Endovascular repair of complex aortic aneurysms

Since the first published report of a fenestrated endovascular aneurysm repair, we have seen an expansion in the range of custom-made devices used to manage complex aortic aneurysms. Fenestrated devices, branched devices, and chimneys are now frequently used in many centers to repair these aneurysms. Similar to standard endovascular aneurysm repair, the advantages of less operative blood loss, decreased hospital stay, and reduced risk of morbidity and mortality hold true for endovascular repair of complex aneurysms as well. This is contrasted by the requirement for long-term surveillance and increased incidence of secondary interventions.     

Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

OBJECTIVE: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. METHODS: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. RESULTS: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. CONCLUSION: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.     

Endovascular repair of abdominal aortic aneurysms: device-specific outcome

OBJECTIVES: Endovascular repair of abdominal aortic aneurysms, while advantageous because of its minimally invasive nature, falls short of achieving the long-term durability of traditional open surgical repair. Problems such as device migration, continued sac pressurization from endoleak, and graft limb thrombosis culminate in a high rate of secondary procedures and failure to protect against aneurysm rupture. While prior studies hint at a correlation between these postprocedural events and specific device design, a single comparative analysis that correlates device attributes with clinical outcome has not been performed. METHODS: Over 6 years ending in 2002, 703 patients underwent endovascular treatment of infrarenal abdominal aortic aneurysms. During this time, five devices were used, ie, Ancure, AneuRx, Excluder, Talent, and Zenith, and six device-specific groups were analyzed; the Zenith group was subdivided into those placed as part of the multicenter trial (Zenith-MCT) and those under a sponsor-investigator investigational device exemption trial (Zenith-SIT). Results were assessed with the Kaplan-Meier method for censored data, and the log-rank test was used to ascertain differences between device groups. RESULTS: While overall survival was diminished in the Zenith-SIT group (P =.046), risk for aneurysm-related death was similar in all groups (P =.336), averaging 2% or less at 12 months. Among the total cohort of patients, freedom from rupture was 98.7% +/- 0.9% at 24 months, without demonstrable differences between groups (P =.533). There were no statistically significant differences in rate of secondary procedures, conversion to open repair, or migration. There were, however, significant differences in risk for graft limb occlusion and rate of endoleak between groups. Limb occlusion occurred most often with Ancure devices (11% +/- 4.6% at 12 months, P =.009). Endoleak of any type was most common with Excluder devices (64% +/- 11% at 12 months, P =.003), a finding directly related to increased frequency of type II leaks in that group (58% +/- 11% at 12 months, P =.001). While there were no differences in frequency of type I or type III endoleak, a trend toward increased risk for microleak was observed with AneuRx devices (4.0% +/- 1.3%, P =.054), and more modular separations were observed with Zenith devices (3.5% +/- 2.3%, P =.032). Shrinkage at 12 months correlated with frequency of endoleak in the device groups, and was most common in the two Zenith groups (54% +/- 7.3% in the Zenith-MCT group and 56% +/- 7.8% in the Zenith-SIT group) and the Talent group (52% +/- 9.7%) and was least in the Excluder group (15% +/- 7.9% at 12 months, P <.001). By contrast, sac growth occurred most often in the Zenith-SIT group (13% +/- 4.5% at 12 months, P =.034), possibly as a result of the challenging aortoiliac anatomy frequently present in these patients. CONCLUSIONS: There are significant differences in frequency of limb occlusion and endoleak between groups with different endovascular devices. Knowledge of these and other differences is instructional in development of next-generation endovascular devices, incorporating design features linked to satisfactory outcome while abandoning those associated with device failure.     

Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes

OBJECTIVE: The impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention. SUMMARY BACKGROUND DATA: As a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. METHODS: From April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy. RESULTS: Perioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 +/- 9 years vs. 72 +/- 6 years; mean +/- SD), surgical time (235 +/- 95 minutes vs. 219 +/- 84 minutes), blood loss (457 +/- 432 mL vs. 351 +/- 273 mL), postoperative hospital stay (4.8 +/- 3.4 days vs. 4.0 +/- 3.9 days), or days in the ICU (1.3 +/- 1.8 days vs. 0.5 +/- 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 +/- 13 mm vs. 51 +/- 14 mm; P <.05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month; P = NS). To date, increased-risk patients have been followed for 17.4 +/- 15 months and low-risk patients for 16.3 +/- 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P <.05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively. CONCLUSIONS: Early and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.     

