Infrarenal Abdominal Aortic Aneurysm Complicated by Persistent Endotension After Endovascular Repair: Report of a Case

Endoleak and endotension may prevent the successful exclusion of an aneurysm after endovascular aortic aneurysm repair (EVAR). The pressurization in the excluded aneurysm sac caused by endotension may lead to rupture of the aneurysm; however, the cause of endotension and its underlying mechanisms remain unclear. We report a case of infrarenal abdominal aortic aneurysm (AAA) complicated by persistent endotension after EVAR. Although no endoleaks were found on conventional double-phase computed tomographic scans, a thrombosed endoleak existed in the side branch and attachment site of the endograft. After treating the undetectable thrombosed endoleaks, physical examination revealed that the pressure of the excluded aneurysm had diminished, with shrinkage of the aneurysm. This case report suggests that a high-pressure undetectable type I or type II endoleak could be a major cause of endotension. Thus, postoperative evaluation of the attachment site of an endograft is important after EVAR.     

Treatment of Type III Endoleak with an Aortouniiliac Stent Graft

The purpose of this study was to present a novel treatment method for repair of a type III endoleak due to separation of modular components of an AneuRx (Medtronic AVE, Sunnyvalle, CA) stent graft as a result of graft kinking. A 73-year-old male had undergone endovascular repair of a 8.2-cm abdominal aortic aneurysm (AAA) 2 years previously. An aortic extender cuff was required to secure the proximal graft. Computed tomographic (CT) follow-up revealed a type III endoleak at 6-month follow-up. Plain radiographs showed separation between the main graft body and the aortic extender cuff. A second custom-made 28 mm × 5.5cm aortic extender cuff was placed to seal the type III endoleak. Follow-up CT showed a persistent endoleak with an increase in AAA size to 10.5 cm. The patient underwent remedial AAA repair with an aortouniiliac endograft placed within the previous stent graft and a femorofemoral bypass. At 3-month follow-up there was no detectable endoleak. This constitutes an alternative endovascular therapy for modular device separation (type-III endoleak) after endoluminal AAA repair in patients who cannot undergo repair with a second bifurcated graft.     

腹主动脉瘤腔内治疗并发症内漏的诊治

目的 探讨血管内技术治疗腹主动脉瘤时特有并发症内漏的诊断与处理方法。方法 对已施行腔内治疗37例腹主动脉瘤患者进行回顾性分析,讨论部分患者并发内漏的原因、诊断、处理、结果及预后。结果 37例支架型血管放置完成后,13例发现存在不同程度的内漏,其中I型6例,Ⅱ型3例,Ⅲ型2例,Ⅳ型1例,不明原因1例,1期经相关技术处理后I型、Ⅲ型内漏完全消失。手术结束时原发性内漏发生率13．5％（5／37）。随诊发现原发性内漏3例自愈,2例转化为持续性内漏;另发现2例继发性内漏发生率13．5％（5／37）。随诊发现原发性内漏3例自愈,2例转化为持续性内漏;另发现2例继发发现人漏。本组患者晚期内漏发生率10．8％（4／37）。结论 引起漏血的原因可能与瘤颈形态、长度、成角、钙化、移植物选择、分支血管血液倒流等因素有关。强调术中发现并一期处理,术后应密切随访。增强CT、血管超声和MRA检查是术检后检测内漏的主要手段。对漏血量及瘤体有增大趋势的内漏应积极处理。     

Alternative technique for endovascular treatment of an abdominal aortic aneurysm with a severely angulated neck

An 86-year-old female was incidentally discovered with an asymptomatic 5.3 cm infrarenal aortic aneurysm. Preoperative imaging demonstrated the aortic neck to have severe suprarenal and infrarenal angulation. The patient was deemed unfit for open aortic repair due to multiple medical comorbidities. Endovascular treatment was performed with a modified Zenith bifurcated graft using a Zenith TX2 endograft as a proximal aortic cuff. There were no perioperative complications, and postoperative imaging demonstrated aneurysm exclusion with no migration or major endoleaks. The patient died of unrelated causes at 21 months. The use of a thoracic endograft as a proximal cuff is an alternative technique in the endovascular treatment of abdominal aortic aneurysms with a severely angulated neck.     

