Migration of a bifurcated endovascular graft into an iliac aneurysm: endovascular salvage and future prevention--a case report

The FDA approval of endovascular grafts for the treatment of abdominal aortic aneurysms has been associated with a dramatic increase in the use of these devices. Major referral centers are reporting the treatment of 75% to 80% of their patients with infrarenal abdominal aortic aneurysms with endovascular devices. The large quantity of endovascular devices being used has produced a growing number of management issues that are often not predictable during the preoperative assessment. These issues require complex intraoperative decision making and innovative techniques for their management as reflected by the subsequent case report. An 82-year-old patient presented with a 7.8-cm abdominal aortic aneurysm. The aneurysm extended into the common iliac arteries bilaterally. The right common iliac artery was 6.5 cm and the left common iliac artery was 2.0 cm in maximal diameter. The preoperative work-up, including a computed tomography scan and arteriogram, suggested that he would be a potential candidate for endovascular repair. The plan was to extend the graft into the right external iliac artery after embolization of the right hypogastric artery and to seal the left limb in the ectatic left common iliac artery using an aortic extender cuff. During the endovascular repair of the aortoiliac aneurysms using the AneuRx bifurcated graft, the main device became dislodged from its infrarenal attachment site and migrated into the large right common iliac artery aneurysm with the iliac limb ending in the distal external iliac artery. A new bifurcated device was deployed from the left side to attempt an endovascular salvage of the difficult situation. The new graft was partially deployed down to the iliac limb. This allowed cannulation of the contralateral stump through the original endovascular graft that had migrated distally. The two grafts were connected with a long iliac limb. This allowed stabilization of the endovascular reconstruction by increasing its columnar strength. The deployment of the second bifurcated graft was completed and the central core with the runners removed safely without migration of the second bifurcated component. The reconstruction was completed with an aortic cuff in the left common iliac artery. The use of the aortic cuff was useful to preserve the left hypogastric artery. No intraoperative endoleak was noted. The patient did well and was discharged the day following the procedure. The follow-up computed tomography scan shows the abdominal aortic aneurysm excluded by the endovascular graft with a defunctionalized portion of one bifurcated graft within the right common iliac aneurysm. There is no evidence of endoleak and the abdominal aortic aneurysm had decreased in size at 6 months. This case demonstrates one of the unique management problems that may arise during endovascular graft placement. Events that initially would suggest failure of the endoluminal treatment may be corrected using advanced endovascular techniques by an experienced surgeon. However, there will be times that the prudent decision will be conversion to open repair. Only good clinical judgement and adequate training will prevent catastrophic outcomes.     

Temporary axillobifemoral bypass as an adjunct to endovascular aneurysm repair using fenestrated stent grafts

Prolonged endovascular procedures requiring a large diameter sheath in each groin can be associated with significant intraoperative lower limb ischemia, particularly in those with pre-existing peripheral vascular disease. We report the case of a patient who suffered severe ischemia-reperfusion injury following endovascular repair of a pararenal aortic aneurysm using a fenestrated stent graft and describe the use of temporary axillobifemoral bypass in a patient with similar comorbidities undergoing the same procedure. We propose this adjunctive technique as a means of maintaining antegrade limb perfusion and avoiding the peripheral and central metabolic consequences of ischemia-reperfusion injury.     

Spinal cord, bowel, and buttock ischemia after endovascular aneurysm repair

A 66-year-old man with multiple comorbidities presented with a juxtarenal perianastomotic aortic aneurysm 10 years after open abdominal aortic aneurysm repair. The aneurysmal disease also involved both iliac bifurcations, the right internal iliac artery, the left common femoral artery (CFA) up to its bifurcation, and the homolateral popliteal artery. We performed bilateral internal iliac artery coil embolization 1-month apart. Later, we performed aortouniiliac endografting extending to the right external iliac artery and placement of an endovascular plug in the left external iliac artery. A right CFA to left femoral bifurcation bypass graft was then constructed after ligation of the left CFA aneurysm. After recovering from anesthesia and despite sequential hypogastric embolization, the patient developed postoperative paraplegia, buttock ischemia, and ischemic colitis and died on postoperative day 5. The possible pathogenic mechanisms involved in the onset of these ischemic complications are discussed in this article.     

