Aneurysm of arteriovenous fistula in uremic patients: is endograft a viable therapeutic approach?

One of the complications of arteriovenous fistulas in chronic hemodialyzed patients is the onset of an aneurysm which can be at risk of rupture. Traditional surgical repair is not always feasible and may not be successful in these cases, leading therefore to the loss of a functioning vascular access and requiring in any case the temporary use of a central venous catheter to allow regular hemodialysis sessions. We applied to this kind of aneurysm the same experience developed in the management of major arterial aneurysms and we considered endografting repair a good alternative in this case. In this paper we present the successful treatment of an arteriovenous fistula aneurysm using that technique. A distal radio-cephalic arteriovenous fistula in one of our patients presented an aneurysm with high risk of rupture. The endografting repair with percutaneous insertion of a WallgraftTM endoprosthesis was well tolerated and the vascular access could be used the day after, without the need for a central venous catheter insertion.     

Endovascular Treatment of a Chronic Contained Ruptured Abdominal Aortic Aneurysm

Case report : We report a 69-year-old Caucasian male who presented with irreversible ischemia to the left foot. CT-scan showed, besides occlusion of both superficial femoral arteries, a chronic contained rupture of an abdominal aortic aneurysm. The aneurysm was excluded with a stent graft placed through a femoral approach in a semi-urgent procedure. CT-scans at 1, 3 and 6 months demonstrated continued exclusion of the aneurysm. Chronic ruptures are a rare but important subset of ruptured abdominal aortic aneurysms. CT-scan with contrast enhancement is the gold standard diagnosing technique. Treatment consists of prompt surgical intervention with endovascular repair being increasingly used as an alternative to an open surgical approach.     

Chronic contained leak of abdominal aortic aneurysm presenting as lumbar neuropathy.

Chronic contained rupture of aortic aneurysm is a rare event which can cause diagnostic difficulties. It can present as high lumbar neuropathy, hence, chronic contained rupture should be borne in mind while examining patients with back pain. Delayed diagnosis and delayed surgical repair of the ruptured aneurysm can compromise the final results. The outcome of urgent repair of a chronic contained leak is equivalent to that of elective aneurysm repairs.     

Combined emergency abdominal aortic aneurysm repair and valve replacement in a patient with severe aortic stenosis

Simultaneous open surgery has been advocated in the elective management of abdominal aortic aneurysm patients with significant ischemic heart disease, as staged procedures risk worsening myocardial ischemia or aortic rupture, depending on which is the first intervention. The argument for combined aneurysm and valve repair is less established. We describe the case of a 70-year-old female who while awaiting aortic valve replacement suffered rupture of an abdominal aortic aneurysm. The patient was successfully managed with emergency combined open abdominal aortic aneurysm repair and open aortic valve replacement. We would advocate that such a strategy be considered as a salvage technique in similarly difficult management dilemmas.     

Surgical repair for rupture of a chronic traumatic thoracic aneurysm 14 years after injury: report of a case

Traumatic thoracic aortic injury is a lethal condition. Because its mortality rate is extremely high in the acute phase, these patients rarely survive long enough for a chronic aneurysm to develop. We herein report a case of surgical repair for a ruptured chronic traumatic thoracic aneurysm. A 32-year-old man, who had been involved in a traffic accident 14 years earlier, was diagnosed with a rupture of a chronic traumatic thoracic aneurysm. Preoperative computed tomography showed that the ruptured aneurysm arose from the aortic isthmus and was accompanied by multiple daughter lesions. He underwent an aorta graft replacement with reconstruction of the left subclavian artery using both a median sternotomy and a left thoracotomy. The surgery was successful and the postoperative course was uneventful. Chronic traumatic thoracic aneurysm is usually a single lesion, and cases with daughter aneurysms have rarely been reported. We include a review of the previous literature and also discuss the etiology of this condition.     

Chronic rupture of abdominal aortic aneurysm

Although the mortality rate after abdominal aortic aneurysm rupture approximates 90% despite the urgent management, a few cases of chronic rupture and delayed repair have been reported in the world literature; anatomic and hemodynamic reasons occasionally allow for the fortunate course of these patients. We report in this article the case of 76-year-old man with a ruptured abdominal aortic aneurysm who was transferred to our facility 4 weeks after his initial hospitalization in a district institution and who finally had a successful open repair.     

A combination of aortic arch debranching and off-pump coronary artery bypass

The prevalence of coronary artery disease in patients with aortic aneurysm is high. As an antecedent percutaneous coronary intervention with antiplatelet therapy may cause a rupture of aortic aneurysm, concomitant treatment for aortic arch aneurysm and coronary artery disease is recommended. We report a technique of a combined procedure of antegrade endovascular repair with aortic arch debranching and off-pump coronary artery bypass grafting.     