腹主动脉瘤腔内修复术中特殊近端锚定区的处理

目的探讨腹主动脉瘤腔内修复术（EVAR）中特殊近端锚定区的处理方法。方法1997年7月至2005年7月对41例特殊类型腹主动脉瘤（瘤颈过短、严重成角、严重钙化、附壁血栓、形态不规则等）的腔内修复术中，根据情况分别采用近端裸支架跨肾动脉技术、覆盖部分肾动脉并肾动脉支架成形技术、针对成角选择合理产品、近端裸支架内支撑技术、近端延长支架型血管内支撑技术、“凹口”状支架型血管保留肾动脉技术来处理特殊近端锚定区的病变。结果41例EVAR中原发性近端Ⅰ型内漏发生率17．1％（7／41），随诊发现原发性内漏4例自愈，3例转化为持续性内漏，另发现4例继发性内漏。术后30d近端Ⅰ型内漏发生率17.1％（7／41）。无中转开腹手术及术中瘤体破裂、肾梗死等情况发生。结论对特殊近端锚定区的病例，通过相关技术处理可以使之适合腔内治疗。     

Endovascular Treatment of Failed Prior Abdominal Aortic Aneurysm Repair

Failure of endovascular or conventional abdominal aortic aneurysm (AAA) repair may occur as a result of attachment site endoleak (type I) or paraanastomotic aneurysm and pseudoaneurysm formation. This study examined the results of the use of secondary endovascular grafts for the treatment of failed prior infrarenal AAA repair procedures. Forty-seven patients were treated with endovascular grafts. These included 14 patients with type I endoleaks (5 proximal, 8 distal, 1 proximal and distal) and 33 patients with paraanastomotic aneurysms after standard open surgical AAA repair (3 proximal aorta, 5 distal aorta, 21 iliac, 4 proximal and distal). The interval between the primary aortic procedure and the endovascular repair was significantly shorter for failed endovascular procedures (mean, 18.2 months; range, 1-42 months) than for failed conventional procedures (mean, 108.9 months; range, 12-216 months) (p <0.01). The endovascular devices used for correction of the failed AAA repairs were Talent (23), physician-made (19), AneuRx (2), Vanguard (2), and Excluder (1). Transrenal fixation was used for repair of all proximal anastomotic failures. Mean follow-up after reintervention was 12.2 months in patients with failed endovascular grafts and 10.6 months in patients with failed conventional grafts. Patient demographics were as follows: average age, 78 years; 36 male and 11 female; and 4.1 comorbid medical conditions per patient. The endovascular graft was successfully deployed in all 47 cases; 1 patient experienced a persistent proximal attachment site endoleak after endograft deployment. Endovascular grafts may be used to treat previously failed endovascular and conventional AAA repair procedures with good short- and intermediate-term results. Endovascular treatments in these cases may avoid the difficulties of aortic reoperation or AAA repair in the setting of prior endovascular aortic grafting.     

Suprarenal Endograft Fixation Avoids Adverse Outcomes Associated with Aortic Neck Angulation

The advent of endovascular therapy has had a profound impact on repair of abdominal aortic aneurysms (AAA). Prudent patient selection, particularly in regard to unfavorable anatomy, is emerging as perhaps the most important determinant of endovascular abdominal aortic aneurysm repair (EVAR) outcome. The aim of this study was to examine the association of one such anatomic factor, proximal aortic neck angulation, with the incidence of adverse events following EVAR. Prospectively collected data on 289 EVAR repairs with the Talent endograft (Medtronic, Inc., Minneapolis, MN) from March 1998 to June 2000 were analyzed. Stent graft–specific adverse events studied were migration, endoleak, kinking, thrombosis, and AAA expansion. Computed tomography (CT) scanning with three-dimensional post-processing and/or aortography was used to measure aortic neck angle. Patients were categorized into one of four groups according to their neck angle: I (0-10°); II (11-39°); III (40-59°); or IV (60-85°). Outcomes were evaluated by chi-squared analysis and ANOVA. There was a direct correlation between AAA diameter and neck angle (p = 0.002). There was no difference in endoleak rate (p = 0.877), stent migration (p = 0.850), or AAA expansion rate (p = 0.599) between groups. Device kinking >45° was associated with neck angulation 60° (p = 0.013), but not with other adverse outcomes. The average neck angle was 30° in patients with endoleaks and 31° in patients without endoleaks. Increasing aortic neck angulation was not associated with the selected adverse outcomes within 1 year following EVAR with the Talent stent graft using suprarenal fixation with the exception of graft kinking. This may be related to the graft design that permits suprarenal aortic fixatiou of the proximal stent graft, Whether severe degrees of angulation of 60° or greater can be safely treated with suprarenal fixation requires further study.Presented at the Twenty-ninth Annual Meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 4-5, 2004.     

