Case report: Endovascular repair of a ruptured abdominal aortic aneurysm under local anaesthesia

Abdominal aortic aneurysm (AAA) is a common degenerative condition affecting the elderly population. Rupture carries a high overall mortality. Elective endovascular stent graft repair is well described. We describe a patient with ruptured AAA and co-morbid conditions making him unfit for surgery and general or epidural anaesthesia, who was successfully treated by endovascular stent graft under local anaesthesia.     

Endovascular repair of a recurrent aortocaval fistula and anastamotic false aneurysm

Aortocaval fistula (ACF) and false aneurysm are a recognized complication of open abdominal aortic aneurysm (AAA) repair. Untreated they are often fatal. However, open surgical repair of this complication is associated with a high operative mortality and a significant complication rate. Endovascular management using a stent-graft to exclude the false aneurysm and fistula is a technically feasible alternative and confers many advantages over open repair by virtue of its minimally invasive nature. We report the endovascular management of this rare but serious complication of open AAA repair.     

A Technique of “Chimney Nellix” for the Management of Type 1a Endoleak After EVAR

This report presents 3 procedures with visceral “chimney stenting” in conjunction with an endovascular aneurysm sealing (EVAS) device, known as chEVAS, for treatment of type 1a endoleak. It includes the first published chEVAS in a patient with previous fenestrated endovascular aneurysm repair (FEVAR). Cases include an 80-year-old man 8 years after FEVAR for a juxtarenal abdominal aortic aneurysm (AAA); an 85-year-old woman 9 months after endovascular aneurysm repair (EVAR) for a ruptured infrarenal AAA; and an 84-year-old woman 3 months after EVAR for a symptomatic infrarenal AAA. Technical success was achieved in all cases, with 1 postoperative death. The remaining 2 patients had no residual type 1a endoleak at 10 and 14 months respectively.     

Helical CT Angiography of Abdominal Aortic Aneurysms Treated with Suprarenal Stent Grafting: A Pictorial Essay

The endovascular repair of abdominal aortic aneurysm (AAA) with stent grafts is rapidly becoming an important alternative to open repair. Suprarenal stent grafting, recently modified from conventional infrarenal stent grafting, is a technique for the purpose of treating patients with inappropriate aneurysm necks. Unlike open repair, the success of endoluminal repair cannot be ascertained by means of direct examination and thus relies on imaging results. The use of conventional angiography for arterial imaging has become less dominant, while helical computed tomography angiography (CTA) has become the imaging modality of choice for both preoperative assessment and postoperative followup after treatment with stent graft implants. There is an increasing likelihood that radiologists will become more and more involved in the procedure of aortic stent grafting and in giving the radiological report on these patients treated with stent grafts. It is necessary for radiologists to be familiar with the imaging findings, including common and uncommon appearances following aortic stent grafting. The purpose of this pictorial essay is to describe and present normal and abnormal imaging appearances following aortic stent grafting based on helical CTA.     

Endovascular Treatment of Ruptured Abdominal Aortic Aneurysm with Aortocaval Fistula

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA). We report the endovascular repair of an AAA rupture into the inferior vena cava. A 78-year-old woman was admitted to our hospital for acute hypotension. She presented with a pulsatile abdominal mass and became rapidly anuric. Abdominal computed tomography (CT) showed an AAA rupture into the inferior vena cava. The features of the AAA made it suitable for endovascular repair. To prevent pulmonary embolism caused by the presence of sac thrombosis near the vena cava lumen, a temporary vena cava filter was deployed before the procedure. A bifurcated stent-graft was placed with the patient under local anaesthesia, and the AAA was successfully treated. A transient type II endoleak was detected on CT 3 days after endograft placement. At routine follow-up 6 and 12 months after the procedure, the patient was in good clinical condition, and the type II endoleak had sealed completely. Endovascular treatment offers an attractive therapeutic alternative to open repair in case of ACF; however, only small numbers of patients have been treated, and long-term follow-up interval is lacking.     

