False aneurysm formation at proximal and distal ends of a stent graft: a rare complication in the repair of endovascular thoracic aortic aneurysm.

This case report demonstrates a rare complication of false aneurysm formation at the proximal and distal ends of a stent graft that was placed in the descending thoracic aorta to repair an atherosclerotic aneurysm with a fibrotic, solid aortic wall. This complication can develop not only in penetrating aortic ulcers and aortic dissections but also in atherosclerotic aneurysms.     

Endovascular repair of a spontaneous ilio-iliac fistula presenting as pulmonary embolism

Spontaneous rupture of a common iliac artery aneurysm into the common iliac vein is a rare phenomenon. We report the case of a 68 year old man admitted with acute cardiac failure and massive pulmonary embolism as a complication of a spontaneous ilio-iliac fistula, secondary to aneurysmal rupture. The aneurysm was successfully excluded using an aorto-uni-iliac stent graft. No complications were noted at 9 months follow-up. Arteriovenous fistulae should be considered in patients with aortic or iliac aneurysms who develop a pulmonary embolism or symptoms of venous congestion. Endovascular repair of these pathologies is a feasible therapeutic option; however long term results remain unknown.     

人造血管覆盖支架成功治疗胸主动脉瘤9例报告

目的 :报告 9例人造血管覆盖支架治疗胸主动脉瘤的结果。方法 :手术暴露股动脉 ,送入带距离标记的pigtail进行主动脉造影以确认人造血管覆盖支架的直径和长度。送入 30 0cm长的AmplatzSuperStiff导丝 ,切开股动脉 ,沿导丝送入人造血管覆盖支架 ,准确定位后 ,将收缩压降到 70～ 80mmHg(1mmHg =0 .133kPa) ,快速退出鞘管 ,释放人造血管覆盖支架 ,主动脉造影检查效果 ,最后缝合股动脉。结果 :共治疗了 9例降主动脉瘤 ,真性动脉瘤 4例 ,溃疡 1例 ,假性动脉瘤 1例 ,夹层 3例。除 1例夹层未能完全封闭假腔外 ,其余均隔绝动脉瘤获得成功 ,无 1例发生严重并发症 ,遇到的主要问题有 :1 动脉瘤非常靠近左锁骨下动脉 ,未能严密覆盖动脉瘤 ,发生了轻微的内漏 ;2 目前使用的人造血管输送系统比较硬 ,1例在主动脉弓部难以释放 ;3 测量不准 ,1例人造血管覆盖支架稍短 ,出现了轻微的内漏 ;4 夹层动脉瘤的治疗主要是封堵入口 ,1例入口和出口距离仅有 3～ 4cm ,故未能完全封闭假腔。结论 :置入人造血管覆盖支架可以隔绝真性动脉瘤 ,封堵夹层动脉瘤和假性动脉瘤入口 ,治疗效果好 ,操作简单 ,并发症少 ,出血少 ,恢复快。     

Endovascular stent grafting of descending thoracic aortic aneurysms

The treatment of descending thoracic aortic aneurysms using endovascular stents is one of the more recent advances in treatment and is receiving increasing attention as it is a less invasive alternative to open surgical repair. Although the technology is still primitive, significant improvements have lately been made in the design and deployment of the endovascular stent-grafts. Aortic stent-grafts were used initially to exclude abdominal, and later thoracic, aortic true and false aneurysms. These prostheses have been increasingly used to treat aneurysms, dissections, and traumatic ruptures of the descending thoracic aorta with good early and mid-term outcomes. Although the long-term outcome of patients with aneurysms of the descending thoracic aorta after stent graft implantation has not been investigated, continued refinement of the endovascular approaches has decreased the need for conventional open thoracic aortic aneurysm repair, especially in patients who are at a high risk for standard surgery because of advanced age or the presence of comorbid diseases. The placement of endoluminal stent-grafts to exclude the dissected or ruptured site of thoracic aortic aneurysms is a technically feasible and relatively safe procedure. With the rapid development of endovascular approaches, the treatment of the descending thoracic aortic aneurysms might alter even more, but an extended follow-up is necessary to determine the longer term outcome. Historical perspectives, advantages, device considerations, complications, and current perspectives of the endovascular stent grafting of the descending thoracic aortic aneurysms are elaborated on.     

