Repair of abdominal aortic aneurysms with aorto-uni-iliac stentgraft and femoro-femoral bypass

Endovascular repair (EVAR) is accepted as effective treatment for abdominal aortic aneurysms (AAAs) and has become the standard of care in many instances. The standard bifurcated stentgraft (BFG) is often not possible in patients with unfavourable aneurysm morphology. The aorto-uni-iliac (AUI) graft configuration with femoro-femoral bypass (FFBP) is a promising alternative which may extend the scope of EVAR for AAAs. The aim of this study was to evaluate the feasibility, efficacy and durability of AUI with FFBP. Design. The results of a single institution and a single surgeon were prospectively collected from January 2002 to August 2010. All patients were followed up at 1, 3, 6 and 12 months and then annually. Results. There were 33 patients (27 males) with a mean age of 71.7 years (range 46 - 84). Open surgery posed an unacceptably high risk to all patients owing to advanced age and/or American Society of Anesthesiologists (ASA) classification 3/4. Ineligibility for BFG was due to unfavourable anatomy or a combination of factors in most cases (31 patients). Two patients had anastomotic aneurysms after previous open surgery. The technical success rate was 100%. One severe intra-operative complication occurred (perforated iliac artery). Two patients (ASA 4) died within 30 days (peri-operative mortality rate 6.1%). Seven patients (21.1%) developed postoperative wound complications. Eight patients died during follow-up of non-aneurysm-related conditions. Twenty-three patients are alive, with mean follow-up of 24.4 months and a survival rate of 69.7%. Two complications occurred during long-term follow-up, namely 1 case of graft sepsis and 1 of FFBP occlusion. Conclusion. AUI with FFBP is a safe, effective and durable alternative in high-risk patients with AAAs where standard open repair is contraindicated and BFG repair is not possible owing to unfavourable aneurysm morphology.     

Preliminary retrograde visceral artery reconstruction for thoracoabdominal aortic aneurysms

The recent availability of thoracic endografts has expanded the options for treatment of thoracoabdominal aortic pathology. However, disease that involves the visceral aortic segment presents a special challenge due to the need to preserve mesenteric perfusion. We present three patients in whom preliminary retrograde visceral artery reconstruction was used as an adjunct prior to endovascular repair.     

Complex thoracoabdominal aortic aneurysms: endovascular exclusion with visceral revascularization

OBJECTIVE: We review our ongoing experience with a transabdominal stent repair of complex thoracoabdominal aneurysms (Crawford type I, II, and III) with surgical revascularization of visceral and renal arteries. METHODS: A retrospective review was conducted of prospectively collected data from 29 consecutive patients who underwent an attempted visceral hybrid procedure between January 2002 and April 2005. Twenty-two patients were elective, four were urgent (symptomatic), and three were emergent (true rupture). The median patient age was 74 years (range, 37 to 81 years). The aneurysms were Crawford type I in 3, type II in 18, type III in 7, and type IV in 1. Previous aortic surgery had been performed in 13 (45%) of 29 and included aortic valve and root replacement in 3, TAA repair in 1, type I repair in 1), type IV repair in 3, type B dissection in 2, infrarenal aneurysm in 5, and right common iliac aneurysm in 1. Severe preoperative comorbidity was present in 23 (80%) of 29: chronic renal impairment in 5, severe chronic obstructive pulmonary disease in 6, myocardial disease in 11 at New York Heart Association grade II (6) and grade III (5), and Marfan's syndrome in 6. Twenty-six patients (90%) had a completed procedure. In two patients, myocardial instability prevented completion of the procedure despite extensive preoperative cardiac assessment, and in one, poor flow in the true lumen of a chronic type B dissection prevented anastomosis of the revascularization grafts. Exclusion of the full thoracoabdominal aorta was achieved in all 26 completed procedures and extended to include the iliac arteries in four, with revascularization of coeliac in 26, superior mesenteric artery in 26, left renal artery in 21, and right renal artery in 21). RESULTS: There was no paraplegia < or =30 days or during inpatient admission, and elective and urgent mortality was 13% (3/23). All of the patients with ruptured thoracoabdominal aneurysms died < or =30 days. Major complications included prolonged respiratory support (>5 days) in 9, inotropic support in 4, renal impairment requiring temporary support in 2 and not requiring support in 2, prolonged ileus in 2, resolved left hemispheric stroke in 1, and resection of an ischemic left colon in 1. Median blood loss was 3.9 liters (range, 1.2 to 13 liters). The median ischemia time was 15 minutes (range, 13 to 27 minutes) for the superior mesenteric and coeliac arteries and 15 minutes for the renal arteries (range, 13 to 21 minutes). The median hospital stay was 27 days (range, 16 to 84 days). Follow-up was a median of 8 months (range, 2 to 31 months), with 92 of 94 grafts patent. Six patients were found to have a type I endoleak. In four, this was a proximal leak, and stent extension in three reduced, but did not cure, the endoleak. One patient with a distal type I endoleak was successfully treated by embolization. Four type II endoleaks resolved without intervention, and one was treated by occlusion coiling of the origin of the left subclavian artery. A single late type III endoleak was found. CONCLUSION: Early results of visceral hybrid stent-grafts for types I, II, and III thoracoabdominal aneurysms are encouraging, with no paraplegia in this particularly high-risk group of patients. These results have encouraged us to perform the new procedure, in preference to open surgery, in Crawford type I, II, and III thoracoabdominal aortic aneurysms.     