Delayed rupture of a postinfarction left ventricular true aneurysm

Delayed rupture of a true left ventricular aneurysm is a rare clinical condition. We report a case of a 60-year-old woman who underwent emergency surgical repair of a ruptured true aneurysm of the left ventricular inferior wall 3 months after the myocardial infarction. The repair consisted of endoaneurysmorraphy patch technique. The patient made a satisfactory recovery.     

"Unpredictable" late rupture of an abdominal aortic aneurysm after bifurcated Ancure endograft repair

The goal of endovascular repair of an abdominal aortic aneurysm is to exclude the aneurysm from systemic arterial pressure, thereby preventing rupture. However, the long-term durability of endovascular repair continues to be in question, as aneurysm rupture after endovascular repair continues to be reported. We report the case of an 89-year-old patient who underwent endovascular repair of a 7.1-cm abdominal aortic aneurysm with an Ancure endograft 5 years earlier. Despite close follow-up and a shrinking aneurysm sac on annual contrast-enhanced computed tomography, he presented with aneurysm rupture and a new proximal type I endoleak. The endoleak and rupture were successfully repaired with endovascular placement of a main body extension.     

Endovascular Repair of a ruptured abdominal aortic and iliac artery aneurysm with an acute iliocaval fistula secondary to lymphoma

Abdominal aortic aneurysms (AAA) are common and generally asymptomatic unless rupture occurs. A 3 to 4-cm AAA has a 1-2% risk of rupture over 5 years. We present the case of an 85-year-old male with a history of chronic lymphocytic leukemia, a 3-cm infrarenal AAA, and a 2-cm right common iliac artery aneurysm whose AAA ruptured and who developed an acute iliac artery–to–vena cava fistula secondary to eroding adenopathy from an aggressive low-grade lymphoma. Initially, an open repair was attempted but access to the aorta was not possible because of complete encasement of the infrarenal and suprarenal aorta with tumor that was clinically invading the aortic wall. Secondary tumor invasion into the aorta is a rare complication. An endovascular repair was accomplished with successful exclusion of both the aneurysm and the iliocaval fistula. Endovascular repair provides a valuable alternative in the "hostile abdomen" when standard open repair may be hazardous or impossible.     

Rupture of abdominal aortic aneurysm previously treated by endovascular stentgraft

We describe a case of abdominal aortic aneurysm (AAA) with rupture 16 months after treatment by an endograft. A 76-year-old patient on Coumadin after aortic valve replacement had initially successful exclusion by stentgraft. There was no evidence of an endoleak seven months after stentgraft repair, although a computed tomography scan detected an enlargement of the aneurysm sac. Sixteen months after initial endograft surgery, rupture of the aneurysm occurred and we performed open emergency surgery. We treated the aneurysm by conventional technique, and the patient survived the rupture. This case emphasized the fact that patients after endograft AAA repair require a close follow-up. An expansion of the aneurysm sac after the procedure should signal failed exclusion, even if a computed tomography scan does not demonstrate an endoleak. Anticoagulation can be an important factor in failure after endoluminal graft treatment. Supravisceral aortic cross clamping is helpful in dealing with a stented aorta. (J Vasc Surg 1998;28:184-7.)     

Aneurysm rupture after endovascular repair using the AneuRx stent graft

OBJECTIVE: The purpose of this study was to determine the cause and frequency of aneurysm rupture after endovascular aneurysm repair. METHODS: We reviewed each patient who sustained aneurysm rupture among all patients enrolled for endovascular aortic aneurysm repair in phases I, II, and III of the US AneuRx Multicenter Clinical Trial from June 1996 through October 1999. RESULTS: A total of 1067 patients were enrolled for endovascular aneurysm repair. The AneuRx stent graft was successfully implanted in 1046 patients (98%). Endovascular repair was unsuccessful in 21 patients (2%); 13 patients (1%) were converted to open aneurysm repair. Among these, two patients (0.2%) sustained aneurysm rupture due to procedure-related instrumentation and underwent open surgical conversion. Aneurysm rupture has occurred in seven patients (0.7%) 3 weeks to 24 months (mean, 16 months) after successful endovascular repair. Four patients survived open surgical repair, and three patients died within 30 days. Overall rupture-related mortality was 0.5% and included late deaths after rupture. Before rupture, two patients had endoleak and aneurysm enlargement, and five patients had no endoleak and no aneurysm enlargement. After aneurysm rupture all seven patients had evidence suggesting that there was poor fixation of the stent graft at the proximal distal, or iliac junction fixation sites. The two patients with endoleak declined recommended open surgical or endovascular repair, which could have prevented aneurysm rupture. In retrospect, the five patients without endoleak could potentially have avoided rupture with better patient selection, better stent graft positioning, or reinforcement of fixation points with stent graft extenders. The probability of no aneurysm rupture for all patients undergoing endovascular repair is 0.996 +/- 0.002 at 1 year and 0.974 +/- 0.011 at 2 years by life table analysis with the longest follow-up of 41 months. CONCLUSION: The early risk of aneurysm rupture after endovascular aneurysm repair is low. However, the possibility of rupture persists even in patients with no endoleak after the procedure. Therefore, all patients treated with endovascular aneurysm repair should continue to be monitored after the procedure. Patients with evidence suggesting insecure stent graft fixation should undergo further endovascular treatment or open surgical repair.     