“三文治技术”在腹主动脉瘤腔内修复中保留髂内动脉血流的应用

目的探讨“三文治技术”在合并髂总动脉瘤的腹主动脉瘤患者腔内修复中保留髂内动脉血流的可行性及安全性。方法我们对1例合并双侧髂总动脉瘤的肾下性腹主动脉瘤患者行腔内修复术。该患者由于腹主动脉瘤合并双侧髂总动脉严重扩张,覆膜支架覆盖腹主动脉及髂总动脉瘤的时需覆盖双侧髂内动脉开口,可能造成髂内动脉血流受阻而引起盆腔缺血。我们在进行左髂总动脉腔内修复时应用了“三文治技术”,以覆盖病变血管同时保留一侧髂内动脉血供。结果手术成功地对腹主动脉瘤及双侧髂总动脉瘤进行了覆膜支架的腔内修复,同时保留了髂内动脉血供。结论在复杂腹主动脉瘤髂内修复时,使用“三文治技术”可能是一种有效的保留分支血管血供的方法。     

Endovascular embolization of a giant renal artery aneurysm with preservation of renal parenchyma

Renal artery aneurysm is a rare condition that has an unclear etiology. Although some patients present with symptoms of hypertension, pain, hematuria, or rupture, the majority are asymptomatic. Traditional surgical repair of renal artery aneurysms is often complex and may require ex vivo repair and reimplantation of the kidney if branch vessels are involved. Very large aneurysms made require nephrectomy. More recently, reports have described endovascular approaches to renal artery aneurysms, including coil embolization and stent graft coverage. This report describes successful endovascular treatment of a 10-cm renal artery aneurysm with preservation of renal mass.     

A contemporary review of popliteal artery aneurysms

Popliteal artery aneurysms account for 85% of all peripheral aneurysms and are frequently associated with abdominal aortic aneurysms. Up to 75% of all popliteal artery aneurysms are discovered in symptomatic patients who present with arterial insufficiency, leg swelling, or pain. Popliteal artery aneurysms can be diagnosed with duplex ultrasonography. Aneurysm repair should be considered for all symptomatic patients with rest pain or limb-threatening symptoms. Asymptomatic aneurysms larger than 2 cm should also be treated to prevent the development of limb-threatening ischemia and assure better surgical bypass graft patency and longer freedom from amputation. Conventional aneurysm repair consists of either opening the aneurysm sac and interposing a bypass graft or aneurysm ligation combined with bypass grafting. If the aneurysm sac is left intact, side branch perfusion may persist and the aneurysm may continue to enlarge and can rupture. Endovascular popliteal aneurysm repair has not demonstrated clinical equipoise to standard surgery but may be advantageous in select high-risk patients.     

Stent graft treatment for abdominal aortic aneurysm repair: recent developments in therapy

PURPOSE OF REVIEW: Minimally invasive endovascular techniques for the treatment of abdominal aortic aneurysms have significantly reduced the morbidity of these procedures compared with standard surgical repair. In addition, patients with extensive comorbid medical illnesses in whom standard operative repair is contraindicated may be successfully treated using endovascular means. RECENT FINDINGS: Recently, several important developments have significantly advanced this area of treatment. The Food and Drug Administration has approved four endovascular stent grafts for the treatment of abdominal aortic aneurysms: the Medtronic AneuRx, the W.L. Gore Excluder, the Cook Zenith, and the Guidant Ancure. The Zenith received approval for marketing in 2003 and has gained relatively wide use, in part because of its ability to treat aneurysms with relatively large-diameter implantations zones. Also in 2003, Guidant Corporation withdrew the Ancure graft from marketing and distribution. The withdrawal was influenced by difficulties encountered using the graft's delivery system and improper reporting to the Food and Drug Administration. Enrollment has also been recently completed for the phase II Food and Drug Administration trials of the Medtronic Talent graft and the Cordis Fortron graft. These devices have been approved for use in the European Union and are awaiting Food and Drug Administration panel meeting in the United States. Several significant advances have also occurred recently in stent graft research and development. Of particular significance has been the initiation of the phase I trial of the Trivascular Enovus graft. Deployment of the Trivascular graft may be accomplished through a delivery system that is considerably reduced in profile. The potential for percutaneous application of the graft may be available in the future. In selecting the specific stent graft to be used for endovascular abdominal aortic aneurysm repair, the specific graft characteristics must be considered, particularly with regard to the individual patient's anatomic and physiologic characteristics. Comparative analysis of the several of the various stent grafts has been performed. Results have varied with regard to the need for secondary interventions, aneurysm sac size reduction, and the occurrence of continued perfusion of the aneurysm sac. In addition, the indications for use of endovascular grafts compared with standard open surgery have not yet been fully defined. SUMMARY: This article describes the general principles of use for endovascular devices for the repair of abdominal aortic aneurysms. It details the features and results for the devices in current use, and highlights the recent developments in stent graft treatment of abdominal aortic aneurysms.     