A Case of Common Peroneal Nerve Palsy Associated with Internal Iliac Artery Embolization by Using N-butyl-2-cyanoacrylate (NBCA)

CardioVascular and Interventional Radiology - A 64-year-old man was scheduled to undergo endovascular aneurysm repair for an abdominal aortic aneurysm (AAA). Since preoperative computed tomography...     

Endovascular abdominal aortic aneurysm repair: how many patients are eligible for endovascular repair?

PURPOSE: The purpose of this study was to determine how many patients with abdominal aortic aneurysm (AAA) are eligible for endovascular abdominal aortic aneurysm repair (EVAR). MATERIALS AND METHODS: We retrospectively reviewed computed tomography (CT) angiograms obtained between January 2002 and June 2003 in 182 patients with suspected AAA. Indication for surgical or endovascular treatment was based on clinical and radiological criteria. The percentage of patients eligible for EVAR was evaluated. RESULTS: Out of a total of 182 patients with suspected AAA studied by CT angiography, after combined radiological-surgical assessment, 130 were considered eligible for surgical or endovascular treatment (71.4%). EVAR was indicated in 51 patients (39.3%, group A) and surgical repair was indicated in 79 patients (60.7%, group B). The reasons for ineligibility for EVAR were the following: unfavourable anatomy of the proximal neck in 41 patients (51.9%), diameter of the aneurysm sac >7 cm in 13 patients (16.4%), markedly tortuous/dilated iliac axis in six patients (7.6%), age <65 years in 17 patients (21.5%) and patient refusal in two cases (2.5%). There were no statistically significant differences in aneurysm diameter (52.7+/-0.8 versus 49.8+/-1.2 mm, p=ns), patients' age (73.2+/-1.2 versus 70.6+/-2.02 years, p=ns) or proximal neck length (2.95+/-1 versus 3.03+/-1.2 cm, p=ns) between groups A and B. CONCLUSIONS: Endovascular repair of abdominal aortic aneurysms through the placement of aortic stent-grafts has now become a viable alternative to open surgery. In recent years, the number of patients treated with EVAR has steadily risen as a result of increased physician experience, availability of new and more versatile devices and improvements in noninvasive imaging techniques. Unfavourable neck anatomy is the primary factor for exclusion from endovascular repair.     

Endovascular Abdominal Aortic Aneurysm Repair in the Presence of a Kidney Transplant: Therapeutic Considerations

Abdominal aortic aneurysm (AAA) repair in the presence of a kidney transplant can be extremely challenging, as it carries significant risks of renal ischemia. Endovascular repair is an attractive option, as it can be performed with little or no impairment of renal arterial flow. We describe the endovascular management of a recurrent AAA in a patient with a functioning renal transplant using a custom-made aorto-uni-iliac device. We discuss the planning and the potential problems of the technique.     

Superior mesenteric artery syndrome secondary to an abdominal aortic aneurysm

Superior mesenteric artery (SMA) syndrome in association with abdominal aortic aneurysm (AAA) is exceedingly rare and has been noted to occur in patients with severe abdominal pain, bilious emesis, and a history of tobacco use. When symptoms of small bowel obstruction occur, it is imperative to investigate further with cross-sectional imaging to determine the etiology. Conservative management is preferred, but in cases of SMA syndrome with concomitant AAA, aneurysm repair should be considered, regardless of size, if initial treatment fails.     

Endovascular stent graft repair of abdominal aortic aneurysms: Current status and future directions

Endovascular stent graft repair of abdominal aortic aneurysm (AAA) has undergone rapid developments since it was introduced in the early 1990s. Two main types of aortic stent grafts have been developed and are currently being used in clinical practice to deal with patients with complicated or unsuitable aneurysm necks, namely, suprarenal and fenestrated stent grafts. Helical computed tomography angiography has been widely recognized as the method of choice for both pre-operative planning and post-operative follow-up of endovascular repair (EVAR). In addition to 2D axial images, a number of 2D and 3D reconstructions are generated to provide additional information about imaging of the stent grafts in relation to the aortic aneurysm diameter and extent, encroachment of stent wires to the renal artery ostium and position of the fenestrated vessel stents. The purpose of this article is to provide an overview of applications of EVAR of AAA and diagnostic applications of 2D and 3D image visualizations in the assessment of treatment outcomes of EVAR. Interference of stent wires with renal blood flow from the hemodynamic point of view will also be discussed, and future directions explored.     