A novel alternative to open conversion for type 1 endoleak resulting in ruptured aneurysm

In this article, a novel technique for the treatment of ruptured abdominal aortic aneurysm secondary to proximal type 1 endoleak as a result of progressive neck dilatation after endovascular aneurysm repair is reported. A 74-year-old man with multiple comorbidities including severe ischemic heart disease, congestive cardiac failure, and chronic renal failure presented with a ruptured abdominal aortic aneurysm. He had an infrarenal endovascular aneurysm repair performed in 1999 and had subsequently developed a proximal type 1 endoleak. At open laparotomy, the placement of 4 nylon ties around the infrarenal aneurysm neck to refashion a seal and exclude the sac from systemic pressurization effectively treated the rupture. In the high-risk patient, ruptured proximal type 1 endoleak can be successfully treated with external banding avoiding the potential morbidity seen with the aortic clamping and blood loss of open conversion.     

Aortoduodenal fistula and associated rupture of abdominal aortic aneurysm after endoluminal stent graft repair

The main complications of endovascular repair of abdominal aortic aneurysms are vascular leaks and rupture, although infection and aortoduodenal fistulas have also been reported rarely. We report a case of aortoduodenal fistula with separate retroperitoneal rupture of an abdominal aortic aneurysm after endovascular stent graft repair. The initial implantation was uneventful, without any leaks at 1 month. The patient underwent open repair and did well. To our knowledge, this is the first case report of aortoduodenal fistula and associated retroperitoneal rupture of the aneurysm after endovascular stent graft repair of an abdominal aortic aneurysm.     

Temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic vessels for hybrid repair of a ruptured aortic arch aneurysm

Hybrid repair of ruptured aortic arch repair has been proposed as a valuable approach. However, the presence of an anterior mediastinal hematoma must be carefully detected because of the inherent risk of rupture at sternotomy. We report the case of a patient presenting a ruptured aortic arch aneurysm with anterior rupture who underwent hybrid repair using a temporary extra-anatomic brain perfusion followed by total rerouting of the supra-aortic trunks. We propose this adjunctive technique as a means of allowing a safe endovascular exclusion of aortic arch lesions and avoiding the risk of acute and total aortic rupture in case of anterior rupture of aortic arch aneurysms.     

Double-patch sandwich repair for left ventricular free wall rupture

We present a case of a patient with left ventricular free wall rupture who successfully underwent emergency surgical repair using the double-patch sandwich technique. This technique has already been used for the treatment of left ventricular aneurysm and retains the proper shape and size of the left ventricle. Multislice computed tomography was fast and non-invasive in the detection of a ventricular rupture.     

Concomitant transabdominal MIDCAB and abdominal aortic aneurysm repair

We present 2 patients who underwent transabdominal minimally invasive direct coronary artery bypass with the right gastroepiploic artery combined with abdominal aortic aneurysm repair. The surgical procedures, both performed through a median laparotomy, proved safe and of limited invasiveness. The one-stage surgical intervention prevented catastrophic complications, such as acute myocardial infarction or rupture of abdominal aortic aneurysm. We believe that concomitant transabdominal minimally invasive direct coronary artery bypass and abdominal aortic aneurysm repair should be considered as a single combined surgical strategy in selected patients.     

Staged hybrid repair using telescoped stent graft fixation for aortic arch and descending aortic aneurysms

Staged repair of extensive thoracic aortic aneurysms is complicated, with a high incidence of interval rupture between stages. We describe the systematic staged hybrid procedure of a previous endovascular repair of a descending aortic aneurysm and open surgical repair of an aortic arch aneurysm. In the second-stage arch repair, the stent graft was easily retracted and fixed, without dissection, around the aortic arch aneurysm distal side. Extensive thoracic aortic aneurysms were managed without interim rupture or neurologic deficits. This approach avoided the potential for interim rupture because recovery from the first-stage endovascular repair was shorter than that from open repair.     

Endovascular treatment of abdominal aortic aneurysms

BACKGROUND: Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms. METHODS: A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated. RESULTS: Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used. CONCLUSION: Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.