Transcarotid artery endovascular reconstruction of the aortic arch by modified bifurcated stent graft for Stanford type A dissection

A 40-year-old man with Stanford type B dissection underwent his first endovascular repair (EVAR) in April 2004 by Talent thoracic stent graft. He had an uncomplicated recovery and maintained good blood pressure control. However, a new retrograde dissection appeared in September 2004. The new dissection involved his aortic arch and ascending thoracic aorta to the opening of the coronary arteries. To reconstruct the aortic arch, bypasses between the right common carotid artery (RCCA), left common carotid artery and left subclavian artery were performed before endovascular repair. A modified bifurcated Talent stent graft was deployed from the RCCA to the ascending thoracic aorta with a long limb in the innominate artery and a short limb in the aortic arch. A further two pieces of graft were deployed via the common femoral artery. The ascending thoracic aorta and aortic arch were reconstructed completely by the bifurcated stent graft. The final angiography confirmed that there was good stent graft configuration, normal blood flow, and stable haemodynamics. No endoleak or other major complications were encountered. This result indicated that it is possible to reconstruct the aortic arch with a bifurcated stent graft and could be a new endovascular repair model for complex thoracic aortic aneurysm and dissection.     

Use of an aortic bifurcation-sparing endograft facilitates hypogastric preservation during aortoiliac aneurysm repair

A significant percent of patients undergoing endovascular abdominal aortic aneurysm repair (EVAR) have concomitant common iliac artery aneurysms. While most of these patients will tolerate sacrifice of the hypogastric artery during repair, a subset will develop sequelae of hypogastric occlusion. EVAR was performed in two patients using a bifurcation-sparing unibody endograft (Powerlink, Endologix, Irvine, CA, USA). To avoid simultaneous bilateral hypogastric occlusion, one side was treated with coil embolization while the other was treated with a hypogastric graft (Viabahn, W L Gore and Associates, Flagstaff, AZ, USA). Access to the preserved hypogastric artery was obtained from a sheath inserted from the contralateral femoral artery and brought over the aortic bifurcation with the assistance of a 'rail-wire' traversing from the contralateral to ipsilateral femoral sheaths. The hypogastric limb was deployed simultaneously with the ipsilateral external iliac limb extension, creating a double-barrel flow lumen preserving both hypogastric and external iliac flow. At a mean follow-up of 5.1 months, both hypogastric limbs are patent and no endoleaks were observed. In conclusion, until commercially-produced branched hypogastric endografts are widely available, techniques such as those described above can allow for hypogastric preservation during aortoiliac aneurysm repair without the need for device modification or brachial access for hypogastric limb delivery.     

Hybrid repair of abdominal aortic aneurysm in a patient with poliomyelitis-related deformities

A 63-year-old man presented with an asymptomatic infrarenal abdominal aortic aneurysm. He had scoliosis and atrophic right leg change as sequelae of poliomyelitis. The patient was not a candidate for endovascular aneurysm repair because of anatomic unsuitability. An open surgical repair was performed by the retroperitoneal approach because of severe scoliosis and left lateral aneurysm deviation. To minimize contralateral exposure, the Viabahn stent graft (W. L. Gore & Associates, Flagstaff, Ariz) was inserted in the right external iliac artery and anastomosed with the right expanded polytetrafluoroethylene graft limb. I report the successful hybrid repair of infrarenal abdominal aortic aneurysm using the modified Viabahn open revascularization technique.     

经颈动脉腔内技术重建主动脉弓治疗Stanford A型夹层动脉瘤(附1例报告)

目的探讨血管腔内技术重建主动脉弓治疗升主动脉、主动脉弓病变的可行性。方法2005年,对1例StanfordA型夹层动脉瘤,腔内修复主动脉病变之前做右颈总动脉-左颈总动脉-左锁骨下动脉的旁路术;经右颈总动脉将修改的分叉支架型血管主体放入升主动脉,长臂位于无名动脉。短臂应用延长支架型血管延伸至降主动脉。通过腔内技术重建主动脉弓实现累及升主动脉和主动脉弓主动脉病变的微创治疗。结果腔内修复术后移植物形态良好,血流通畅,病变被隔绝,脑、躯干、四肢循环稳定。无严重并发症。结论该手术方案设计合理、技术可行。可能成为复杂胸主动脉病变新的腔内治疗模式。     

Repair of abdominal aortic aneurysm by transfemoral endovascular graft placement.

PURPOSE: The authors describe the initial clinical experience with a new device, approved by the FDA for investigation, for repair of abdominal aortic aneurysm by transfemoral endovascular insertion of an aortic graft. METHODS: Sixty-nine patients with abdominal aortic aneurysms were screened, and ten were found to be suitable for endovascular grafting. Repair was done in the operating room using general anesthesia. One femoral artery was surgically exposed, and the device, containing a premeasured graft with proximal and distal self-expanding fixation devices, was inserted with fluoroscopic control through an open arteriotomy. FINDINGS: Eight of ten patients underwent successful graft placement, and two patients required conversion to an open repair. On follow-up, six of eight patients who underwent graft placement functioned normally, with documented aneurysm thrombosis. Two patients who underwent graft placement functioned normally, with contrast computed tomography evidence of incomplete aneurysm thrombosis, but without further expansion. CONCLUSION: Transfemoral repair is safe and appears to be effective. Phase II study currently is appropriate, with need for long-term follow-up.     