Postoperative splanchnic perfusion following the reconstruction of thoracoabdominal aortic aneurysm involving abdominal visceral branches. Report of a case

A 58-year-old man with thoracoabdominal aortic aneurysm involving visceral arteries underwent graft replacement of the thoracoabdominal aorta and associated reconstruction of abdominal visceral branches. Femoro-femoral extracorporeal bypass, intermittent selective visceral arterial perfusion and a staging cross-clamping method of the aorta were utilized at surgery. The total cross-clamping time of the aorta was 165 minutes. The patient's postoperative course was uneventful with no incidence of hepatic and renal failure or paraplegia. Although postoperative systemic blood pressure and cardiac output recovered to normal values within 7 hrs after the release of aortic clamping, it took 18 hrs for hepatic venous hemoglobin oxygen saturation (ShvO2) to recover. Base excess in arterial blood, lactic acid in arterial and hepatic venous blood, and ketone body ratio in arterial blood (AKBR) and hepatic venous blood (HVKBR) recovered to within normal ranges after 18 hrs of the release of aortic clamping. ShvO2 monitoring is a simple and may be a useful parameter in evaluating postoperative splanchnic perfusion and predicting abdominal organ failure at the time of thoracoabdominal aortic reconstruction involving visceral arteries.     

Adjunctive methods during surgery for thoracoabdominal aneurysms--effect of selective visceral arteries perfusion incorporated with partial femoro-femoral bypass]

In this study, we report the effect of selective perfusion to the visceral arteries during aortic cross-clamping at surgery for thoracoabdominal aortic aneurysms with an adjunct of femoro-femoral (F-F) extracorporeal bypass. The total series comprising 28 patients were divided into 3 groups according to the perfusion mode to the celiac and the renal arteries, i.e., group I; the arteries were continuously perfused by the extracorporeal bypass, group II; aortic cross-clamp excluded the branches from the bypass flow but selective perfusion was employed, and group III; the liver or the kidneys were subjected to ischemia. As a result, group III developed hepatic failure at the incidence of 50% which was characterized by hepatocellular damage followed by cholestatic dysfunction. As for postoperative renal function, this group revealed persistently high level of serum creatinine, and 60% of this series resulted in renal failure. On the contrary, group II showed a comparable effect to group I on the preservation of hepato-renal function, and there were no differences in the incidence of hepatic or renal failure between the two groups. Multiple organ failure was a predominant cause of hospital death, and it developed only in the cases with aortic cross-clamp time more than 90 minutes. However, avoiding ischemia achieved in group I or II significantly reduced the incidence of MOF and its related deaths. It is concluded that selective perfusion system incorporated with an aid of F-F partial bypass was a useful measure to protect vulnerable organs from ischemia and to reduce postoperative mortality and morbidities.     