Surgical techniques. Thoracoabdominal aorta

Patients presenting with impending rupture of a thoracoabdominal aortic aneurysm require emergency operative repair. To prevent rupture and its associated mortality, elective repair of thoracoabdominal aortic aneurysms exceeding 5.5 cm to 6.0 cm in diameter is recommended in patients with adequate physiologic reserve. Similarly, surgery should be considered for patients with smaller symptomatic aneurysms. Atypical symptoms have been associated with rupture, therefore, they require thorough evaluation. Whether the aortic conditions are caused by medial degenerative disease or chronic aortic dissection, surgical techniques allow for graft repair of thoracoabdominal aortic aneurysms with low mortality and morbidity rates. Although surgery is usually avoided in patients with acute distal aortic dissection, operative intervention is occasionally required when complications develop. Patients with acute aortic dissection complicated by impending rupture of the thoracoabdominal segment require graft repair to restore aortic integrity; although the mortality rate is acceptable, the incidence of postoperative paraplegia approaches 20% in this setting. For patients presenting with ischemic complications of acute distal aortic dissection, less-extensive surgical options have been effective in restoring perfusion. In experienced centers, overall operative survival rate following thoracoabdominal aortic surgery can exceed 92%. Retrospective data suggest that left heart bypass reduces the incidence of paraplegia following extensive thoracoabdominal aortic repairs. Although recent advances have led to improved outcomes, paraplegia continues to occur regardless of the strategy used. The prevention of spinal cord ischemia during thoracoabdominal aortic surgery, therefore, will remain a focus of controversy and investigation, just as it was more than 4 decades ago.     

Screening, diagnosis and advances in aortic aneurysm surgery

BACKGROUND: Aortic aneurysms are common in the elderly and a frequent cause of sudden death. As elective aneurysm repair has a mortality drastically lower than that associated with rupture, the emphasis must be on early detection and repair free from complications. Recent advances include ultrasound screening for asymptomatic abdominal aortic aneurysm (AAA) and clinical trials on the size of AAA that require repair. Pre-operative assessment, management of cardiac risk, autologous blood transfusion strategies, and endovascular stent graft technology to avoid major open surgery are all issues to be addressed. METHODS: Following a computerized Medline search for publications on the detection and treatment of abdominal and thoracic aortic aneurysm, the publications identified were then read and the references within those publications examined for further publications on this topic. We have reviewed these publications without attempting a meta-analysis. RESULTS: Randomized population studies have addressed ultrasound screening for AAA. Attendance for screening was good and AAA detection inexpensive. Screening men from 65 years reduces the mortality from rupture and is cost-effective. Open thoracic and abdominal aneurysm repair has a mortality of around 8%, with myocardial infarction being a frequent cause of death. Pre-operative reduction of cardiac risk by cardiac investigations and beta-blockade may reduce this mortality. Autologous transfusion techniques such as acute normovolaemic haemodilution and interoperative cell salvage reduce the need for allogeneic blood and the complications associated with open surgery. Minimally invasive endovascular repair is now possible for 40% of the AAA and an increasing proportion of thoracic aneurysms. CONCLUSIONS: The combination of screening, reduced pre-operative risk, and new minimally invasive techniques extends aortic aneurysm treatment into an increasingly elderly population. The combination of these techniques will reduce mortality from ruptured aortic aneurysm in the elderly and also reduce the stress associated with aneurysm surgery.     

Emergency stent graft deployment for acute aortic rupture following primary stenting for aortic coarctation.

We present a case of endovascular stenting for aortic recoarctation complicated by acute aortic rupture, which was successfully treated by emergency stent graft deployment. This case illustrates the potential serious complication that can occur during aortic stent dilatation and how the prompt deployment of a stent graft helped to change the clinical outcome of this life-threatening situation.     