Endovascular repair of ruptured abdominal aortic aneurysms: systematic literature review

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient -0.378, p< .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.     

腹主动脉瘤的腔内修复治疗

腹主动脉瘤 (abdominalaorticaneurysms ,AAA)是血管外科常见的严重疾病 ,发病高峰年龄在 6 0～ 70岁之间 ,发病率男性是女性的 4～ 6倍 ,95 %的病例位于肾动脉平面以下。AAA最大的危险是瘤体破裂引起的致死性出血。通常认为 :瘤体 <5cm的AAA破裂发生率每年约 3% ;直径在 5～ 6cm的破裂发生率每年上升 10 %。一旦发生破裂 ,病死率高达 90 % ,手术死亡率 4 1%～ 70 % ,而择期手术死亡率仅 3%～ 5 %。因此只要无心、肺、肾功能不全等手术禁忌 ,本病均有手术适应证。最近的文献报告 ,AAA直径≥ 5 5cm是手术适应证[1] 。195 2年 ,Dubost[…     

Endovascular repair of abdominal aortic aneurysms and other arterial lesions

Purpose: This report describes our experience with endovascular stented graft repair of abdominal aortic aneurysms and other arterial lesions.Methods: Between September 1990 and April 1994, 57 patients were treated with endovascular stented grafts (50 with abdominal aortic aneurysms or iliac aneurysms; five with traumatic arteriovenous fistulas; one with an infected femoral false aneurysm; and one with a false aneurysm of the proximal right common carotid artery). The devices consist of either a Dacron or an autogenous vein graft sutured to a balloon-expandable stent. The stented grafts are placed through remote arteriotomies, advanced under fluoroscopic guidance to their predetermined sites, and secured into position.Results: Forty of the 50 endovascular stented graft procedures used to treat abdominal aortic aneurysms or iliac aneurysms were considered successful, even though some secondary treatment was required in six patients (two open operations; four secondary endovascular procedures). The 10 failures include four early procedural deaths, one late procedural death, and five leaks. All five arteriovenous fistulas and the two false aneurysms were successfully treated with endovascular stented grafts.Conclusions: Although our experience with endovascular stented grafts has been promising, remaining problems require resolution, and further follow-up is needed. However, the potential advantages of these endovascular grafts warrant their continued evaluation. (J VASC SURG 1995;21:549-57.)     

腔内支架人工血管治疗主动脉弓部动脉瘤

目的 探讨腔内支架人工血管治疗主动脉弓部动脉瘤的基本方法。方法 采用国产腔内支架人工血管治疗主动脉弓部动脉瘤患者46例,其中主动脉瘤累及主动脉弓中部23例(50％),单纯累及弓降部22例(48％),累及胸降主动脉1例(2％)。选择支架直径是夹层破裂口或瘤口近端相应部位主动脉直径宽的1．15～1．20倍。支架近端直径34～38mm,长度90～120mm。支架材料为国产形状记忆镍钛合金。结果 支架释放成功45例(98％),无远端动脉并发症发生。支架释放后即刻封闭瘤口或破裂口43例(96％),早期内漏2例(4％)。夹层真腔全部恢复正常。急性期患者中转手术1例,死亡2例。术后43例患者获随访,随访时间1～23个月,远期内漏3例(7％),但所有随访患者均恢复正常生活。结论 腔内支架人工血管可用于主动脉弓部动脉瘤的治疗,其治疗的长期效果还需进一步观察。     

Endovascular repair of Salmonella-infected abdominal aortic aneurysms: a word of caution

Over the last several years, treatment modalities have changed for infected aortic aneurysms. Surgical treatment has undergone a paradigm shift from débridement and extra-anatomic bypass to direct reconstruction to, most recently, endovascular repair. Although many reports of endovascular repair of such aneurysms are favorable, the following two cases highlight some of the concerns with endografts in an infected field. Specifically, we urge caution when considering endovascular repair of Salmonella-infected arterial pathologies.     

Endovascular repair of thoracoabdominal aortic aneurysms using fenestrated and branched endografts

Purpose

The study purpose was to review the outcomes of patients treated for thoracoabdominal aortic aneurysms using endovascular repair with fenestrated and branched stent-grafts in a single center.