解剖条件复杂的肾下型腹主动脉瘤的腔内治疗

目的 探讨腔内修复术治疗复杂解剖条件肾下型腹主动脉瘤的安全性和有效性.方法 对2003年1月至2011年3月接受经股动脉植入分体式覆膜支架治疗解剖条件复杂的48例腹主动脉瘤患者的临床资料进行回顾性分析.男性37例,女性11例;年龄50～81岁,平均71.4岁.其中近端短瘤颈(＜15 mm) 14例,近端瘤颈成角大(＞60°)13例,复杂髂动脉解剖者21例,其中髂动脉严重扭曲者15例,髂动脉狭窄(直径＜7 mm)者6例.结果 所有病例治疗均获成功,术中无中转开腹手术者,围手术期生存率100％.40例患者获得随访,随访时间4-122个月,平均63个月,死亡2例,均为心脑血管意外,其余生存良好,累积生存率95.8％.Ⅰ型内漏2例,其中1例2周后消失,1例长期存在,随访过程中未发现新发内漏、支架移位或堵塞、瘤体扩大或瘤体破裂等并发症;2例封堵一侧大部分肾动脉的患者恢复良好,术后未出现肾功能不全.结论 腔内修复术治疗复杂解剖条件肾下型腹主动脉瘤安全、有效.随着经验的不断积累,腔内修复术在治疗解剖条件复杂的肾下型腹主动脉瘤中将发挥更重要的作用.     

Abdominal aortic endograft proximal collapse resulting in aortic aneurysm rupture

An 82-year-old man was transferred to our emergency department due to acute abdominal pain. He had undergone an endovascular abdominal aortic aneurysm repair (EVAR) six years ago. An intravenous contrast-enhanced abdominal computed tomography revealed the rupture of the abdominal aortic aneurysm (AAA) with a large retroperitoneal hematoma. A Talent (Medtronic, Santa Rosa, CA, USA) modular bifurcated endoprosthesis had vertically collapsed approximately 7 cm after losing its infrarenal fixation. As a result, it led to the repressurization of the aneurysm sac and rupture. The patient was successfully treated by placing three Talent (Medtronic) aortic cuffs. To our knowledge, this is the first reported case of endograft collapse that has manifested with aortic aneurysm rupture. Although they are gradually declining, considerable rates of complications create the 'Achilles' heel' of endovascular repair of AAAs. A lifelong follow-up strategy for patients treated for AAA with EVAR is essential for the early detection and treatment of complications of the procedure.     

高外科风险腹主动脉瘤腔内修复术的近远期结果

目的 探讨高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果.方法 1997年7月至2011年7月,120例因肾下腹主动脉瘤行腔内修复术治疗的高外科风险患者纳入本研究.本组患者男性96例,女性24例;年龄52～95岁,平均74岁.平均动脉瘤直径(57±8)mm.术后1、3、6、12个月及此后每年进行CT血管造影或B超随访.主要研究内容是手术病死率及远期生存率,次要研究内容是二次手术率、动脉瘤体术后的变化以及支架的通畅率.结果 全身麻醉83例,局部麻醉37例.术后Ⅰ型内漏5例,Ⅱ型内漏25例,Ⅲ型内漏1例,技术成功率95％.手术病死率2.5％.随访6～144个月,平均(36±3)个月.术后1年生存率为92％,3年生存率为75％,5年生存率为43％.术后3年支架的一、二期通畅率分别为97％和100％.5年二次手术率为10％ (12/120),手术原因为:7例内漏,2例支架断裂,2例支架移位,1例支架内血栓形成.结论 高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果满意,证实该技术适用于这类人群.     