Off-pump endovascular treatment of aortic arch aneurysms]

BACKGROUND: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia and circulatory arrest. Endovascular repair is an attractive, less invasive alternative that may change our therapeutic approach. The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms and to address the new problems in this area. METHODS: In the last 5 years, we treated 21 patients for aortic arch pathology with an "off-pump" endovascular repair (18 men, 3 women, mean age 71.4 +/- 7.2 years). We used 26 stent grafts (5 Gore Excluder TAG, 3 Endomed Endofit, 6 Medtronic Talent, 12 Cook Zenith TX1) with a mean of 1.2 graft/patient. Proximal fixation of endograft was achieved by means of aortic "de-branching" in 11 cases. In 10 cases the left subclavian artery was intentionally covered without revascularization. Follow-up included clinical examination, chest X-ray and computed tomography at discharge and at 6-month intervals thereafter. RESULTS: Technical success was 85% (18/21). There was one in-hospital death (4.7%) due to endograft migration. We observed 2 cases of type I endoleak (9.5%). One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the stent graft with rupture of three stents. No complications related to the coverage of the left subclavian artery were observed. At a mean follow-up of 18.7 +/- 12.8 months, no mortality or morbidity including new-onset endoleak, stent-graft migration and thrombosis of supra-aortic grafts were recorded. CONCLUSIONS: Endovascular treatment of aortic arch pathology is feasible even in elderly patients. However, accurate placement in the arch and aneurysm sealing with the currently available devices, may be challenging due to the involvement of supra-aortic vessels, the anatomical curvature of the arch, the high blood flow, and substantial movement of the aorta with each heartbeat.     

Successful deployment of an iliac limb graft to repair acute aortic rupture after balloon aortoplasty of recoarctation in a child with Turner syndrome

Aortic rupture is a rare but potentially catastrophic complication following a balloon aortoplasty for recoarctation. The treatment of aortic ruptures remains challenging. We present here a 9-year-old girl with Turner syndrome who experienced a life-threatening rupture in her aorta after a balloon aortoplasty for recoarctation. She was successfully rescued by the antegrade deployment of a commercially available iliac limb extension stent-graft via an ascending aortic conduit. Prudent balloon aortoplasty for recoarctation in patients with Turner syndrome is important due to their inherent aortopathy and previous surgical repairs. Possible reasons for an aortic rupture are oversized ballooning and the choice of balloon diameter based only on an angiographic measurement. In agreement with earlier reports, our case also confirms the importance of keeping a commercially available stent graft available to treat this complication that has potentially fatal consequences.     

Aortic dissection after open repair of an infrarenal aortic aneurysm

INTRODUCTION:

A case of thoracic-abdominal dissection after open surgical exclusion of an infrarenal aortic aneurysm is presented.

CASE PRESENTATION:

A 62-year-old woman was diagnosed with an infrarenal abdominal aortic aneurysm with a rapid increase in maximal diameter. She underwent surgery for aneurysm exclusion by an end-to-end aortoaortic bypass with Dacron collagen (Intervascular; WL Gore & Associates Inc, USA). After 15 days, she was admitted to the emergency department with intense epigastric and lumbar pain. Computed tomography angiography with contrast revealed an aortic dissection with origin in the proximal bypass anastomosis and cranial extension to the thoracic aorta. The true lumen at the level of the eighth thoracic vertebra was practically collapsed by the false lumen. The celiac trunk, and the mesenteric and renal arteries were perfused by the true lumen. After the acute phase of the aortic dissection, surgical repair was planned. Two paths of false lumen were found – one at the thoracic aorta and the second in the proximal bypass anastomosis. Surgical repair comprised two approaches. First, a Valiant Thoracic stent graft (Medtronic Inc, UK) was implanted distal from the left subclavian artery, expanding the collapsed true lumen and covering the false and dissected lumen. Second, an infrarenal Endurant abdominal stent graft (Medtronic Inc) was implanted. This second device was complemented with an aortic infrarenal extension using a Talent abdominal stent graft (Medtronic Inc) in the infrarenal aortic neck to achieve a hermetic seal. The postoperative clinical course was uneventful, and her symptoms were completely resolved in six months.

CONCLUSION:

Arteritis must be taken into account in young patients with high inflammatory markers. Covered stents and endoprosthetic devices seem to be effective methods to seal the dissected lumen.     

Successful endovascular management of an aortic rupture following stent placement for severe atherosclerotic stenosis: A case report

Aortic rupture during endovascular procedures is a devastating complication that mandates expedient intervention. The present report describes a case in which endovascular treatment was used to successfully manage an aortic rupture following placement of a covered stent graft for severe infrarenal aortic stenosis. Successful management of this case was the result of the procedure being performed in an operating room under appropriate anesthesia and close hemodynamic monitoring. Bilateral common femoral arterial access and use of covered aortic stent grafts also contributed to a favourable outcome.     