累及内脏动脉分支的主动脉疾病治疗对策探讨

内脏动脉分支主要指肾动脉、腹腔动脉和肠系膜上动脉的范围.累及内脏动脉分支的主动脉疾病主要有胸腹主动脉瘤(thoraco-abdominal aortic aneurysm,TAAA)、主动脉夹层(aortic dissection,AD)和腹主动脉瘤(abdominal aortic aneurysms,AAA)等疾病.经典的胸腹主动脉瘤,Crawford-Safi五型分型:Ⅰ型,病变从左锁骨下动脉始,延伸至腹主动脉上段,正好位于肾动脉水平以上,没累及肾动脉.Ⅱ型,病变最广泛,从左锁骨下动脉始,延伸至腹主动脉分叉处.Ⅲ型,病变从降主动脉下部,约第6肋间隙处,延伸至腹主动脉分叉处.Ⅳ型,病变累及全部腹主动脉,从膈肌处主动脉至腹主动脉分叉处.Ⅴ型,病变从第6肋间隙处的降主动脉,延伸至肾动脉水平以上的部位.     

Successful endografting with simultaneous visceral artery bypass grafting for severely calcified thoracoabdominal aortic aneurysm

We present two cases of severely calcified thoracoabdominal aortic aneurysm treated by means of endografting with a retrograde aortomesenteric bifurcated bypass graft reconstructing the celiac axis and superior mesenteric artery. To avoid spinal ischemia, we monitored evoked spinal cord potential and performed an occlusion test of the intercostal arteries using a retrievable stentgraft. No change in evoked spinal cord potential was noted, and no endoleaks or complications, including paraplegia, were observed. This procedure is a feasible and less-invasive treatment for severely calcified thoracoabdominal aortic aneurysms.     

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.     

The six-year results of a combined surgical and endovascular repair for thoracoabdominal aortic aneurysm involving the visceral arteries

The authors report a case of a combined endovascular and open repair (hybrid procedure) for a mycotic thoracoabdominal aneurysm (TAAA) including its 6-year result. A 72-year-old man with diabetes mellitus, old brain infarction and moderate aortic stenosis was transferred to the hospital because of obstinate fever and back pain, The initial computed tomography (CT) scan revealed giant (TAAA), and from the laboratory findings, the white blood cell and C-reactive protein (CRP) were significantly elevated 12,400/mm3 and 23.9 mg/dL respectively. Based on the CT and laboratory findings, a mycotic TAAA was highly suspected. After the remission of inflammation, graft replacement with reconstruction of celiac trunk (CA) and superior mesenteric artery (SMA) was performed via spiral incision under extracorporeal circulation. two months after the first operation, the patient complained about his back pain again. CT showed a pseudoaneurysm which formed at the distal anastomotic site. A hybrid procedure was deemed to be the most appropriate for such patient who needs a second operation. First bilateral renal artery bypass (ilio-renal artery bypass) were done using the saphenous vein grafts (SVGs). Following bypass grafting to renal arteries, endovascular aneurysm repair was performed with handmade stent-graft which was fabricated using a self-expanding "Z" stent and woven Dacron graft. The postoperative course was uneventful, and follow-up CT showed the aneurysm to have shrunk with no endoleaks. At six months after hybrid procedure, the shrinkage of the aneurysm sac and the patency of the graft to renal arteries were confirmed by a CT scan. A hybrid procedure is considered to be useful and feasible for the poor surgical candidate with severe comorbidities, hostile abdomen and a complex anatomy. The long-term results of this hybrid procedure is considered to be promising.     

Use of left heart bypass in the surgical repair of thoracoabdominal aortic aneurysms