Clinical implications of internal iliac artery embolization in endovascular repair of aortoiliac aneurysms

To overcome constraints imposed by iliac artery anatomy, the anatomic inclusion criteria for endovascular aortic aneurysm repair can be extended by means of intentional coil occlusion of one or both internal iliac arteries and extension of the distal limb of the graft into an external iliac artery. We reviewed our experience with this intervention to determine the safety and efficacy of this approach to aneurysm repair. Over a 30-month period, 84 patients underwent endovascular abdominal aortic aneurysm repair; 23 underwent intentional unilateral (22) or bilateral (1) internal iliac artery occlusion. Morbidity, mortality, and long-term clinical outcomes were evaluated in these 23 patients. Patients were specifically questioned about exercise-induced buttock and extremity symptoms. Our results showed that intentional internal iliac artery embolization to allow endovascular repair of abdominal aortic aneurysms is accompanied by significant morbidity and should be approached with caution.     

A novel hybrid approach to the treatment of common iliac aneurysms: antegrade endovascular hypogastric stent grafting and femorofemoral bypass grafting

A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.     

Endovascular treatment of a symptomatic suture aneurysm caused by an aortic isthmus restenosis

After operative treatment of aortic isthmus stenoses, late complications, such as aneurysm formation or aortic restenosis, might occur, with relevant morbidity and mortality rates during open surgical reintervention. We report on the endovascular repair of a symptomatic suture aneurysm caused by an aortic isthmus restenosis by thoracic aortic stent graft implantation and additional intraoperative balloon dilatation. Based on our experience, endovascular repair of thoracic aortic aneuryms caused by native aortic isthmus stenosis or postcoarctation restenosis is a valuable treatment option, especially in symptomatic patients with an imminent risk of rupture or a difficult immediate transthoracic surgical approach. Long-term follow-up is required to assess the durability of the stent graft treatment.     

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.     

Patient selection for endovascular repair of abdominal aortic aneurysms: changing the threshold for intervention.

The success of endovascular graft repair depends greatly on appropriate patient selection. These selection criteria are completely different from those traditionally used for open repair. Although each endovascular graft has its own unique criteria, several anatomic constraints are common for each graft, including presence of a proximal and distal landing zone, absence of indispensable branches arising from the aneurysm, and an access artery large enough to accommodate the delivery system. Although theoretically attractive, due to the uncertainty regarding long-term durability and a finite incidence of both conversion and perioperative mortality, endovascular repair of the small aortic aneurysm is not justified at this time.     

Prevention and management of sigmoid and pelvic ischemia associated with aortic surgery.

Ischemia of the colon, rectum, and pelvis continues to be a significant source of morbidity and mortality after aortic reconstruction. Complications associated with colonic and pelvic ischemia are severe and include impotency, buttock claudication, colonic and rectal infarction, buttock and perineal necrosis, and spinal cord or lumbar plexus injury. To prevent these complications the vascular surgeon must make every attempt to guarantee the adequacy of colonic and pelvic blood supply after aortic reconstructive procedures. During open surgical repair of aneurysms or aortoiliac arterial occlusive disease, patent inferior mesenteric arteries must either be routinely reimplanted or selectively ligated on the basis of object intraoperative assessment of colonic perfusion. In addition, when possible, antegrade perfusion should be maintained in patent internal iliac arteries, and femoral reconstructions should include reconstruction of the deep femoral artery to assure adequate perfusion of potential pelvic collaterals. The rate of colonic and pelvic ischemia after endovascular aneurysm repair appears lower than after open repair, but all of the complications of colonic and pelvic ischemic seen after open repairs have been reported after endoluminal aneurysm repair. Thus, during stent-graft repair of abdominal aortic aneurysms, all attempts also should be made to preserve pelvic perfusion by maintaining antegrade flow to a least one patent internal iliac artery. The principle to remember in the management of complications of pelvic ischemia associated with aortic reconstruction is prevention because when complications of pelvic ischemia occur, the damage often is irreversible.     

Complications of aortic endografting

Endovascular repair of abdominal aortic aneurysm has been shown to have a significantly lower perioperative mortality rate compared with open repair. It has been a blessing for patients at high risk who were previously denied treatment for their aortic aneurysms. It does, however, have a substantial need for re-intervention for complications. Many of these complications including endoleak, endotension, migration, post implant syndrome and conversion to open repair are unique to endovascular aneurysm repair. Others including injury to the iliac arteries, graft limb thromboses and structural failure of prostheses occur with greater frequency in endovascular repair compared with open repair. It is important, therefore, for vascular surgeons to be aware of these complications including their prevention and appropriate that patients are informed of their incidence. This review discusses the local and vascular complications of endovascular repair of abdominal aortic aneurysm with an emphasis on newer aspects.     