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.     

Endoluminal repair of abdominal aortic aneurysms - state of the art.

This paper considers the historical aspects of endovascular aneursym repair; the major findings of our Departments experience over an 812-year period and reviews recent developments in endovascular prostheses. Analysis of 400 patients undergoing primary repair of abdominal aortic aneurysm between 1992 and 2000 revealed a perioperative mortality rate of 2.7% and primary conversion rate of 5%. With sequential studies it was shown that the outcome was better with bifurcated/aorto uni iliac grafts than tube grafts; better with second generation prostheses than first generation protheses and that survival in consecutive patients treated concurrently by open repair and endoluminal repair was superior in the endoluminal group. Endoluminal AAA repair is at a critical point of its development. It is unquestioned that it can dramatically reduce the need for intensive care and length of hospital stay and more recently it has been reported that survival is improved compared with open repair. The need for lifetime surveillance, the probability of graft failure and need for re-intervention, however, negate some of the advantages. The small incidence of unpredictable rupture following endoluminal AAA repair is a timely reminder of the need for continued careful follow-up.     

Multislice CT angiography in aortic stent grafting: relationship between image noise and body mass index

PURPOSE: To investigate the correlation between image noise and body mass index (BMI) in multislice CT angiography (MSCT) for patients with abdominal aortic aneurysm (AAA) treated with endovascular stent grafts. MATERIALS AND METHODS: Seventeen patients who underwent MSCT following endovascular repair of AAA were included in the study. Image noise (standard deviation of the CT attenuation: S.D.) and signal to noise ratio (SNR) were plotted against BMI to demonstrate the correlation using a linear regression method. Image quality of 3D reconstructions was correlated to the SNR and BMI. RESULTS: The r-value of linear regression between S.D. and BMI was 0.578 (p<0.05), 0.835 and 0.802 (p<0.001), respectively, at the level of renal artery, aortic aneurysm and common iliac artery. The r-value of linear regression between SNR and BMI was 0.332, 0.516 and 0.552 (p<0.05), respectively, at above three levels. Image quality of 3D reconstructions was compromised in five patients and diagnosis was affected in two patients with BMI more than 30. CONCLUSION: A significant correlation was observed between image noise and BMI in MSCT angiography of endovascular repair of AAA. Our findings are valuable for optimisation of MSCT angiography scanning protocols and reduction of radiation dose in MSCT examinations.     

Delayed complications following EVAR

More than a decade after the first clinical attempts, two large randomized studies have proven that endovascular aortic aneurysm repair (EVAR) provides immediate advantages over open repair. In the long run, however, a relatively high number of reinterventions is necessary to improve the long-term efficacy of EVAR, which may outweigh the early benefits. Since EVAR is gaining popularity in the medical community and in patients with abdominal aortic aneurysm (AAA), it is expected that a growing number of patients will present with delayed complications requiring some kind of reinterventions. For the patient's safety, vascular surgeons and interventional radiologists involved in EVAR must be well aware of these complications and the ways to overcome them. We began our endovascular program for AAA in 1994 and currently follow 485 patients with a variety of manufactured grafts. In this article we describe the delayed complications observed with EVAR, their mechanisms, favoring factors, and ways to treat them.     

腹主动脉瘤的腔内治疗

腹主动脉瘤（AAA）常发生于老年人，破裂是其最常见、最凶险的并发症，病死率可高达63%。传统开腹性手术是治疗AAA十分有效的手段，但对于高危患者其病死率显著增加。因此，发展一种微创方法治疗AAA对于降低病死率十分必要。经股动脉放置血管内支架-移植物是治疗AAA的一个重要里程碑，尤其对于那些高危患者。这一新技术作为外科修复的替代疗法已经得到广泛的应用。内支架-移植物植入后的常见并发症包括内漏、移植物移位或变形和移植物血栓形成，以内漏最常见且最重要。内漏是指移植物植入后仍有持续性血液进入动脉瘤囊，主要通过某些影像学技术证实，螺旋CT增强检查是检出内漏的首选方法。术后30天内发生的或早期内漏可通过一段时期观察，然后对待持续性内漏进行血管内介入治疗，30天后的晚发内漏应及时进行介入处理，无观察期。     