Successful percutaneous closure of an aortic graft pseudo-aneurysm with a patent foramen ovale occluder device

Endovascular stent grafts, prosthetic grafts placed over expandable stents, are an alternative therapy for the treatment of arterial aneurysms, pseudo-aneurysms, dissections, penetrating ulcers and coarctations. However, there are limitations to their applicability. This case describes a patient with Takayasu's arteritis, an inflammatory disease of medium- to large-sized vessels, who developed an aneurysm in an open surgically placed aortic graft. The patient had previously undergone two separate surgeries for the treatment of thoracic aortic aneurysms. Due to the potential for reduced morbidity and mortality, endovascular stenting was a rational approach for a focal graft defect. Endovascular stent graft repair could not be performed because the ratio of the required vascular sheath to peripheral vessel size was prohibitive in this patient. Instead, endovascular therapy using an Amplatzer patent foramen ovale occluder device was delivered within the pseudo-aneurysm to seal the connection to the aortic lumen. At 9-month follow up, the patient has done well clinically and has not required any additional procedures.     

Non-Surgical Repair of Abdominal Aortic Aneurysm

The conventional treatment of abdominal aortic aneurysm is surgical replacement with a synthetic graft. Attempts have been made to treat these aneurysms using stent mounted grafts with reasonable success, thus obviating the need for surgery. However, certain problems like thromboembolism and the large profile are yet to be overcome. We report a case of a 75-year-old man where an attempt to repair a symptomatic abdominal aortic aneurysm was made using an endovascular uncovered òwalló stent combined with endosaccular coil implantation.     

Early experience shows rapid shrinking of abdominal aortic aneurysms after endovascular treatment with Anaconda device

BACKGROUND: The Anaconda prosthesis is a new endovascular device for abdominal aortic aneurysms repair. AIM: of the study was to evaluate successful access to the arterial site, safety and efficacy of stent placement and fixation, assessment of endoleaks, patency of the graft due to twists, kinks or obstruction within the first 30 days after the procedure. Secondary objectives were the assessment of clinical success after 6 months due to graft patency and aneurysm exclusion without endoleak as well as the continuing clinical success without showing aneurysm expansion or any graft failure. PATIENTS AND METHODS: Between 2003 and 2006 a total of 14 patients with infrarenal aortic aneurysm (median diameter prior to endovascular treatment: 56.7 mm (range: 50 to 70 mm) were treated with the Anaconda endovascular device. 8 of these patients were treated in accordance to a prospective Phase II clinical study protocol (Anaconda ANA 004). 6 more patients received the same endovascular device after CE-certification. RESULTS: Primary and secondary objectives were achieved in 12 of 14 patients after 6 months. In one patient insertion of the graft system was impossible due to kinking and circular calcification of the iliac arteries. Iliac access utilizing an alternative stent graft system (Cook, Zenith) was also unsuccessful. This patient underwent a conversion to open surgery and died. Another patient died 6 months after treatment unrelated to the procedure. A significant reduction of the median aneurysm diameter from 56.7 to 49.0 mm (range: 45 to 54 mm) was achieved after 6 months (p = 0.05). No endoleak was seen in the follow up. CONCLUSIONS: Early results show that he Anaconda endovascular device for aneurysm repair is a safe and effective device for patients with suitable abdominal aortic aneurysms and proper distal access vessels which results in significant aneurysm diameter decrease and a low complication rate after 6 months of follow-up.     

Percutaneous closure of aortocaval fistula using the amplatzer muscular VSD occluder

Aortocaval fistula is an uncommon but often fatal complication of abdominal aortic aneurysm. Both open and endovascular repair of aortic aneurysm with aortocaval fistulae have been previously reported. We present the case of a patient with persistent aortocaval fistula after endovascular stent graft repair, which is closed using an Amplatzer muscular VSD occluder. Further studies using the Amplatzer muscular VSD occluder for closure of aortocaval fistulae are warranted.     

Endovascular treatment for the spontaneous rupture of a non-aneurysmal subdiaphragmatic aorta

The case of a patient who underwent an endovascular aortic repair for a spontaneous rupture of a non-aneurysmal subdiaphragmatic aorta without trauma, infection, or inflammation is reported. The patient is a 51-year-old male diagnosed with subdiaphragmatic aortic rupture and was in a state of hemorrhagic shock upon admission to the hospital. Intraoperative aortography revealed the abdominal aortic rupture site located above the celiac artery. A coated thoracic stent graft was used. Completion angiography showed a total exclusion with no endoleaks. After six months of follow-up, computed tomographic scans confirmed the absence of endoleaks or graft displacements.