Use of a bifurcated endovascular graft for treatment of endograft migration with major endoleak

The purpose of this study was to describe the use of a bifurcated endovascular graft to treat endograft migration with major endoleaks. We present four patients who presented at a mean of 72.0 months after their initial endovascular abdominal aortic aneurysm repair. Three patients had type I endoleaks resulting from proximal attachment failure and graft migration. A fourth patient had separation of a proximal aortic cuff from a migrated main body device resulting in a type III endoleak. All were treated with a bifurcated Zenith (Cook Medical Incorporated, Bloomington, IN, USA) endovascular graft. There was 100% technical success with no perioperative complications. On follow-up, one patient died of unrelated causes at five months. The mean survival for the remaining three patients was 37 months. In conclusion, treatment with a bifurcated Zenith endograft has advantages over the use of an aortic cuff or aortouniiliac reconstruction. To perform this technique, there must be a sufficient distance between the proximal landing zone and the flow divider of the migrated endograft to allow for deployment of the Zenith device. While there remain limitations in its applicability, the use of a bifurcated endovascular graft is a viable alternative for endovascular salvage in treatment of endograft migration with major endoleaks.     

Sac enlargement without endoleak: when and how to convert and technical considerations

The primary goal of endovascular treatment of abdominal aortic aneurysms (AAA) is prevention of death from rupture. Even in the absence of an endoleak, the AAA may continue to enlarge. The pathogenesis of this phenomenon remains unclear. Therefore, surveillance after endovascular AAA treatment must include regular evaluation of aneurysm size, or even better, aneurysm volume. Aneurysm sac enlargement without an endoleak is not a benign condition. Recurrent or persistent pressurization of the AAA sac will eventually result in rupture. Besides that, continued expansion of the AAA sac can result in dilatation of the infrarenal neck and/or iliac arteries, which may threaten the integrity of proximal and distal anastomotic seals. Many centers will take a pragmatic approach in case of endotension and a growing AAA, and convert to open surgery with removal of the endograft and placement of a regular vascular graft. Direct puncture and pharmacological intervention in the cause of sac enlargement by local instillation seems logical, but has failed so far. The third option for aneurysm sac enlargement without an endoleak is laparoscopic or open fenestration of the aneurysm. Until permanent solutions for endotension and endoleaks are found, endovascular aneurysm repair will remain an imperfect long-term treatment and continued follow-up will be mandatory.     

Use of proximal aortic cuffs as an adjunctive procedure during endovascular aortic aneurysm repair

The purpose of this study was to evaluate the incidence and durability of additional proximal cuffs during endovascular abdominal aortic aneurysm repair (EVAR). A retrospective review of 90 EVAR patients was conducted. Postoperative survival, proximal sealing zone-related complications, and secondary procedures were analyzed. Additional proximal cuffs were used in 11%. Their use did not affect postoperative survival (p = .58), type I endoleak rate (4.4%; p = .19), or the need for sealing zone-related secondary procedures (6.3%; p = .38) compared with patients without cuff placement but was related to a higher cumulative graft migration rate (2.2% overall p = .02). Two patients (2.5%; p = .79) underwent conversion to open surgery, both for proximal sealing zone-related complications. Application of proximal cuffs appears to be an effective intraoperative adjunctive procedure to achieve a proximal seal during EVAR, with favorable midterm results. However, the risk of late endograft migrations may be elevated in this group.     

肾动脉下腹主动脉瘤腔内治疗后并发症的防治

目的　总结肾动脉下腹主动脉瘤腔内治疗后常见并发症的预防与处理。　方法对已施行腔内治疗的 71例肾下腹主动脉瘤患者的临床资料进行回顾性分析 ,讨论常见并发症发生的原因、处理、结果及预后。　结果　 71例接受腔内治疗的肾动脉下腹主动脉瘤患者技术成功率1 0 0 % ,无中转开腹手术者。原发性内漏 8例 ,神经并发症合并急性血栓形成 1例。一过性缺血性肠炎 2例。无肾动脉梗死、肢体栓塞等并发症。平均随访时间 (2 6± 5)个月。围手术期病死率 1 3 % (1 /71 ) ,总病死率 4 2 % (3/ 71 )。死亡原因 2例为急性心肌梗死 ,1例为急性心功能衰竭。随访过程中发现 3例原发性内漏转为持续性内漏 ,另发现继发性内漏 4例。本组患者 1个月后内漏发生率 9 8%(7/ 71 )。 2例继发性Ⅰ型内漏随访中瘤体增大 ,1例进行二期腔内治疗。　结论　动脉瘤的腔内治疗具有创伤小、技术操作可行、效果肯定的优点 ,内漏血是该技术主要并发症。对漏血量及瘤体有增大趋势的内漏应积极处理     