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     

Revisión de aneurisma de aorta abdominal: hallazgos en la tomografía computarizada multidetector pre y postratamiento

The increase in the frequency of abdominal aortic aneurysms (AAA) and the widely accepted use of endovascular aneurysm repair (EVAR) as a first-line treatment or as an alternative to conventional surgery make it necessary for radiologists to have thorough knowledge of the pre- and post-treatment findings. The high image quality provided by multidetector computed tomography (MDCT) enables CT angiography to play a fundamental role in the study of AAA and in planning treatment.     

Endovascular abdominal aortic aneurysm repair in 144 patients: correlation of aneurysm size, proximal aortic neck length, and procedure-related complications.

PURPOSE: During endovascular abdominal aortic aneurysm (AAA) repair, larger aneurysms often present formidable anatomic challenges to the insertion of the delivery catheter and graft deployment. The authors sought to evaluate whether large-diameter aneurysms and those with short proximal aortic necks might be associated with a higher frequency of insertion-related and short-term complications. MATERIALS AND METHODS: From October 1999 to August 2000, 144 patients underwent elective endovascular graft placement for infrarenal AAA disease at the authors' institution. These patients were treated with use of the AneuRx bifurcated endoprosthesis. AAA size (maximum aneurysm diameter) and proximal aortic neck length were compared to estimated blood loss, operative time, accuracy of graft placement, presence of endoleak, intraoperative and postoperative complications (such as limb occlusion or vascular injury), length of hospital stay, and mortality. Statistical methods included correlation analysis and logistic regression. RESULTS: There were 121 men and 23 women whose aneurysms ranged in size from 3 cm to 9.8 cm (mean, 5.6 cm; 95% CI, 5.4-5.8 cm). Endograft insertion was successful in all cases. There were three deaths within 30 days (2.1%) and seven deaths overall (4.9%). There were 43 intraoperative complications (29.9%) in 31 patients (21.5%), most of them minor. Patients with major intraoperative complications had significantly longer procedure times than those without complications (337 vs. 149 min; P <.0001). In the postoperative period (within 30 days), 31 complications (21.5%) occurred in 28 patients (19.4%), again most of them minor. AAA size was unrelated in any way to the rate of complications, but short proximal aortic neck length was associated with more serious intraoperative and postoperative complications (P =.0404 and P =.0230, respectively), and decreased 30-day and overall survival (P =.0240 and P =.0152, respectively). CONCLUSIONS: Endovascular repair of large AAAs can be challenging; however, the size of the AAA does not influence the rate of complications. A short proximal aortic neck is the only significant risk factor for more serious complications.     

腹主动脉瘤的外科诊疗

目的：总结腹主动脉瘤的诊断和外科治疗方法.方法：回顾性分析2003-01～2005-04我院治疗的23例肾下型腹主动脉瘤的临床资料.男21例,女2例,年龄54～76岁.均为肾动脉下型腹主动脉瘤,瘤体直径4.0～7.5 cm.采取常规的腹主动脉瘤切除和原位人造血管移植术20例,腔内人造血管移植术3例.结果：全组无术后早期死亡,无严重出血、肾功能衰竭和下肢动脉栓塞等,术后并发心律失常2例,腹泻2例,切口裂开1例.全组患者随访1～27个月,无晚期死亡和肾功能衰竭.结论：常规外科手术和腔内人造血管移植治疗腹主动脉瘤均获得良好效果.早诊断、合理选择手术时机和手术方式是提高手术成功率、减少术后并发症和死亡率的关键.     

Endovascular Aneurysm Repair with Balloon Thrombectomy for Acute Thrombosis of Abdominal Aortic Aneurysm

CardioVascular and Interventional Radiology - Acute occlusion of abdominal aortic aneurysm (AAA) is a rare complication and is usually treated with surgical reconstruction. We present a case of...