or injury who were deemed to be high-risk candidates for surgery. After medical stabilization, patients were evaluated for suitability for endovascular interventions. Anatomic criteria for stent-grafting included: (1) contained ruptures of the thoracic aorta located distal to the left subclavian artery and above the celiac axis, and (2) a proximal and distal neck of ≥ 15 mm in length and ≤ 40 mm in diameter. Stent-grafts consisted of a modified Z-stent endoskeleton covered with woven polyester vascular graft material. All devices were placed under general endotracheal anesthesia. A transfemoral approach was utilized if the iliofemoral artery diameter was ≥ 8 mm. For iliofemoral diameters < 8 mm, the catheters were inserted directly into the infrarenal aorta after a retroperitoneal exposure. Patient follow-up consisted of angiography and spiral CT scan prior to discharge from the hospital. Subsequent spiral CT studies were performed at 6 and 12 months, and at 1-year intervals thereafter. Results: Thirteen patients (11 men and 2 women) with a mean age of 60 years (range 34–81 years) underwent emergent placement of thoracic stent-grafts for acute aneurysmal rupture (n = 8), traumatic transection (n = 3), or tumor and abscess erosions (n = 2). The stent-grafts were deployed successfully in all cases and there were no cases of embolization, paraplegia, or stent-graft migration. No patient required surgical conversion. The average stent-graft dimension was 34 mm in diameter (range 24–38 mm) by 15.8 cm in length (range 5.0–17.5 cm). No patient with traumatic aortic injury was excluded on the basis of anatomic criteria. Two patients died within 1 month of the procedure, one of ventricular rupture and the other of cardiac arrest on day 28 after an uneventful hospital course for a ruptured aneurysm. Conclusion: The preliminary experience from our series demonstrates that aortic stent-grafting for traumatic aortic injury is technically feasible and can be used to treat thoracic aortic rupture in patients at high risk for standard operative therapy.     

腹主动脉瘤腔内隔绝术后神经缺血性损伤

目的：探讨在腹主动脉瘤（AAA）腔内隔绝术（EVE）中神经缺血性损伤的发生原因及防治。临床资料：我科在施行AAA EVE中遇到1例术后发生神经缺血性损伤。患者为Ⅱa型AAA，选用Talent分叉型移植物行EVE，手术顺利。术后出现双侧股部酸痛不适、乏力，伴右侧屈髋无力。行肌电图检查提示双侧腓总神经、胫神经、H反射传导速度均减慢，双侧股神经未能引出动作电位。给予甲钴胺0.5mg肌内注射，隔日1次，地巴唑10mg3次/d，并辅以高压氧治疗和股四头肌功能锻炼。治疗2个月后患者股部疼痛、乏力逐步缓解，无明显功能障碍。复查下肢肌电图无明显改善。结论：AAA EVE后可能会发生脊髓的缺血性损伤，但发生率很低，术中封闭腰动脉是导致脊髓缺血的原因。脊髓缺血性损伤早期治疗最为重要，后期的神经营养治疗和功能锻炼也可以改善部分症状。     

Endovascular Treatment of Acute and Chronic Thoracic Aortic Injury

Our aim is to present midterm results after endovascular repair of acute and chronic blunt aortic injury. Between December 1999 and December 2005, 13 patients were endovascularly treated for blunt aortic injury. Ten patients, 8 men and 2 women, mean age 38.7 years, were treated for acute traumatic injury in the isthmus region of thoracic aorta. Stent-graftings were performed between the fifth hour and the sixth day after injury. Three patients (all males; mean age, 66 years; range, 59–71 years) were treated due to the presence of symptoms of chronic posttraumatic pseudoaneurysm of the thoracic aorta (mean time after injury, 29.4 years, range, 28–32). Fifteen stent-grafts were implanted in 13 patients. In the group with acute aortic injury one patient died due to failure of endovascular technique. Lower leg paraparesis appeared in one patient; the other eight patients were regularly followed up (1–72 months; mean, 35.6 months), without complications. In the group with posttraumatic pseudoaneurysms all three patients are alive. One patient suffered postoperatively from upper arm claudication, which was treated by carotidosubclavian bypass. We conclude that the endoluminal technique can be used successfully in the acute repair of aortic trauma and its consequences. Midterm results are satisfactory, with a low incidence of neurologic complications.     

Endovascular Therapy of Ruptured Abdominal Aortic Aneurysm: Mid- and Long-Term Results

As an alternative to open aneurysm repair, emergency endovascular aortic repair (EVAR) has emerged as a promising technique for ruptured abdominal aortic aneurysm (rAAA) within the last decade. The aim of this retrospective study is to present early and late outcomes of patients treated with EVAR for rAAA. Twenty-two patients (5 women, 17 men; mean age, 74 years) underwent EVAR for rAAA between November 2000 and April 2006. Diagnostic multislice computed tomography angiography was performed prior to stent-graft repair to evaluate anatomical characteristics and for follow-up examinations. Periprocedural patient characteristics and technical settings were evaluated. Mortality rates, hospital stay, and early and late complications, within a mean follow-up time of 744 ± 480 days, were also assessed. Eight of 22 patients were hemodynamically unstable at admission. Stent-graft insertion was successful in all patients. The total early complication rate was 54%, resulting in a 30-day mortality rate of 23%. The median intensive care unit stay was 2 days (range, 2–48 days), and the median hospital stay was 16 days (range, 9–210 days). During the follow-up period, three patients suffered from stent-graft-related complications. The overall mortality rate in our study group was 36%. EVAR is an acceptable, minimally invasive treatment option in patients with acute rAAA, independent of the patient’s general condition. Short- and long-term outcomes are definitely comparable to those with open surgical repair procedures.     

Endovascular treatment of late in-stent-graft dissection after thoracic endovascular aneurysm repair

Complications after endovascular repair of thoracic aortic pathologies may be devastating. We report the case of endovascular treatment of late in–stent-graft dissection after thoracic endovascular aneurysm repair (TEVAR). A 25-year-old man was admitted to our hospital 2 years after endovascular treatment of posttraumatic aortic pseudoaneurysm using stent-graft implantation with an acute sudden onset of ischemia in both legs with absent femoral pulses, numbness, and renal functions deterioration. Multidetector computed tomography (MDCT) angiography showed an intimal flap in the distal part of the stent-graft with critical stenosis of the residual lumen. The patient was successfully treated with stent-graft implantation by way of percutaneous approach while under local anesthesia. The risk of this late complication after TEVAR should be considered during follow-up, especially in young patients with increased physical activity. Endovascular treatment can be the method of choice for these patients.     

Graft Distortion After Endovascular Repair of Abdominal Aortic Aneurysm: Association with Sac Morphology and Mid-Term Complications

Purpose: To investigate the incidence, significance, and mechanism of stent-graft distortion after endovascular repair (EVR) of abdominal aortic aneurysm. Methods: EVR of abdominal aortic aneurysm was performed in 51 cases (49 modular, bifurcated; 2 tube). Thirty-two patients were followed for 6 or more months and had equivalent baseline and follow-up images which could be used to determine changes in graft configuration. Sac dimensions were measured using computed tomographic (CT) images and graft-related complications were recorded. Results: Amongst 32 patients evaluated on follow-up, there was graft distortion in 24. Distorted grafts were significantly (p= 0.002) associated with sac diameter reduction (mean 5 mm) and sac length reduction (mean 8.1 mm). All graft-related complications occurred in the limbs of eight distorted grafts, with a mean reduction of sac length in this group of 7.8 mm on reformatted CT images. Conclusion: There was a highly significant association between graft distortion and limb complications, and reduced sac dimensions.