Fenestrated and branched stent-grafting after previous surgery provides a good alternative to open redo surgery.

OBJECTIVE: To present our experience using fenestrated and branched endoluminal grafts for Para-anastomotic aneurysms (PAA) following prior open aneurysm surgery, and after previous endovascular aneurysm repair (EVAR) complicated by proximal type I endoleak. METHODS: Fenestrated and/or branched EVAR was performed on eleven patients. Indications included proximal type I endoleak after EVAR and short infrarenal neck (n=4), suprarenal aneurysm after open AAA (n=4), distal type I endoleak after endovascular TAA (n=1), proximal anastomotic aneurysm after open AAA (n=1), and an aborted open AAA repair due to bleeding around a short infrarenal neck. RESULTS: The operative target vessel success rate was 100% (28/28) with aneurysm exclusion in all patients. Mean hospital stay was 6.0 days (range 2-12 days, SD 3.5 days). Thirty day mortality was 0%. All cause mortality during 18 months mean follow-up (range 5-44 months, SD 16.7 months) was 18% (2/11) with no deaths from aneurysm rupture. Cumulative visceral branch patency was 96% (27/28) at 42 months. Average renal function remained unchanged during the follow-up period. CONCLUSIONS: Our report highlights the potential of fenestrated and branched technology to improve re-operative aortic surgical outcomes. The unique difficulties of increased graft on graft friction hindering placement, short working distance, and increased patient co-morbidities should be recognized.     

Iliorenal artery bypass grafting to facilitate endovascular abdominal aortic aneurysm repair

Effective endovascular repair of an infrarenal abdominal aortic aneurysm (AAA) requires adequate proximal and distal landing zones to allow secure endograft attachment. We report a patient with an infrarenal AAA originating 3 mm below the left renal artery with cardiac morbidity that precluded open AAA repair. Left renal artery relocation with retroperitoneal iliorenal bypass grafting was performed to lengthen the proximal landing zone, which facilitated successful endovascular AAA repair. Postoperative surveillance after 3 years showed aneurysm reduction with a patent iliorenal bypass graft. This case underscores the utility of a combined open and endovascular approach in treatment of a challenging aortic aneurysm.     

Endovascular abdominal aortic aneurysm repair in patients with challenging anatomy: utility of the hybrid endograft

Commercially available aortic stent grafts differ in construction and clinical advantage such that creating hybrid endografts by combining components from different manufacturers is sometimes useful. We describe a multicenter experience using hybrid endografts to treat patients with challenging anatomy. Hospital records and office charts were reviewed from four institutions. Hybrid endografts were defined as those with two types of covered stents in continuity to treat an abdominal aortic aneurysm (AAA). Indications for hybrid grafts were defined by type of endoleak and whether an endoleak was expected or unexpected as determined by the preoperative radiographic evaluation. Endpoints include intraoperative endoleaks, late endoleaks, change in aneurysm size, and rupture. Hybrid endografts were used to treat AAA (endovascular aneurysm repair [EVAR]) in 90 patients, representing 7.9% of the total multicenter experience. In 7 patients (7.8%), a hybrid graft construction as a secondary procedure successfully corrected a type 1 endoleak. In the remaining 83 patients (92.2%), hybrid grafts were created at the time of original EVAR to treat expected challenging anatomy or unexpected endoleaks. Hybrid endografts corrected 88 (97.8%) type 1 endoleaks, but 2 patients (2.2%) persisted with a proximal type 1 leak requiring conversion. During follow-up of 1 to 24 months, computed tomography and ultrasound surveillance, available for 73 patients (81.1%), detected one unresolved distal type 1 (1.1%) and seven type 2 (7.8%) endoleaks. Aneurysm size decreased at least 0.5 cm in 23 of 50 patients (46.0%) at 6 months and in 19 of 31 patients (61.3%) at 12 months. Aneurysm size increased at least 0.5 cm in 4 of 50 patients (8.0%) at 6 months and in 1 of 31 patients (3.2%) at 12 months. There were no ruptures. Hybrid endografts have favorable early and intermediate results in the treatment of AAA. Long-term follow-up will be needed to confirm the absence of significant adverse biomaterial interaction and the effect on AAA exclusion. We advocate the use of hybrid endografts as endovascular therapy for patients whose anatomy may be unsuitable for a single endograft type.     