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.     

一期杂交手术治疗弓部和胸腹段主动脉病变

目的 总结单中心手术结合微创的杂交技术,同期治疗弓部、胸腹段主动脉病变的经验.方法 回顾性分析2007年6月至2008年5月在澳门仁伯爵综合医院应用杂交技术,同期治疗主动脉病变5例的临床资料.其中胸降主动脉瘤累及半弓合并夹层1例,弓降主动脉瘤1例,DebarkeyⅢ型急性主动脉夹层1例,累及双侧髂总、髂内动脉的肾下腹主动脉瘤2例.弓部近端锚定区分类,ZAP 0区2例,ZAP 2区1例.弓降主动脉瘤正中开胸行升主动脉至双侧颈总人工血管搭桥+左颈总动脉至左锁骨下动脉搭桥术,同期导管室血管造影(digital seduction angiogram,DSA)下经股动脉释放Zenith覆膜支架.Debakey Ⅲ型夹层行左颈总至左锁骨下动脉搭桥后释放覆膜支架封闭破口.对于累及双侧髂内动脉的腹主动脉瘤,预先髂内、外动脉搭桥后释放腹主动脉分叉支架.结果 手术5例均获成功,术后即刻造影和随访CTA无内漏发生,随访期2～10个月.出血量约200～600 ml之间,均未输血.1例弓部杂交术后相继发生成人呼吸窘迫综合征(adult respiratory distresssyndrome,ARDS),及急性左心衰,经积极治疗后痊愈.1例术后因心肌梗塞死亡.2例弓部杂交治疗病例各颈动脉阻断时间均小于10 min,均无神经并发症或者轻微神经症状.另1例腹主动脉瘤患者杂交术后恢复正常,无并发症.结论 应用手术结合微创这一新型杂交技术治疗胸腹各段主动脉病变,有利于减少外科创伤和体外循环等所带来的血流动力学改变.     

Vascular complications after surgical repair of aneurysms in Behçet's disease

The poor prognosis of vasculo Behcet's disease is often due to postoperative vascular complications (false aneurysm and graft occlusion). We report a case of an abdominal aortic aneurysm associated with an aneurysm of the left common femoral artery in a 23-year-old Portuguese man. The primary treatment was surgical (aneurysmectomy and prosthetic revascularization). The early occlusion of the left femoral revascularized artery was treated surgically with a new bypass. The occlusion of the right limb of the aortoiliac graft was asymptomatic and was not treated. Two months after admission to our hospital, the stenosis of the infrarenal aorta successfully treated by angioplasty via the occluded right limb of the graft. The patient was followed up for 18 months. He could only walk a short distance and had rest pain in the left foot. Magnetic resonance angiography showed a false aneurysm of the infrarenal aorta, and an occlusion of the remaining left limb of the aortoiliac graft. The endovascular treatment performed does not avoid the need for surgical treatment, because occlusion and false aneurysm may occur after dilatation. The endovascular approach can also be used during a sudden inflammatory surge, and makes it possible to wait for a quiescent period when surgery can be performed.     

Thoracic aorta aneurysm repair using the right axillary approach

We present a 66-year-old man with a 5.7-cm saccular descending thoracic aortic aneurysm and a smaller 4.6-cm aneurysm just proximal to the celiac artery. The patient was judged to be too risky for open surgical repair because of poor anatomy and health. Previous stenting of the iliac arteries for a kinked aortoiliac open graft precluded conventional endovascular aneurysm repair. The descending thoracic aorta was successfully repaired using endovascular methods with a standard Talent (Medtronic, Los Angeles, Calif) thoracic proximal main stent graft, which was reverse-loaded onto the delivery device and delivered antegrade through the right axillary artery.     

Simultaneous Open and Endoluminal Repair of Ruptured Abdominal and Thoracic Aortic Aneurysms: Report of a Case

A 66-year-old woman was transferred to our hospital for emergency treatment of a ruptured abdominal aortic aneurysm (AAA) and impending rupture of a descending thoracic aortic aneurysm (TAA) caused by a Stanford type-B dissection. She had severe coronary artery disease and a highly calcified aorta, and had been taking long-term steroids for rheumatoid arthritis. Endovascular repair of the TAA failed because the femoral artery was too small, so we performed simultaneous repair of the TAA and the AAA. A temporary axillofemoral bypass was constructed and the AAA was replaced with a bifurcated prosthetic graft. A thoracic stent graft was delivered successfully through a chimney graft of the abdominal graft. About 4 months later, the TAA extended proximally, causing hemoptysis, which was stopped by placing a new stent graft proximal to the previous one. This case report shows that a combination of open and endovascular repair is useful for treating a TAA with an AAA, especially in a small or frail patient.