The purpose of this study was to assess the usefulness of left heart bypass in thoracoabdominal aortic aneurysm surgery. Data from 50 patients who underwent thoracoabdominal aortic aneurysm repair between July 1987 and October 1993 were retrospectively reviewed. In all of them a left heart bypass (left atrium to left femoral artery) with a centrifugal pump (without systemic heparinization) was used. Patient-, disease-, and operation-related variables were analyzed using univariate methods. There were no intraoperative deaths. The in-hospital mortality rate was 8% (n = 4). Survival rates were 77% (±6.5) at 2 years and 62% (±8.7) at 5 years. Renal failure requiring dialysis occurred in five (10%) patients and paraplegia in five (10%). Sixteen (32%) patients had respiratory insufficiency requiring prolonged (>8 days) ventilation. After univariate analysis, the risk factors for developing a need for postoperative dialysis were found to be the preoperative creatinine level (p = 0.002) and the presence of preoperative arterial hypertension (p=0.018). A history of peripheral vascular occlusive disease (p=0.008) was an important risk factor for predicting late death. No factors retained significance in the univariate analysis of hospital deaths and postoperative paraplegia. Renal and spinal ischemic times were substantially reduced in comparison to the theoretic times calculated if cross-clamping had been used. Bypass-related complications were completely absent. The use of a left heart bypass during thoracoabdominal aortic aneurysm surgery may not reduce the global complication rate; the results were similar to those achieved using simple cross-clamping. However, this technique appears to be the method of choice for protecting organ systems at risk during difficult repairs.     

Emergency surgery for thoracoabdominal aortic aneurysms with acute presentation

PURPOSE: The mortality rate for elective repair of thoracoabdominal aortic aneurysms is as low as 4% in some surgical centers. However, patients with emergent presentation with acute pain, rupture, or complicated acute dissection traditionally have a poor outcome. We evaluated the results of surgery in a large contemporary series of patients with acute presentation at a tertiary referral center with a special interest and experience in aortic surgery. METHODS: Between 1986 and 1998, 1220 patients underwent repair of thoracoabdominal aortic aneurysms. One hundred twelve patients had acute presentation, and 1108 patients underwent elective repair. Data were collected in a prospectively generated database. RESULTS: Seventy-six patients had rupture, and 36 patients had acute dissection without rupture. The operative mortality rate was 6% for elective cases and 17% for acute cases (P =.0004). The long-term survival was longer for the elective group compared with the acute group (mean, 8.3 +/- 0.4 years versus 5.5 +/- 0.7 years; P <.005). Age did not influence survival rate in the acute group. Postoperative pulmonary complications, paraplegia/paraparesis, and renal impairment occurred in 45%, 14%, and 25%, respectively, of acute cases and were significantly more common than in elective cases (P < or =.01). Left heart bypass was used in 34 acute patients (30%), and intercostal arteries were reattached in 66 acute patients (59%). Surgery without the use of either adjunct was associated with significantly higher mortality and renal impairment rates. CONCLUSION: Repair of thoracoabdominal aortic aneurysms with acute presentation is associated with worse outcome compared with elective cases. Nevertheless, repair may be performed with reasonable mortality and morbidity rates at specialized centers. In the acute setting, the use of surgical adjuncts is associated with improved outcome and should be used when possible. Age does not impact on survival rate in patients with acute presentation, and surgery should not be restricted to only younger patients.     

Long-term results of femoro-femoral crossover bypass after endovascular aortouniiliac repair of abdominal aortic and aortoiliac aneurysms

Aortouniiliac stent grafts allow the endovascular treatment of complex anatomy aortoiliac aneurysms. The main drawback is the need for femoro-femoral crossover bypass, with its complications and its patency limitations. However, some authors have shown good results of femoro-femoral crossover bypass in aneurysmal disease. In this article, initial and long-term results of our experience in femoro-femoral crossover bypass revascularization after endovascular aortouniiliac stent grafts repair of aortoiliac aneurysms is reported. Prospective collection, intention-to-treat, and retrospective analysis maintained database. Femoro-femoral crossover bypass patency assessment of all patients treated between January 1999 and September 2002, compared patients with or without associated occlusive arterial disease. Urgent indications were excluded. In total of 52 patients, with a mean age 72.6 years, 30.8% of patients were identified with associated occlusive arterial disease. Initial systemic and local, access site, complications were 7.7% and 7.7%, respectively, no early thrombosis or death is reported. Primary patency was 90.9% at 54 months, 66 months assisted primary and secondary patency were 97.7% and 100%, respectively. The 48-month survival rate was 84.2%. No significant differences between patients with or without associated occlusive arterial disease were found. Femoro-femoral crossover bypass after aortouniiliac stent grafts treatment of aortoiliac aneurysms shows excellent initial and long-term patency and low complication rate.