肾下腹主动脉瘤105例腔内修复的早中期疗效

目的 评估肾下腹主动脉瘤腔内修复治疗的早中期疗效.方法 回顾分析2001年1月至2007年2月105例肾下腹主动脉瘤行腔内修复治疗的经过、结果和并发症.结果 所有患者均获技术成功,82例(78.09%)获随访,随访时间1～73个月,平均(8.9 4±5.8)个月.围手术期死亡3例(2.86%),分别死于急性心肌梗死、多系统器官功能衰竭和上消化道大出血.1例(1.21%)术后30个月死于肝癌.原发性内漏21例:Ⅰ型18例,其中10例行球囊扩张(9例)或延伸段植入(1例)后治愈,8例自愈;2例Ⅱ型内漏自愈;1例Ⅲ型内漏支架植入后治愈.1例于术后2周支架的一侧髂支血栓形成,急诊行股-股动脉人工血管旁路术.4例迟发性Ⅰ型内漏.随访观察.1例于术后6年支架向远心端移位,无明显内漏而随访观察.2例支架感染发生于术后1和3个月,行清创引流和抗感染治疗后痊愈.随访期间,9例股-股或髂-股动脉旁路和3例髂内动脉旁路通畅.结论 腔内修复治疗肾下腹主动脉瘤安全、有效,早、中期疗效较好.     

Aortic Neck Attachment Failure and the AneuRx Graft: Incidence, Treatment Options, and Early Results

Some investigators have reported that proximal attachment failure is a long-term complication of endovascular abdominal aortic aneurysm repair (EVAR) with the AneuRx (Medtronic, Santa Rosa, CA) device. We evaluated the need for an intervention in patients with suboptimal proximal fixation as well as the feasibility and early success of a variety of treatment strategies. From October 1999 to October 2003, we performed 365 EVARs using the AneuRx graft. At a mean follow-up of 23.7 ± 14.8 months, 20 patients (5.5%) with suboptimal outcomes (14 with a type I endoleak, one with a type III endoleak, and 5 with an inadequate seal zone <1 cm) were considered for treatment. Characteristics of each patient’’s aortic neck anatomy that could be associated with proximal attachment failure were evaluated. Eighteen patients (90%) underwent successful treatment (9 AneuRx cuffs, 6 Talent cuffs, 5 aortic stents, one redo endograft, and two surgical conversions) without major perioperative complications, one patient had a persistent type I endoleak despite endovascular treatment, and one patient refused treatment, ultimately leading to aneurysm rupture. There have been no further endoleaks or graft migrations noted since the secondary intervention at a mean follow-up of 13.9 ± 11.8 months. In our experience, proximal attachment failure associated with the AneuRx graft is relatively uncommon and usually associated with unfavorable neck anatomy. Despite this, most cases are treatable by endovascular means. Long-term follow-up is needed to assess the ultimate frequency of these combined device reconstructions.Presented at the spring meeting of the Peripheral Vascular Surgery Society, Anaheim, CA, June 5, 2004.     

Use of endostaples to secure migrated endografts and proximal cuffs after failed endovascular abdominal aortic aneurysm repair

Distal migration of aortic abdominal endografts may lead to endoleaks and must be overcome. Revision surgery has been related to substantial morbidity and mortality. In this case report, a new endovascular technique has been described to secure migrated primary endografts and proximal extender cuffs during revision surgery after failed endovascular aneurysm repair with the use of endostaples. At 6-month follow-up, no complications were noticed in both treated patients.