Treatment of extracranial and intracranial aneurysms and arteriovenous fistulae using stent grafts

OBJECTIVE: Treatment of 11 patients with aneurysms or arteriovenous fistulae of the craniocervical arteries with stent grafts. METHODS: Peripheral stent grafts were deployed in two extracranial internal carotid arteries. Coronary stent grafts were used to treat two giant aneurysms, five direct carotid-cavernous fistulae, one vertebrojugular fistula, and two dissecting aneurysms of the vertebral artery (V2 and V4). RESULTS: Stent grafts were used successfully in two extracranial internal carotid and two extracranial vertebral arteries, one dissecting aneurysm of the intracranial vertebral artery, one giant aneurysm and one pseudoaneurysm of the cavernous internal carotid artery, and five direct carotid-cavernous sinus fistulae. Angiographic follow-up examinations (available in nine patients; obtained at 3 mo to 5 yr; average, 24 mo) revealed normal vessel caliber, and the stent grafts in all 9 of 11 initial patients were patent. There was a recurrent saccular aneurysm adjacent to the stent graft in the patient with the intracranial vertebral artery aneurysm. The following five complications were encountered: transient hemiparesis (n = 2), increased hemiparesis, postprocedural management-related fatality, and ICA dissection. In six patients, stent graft deployment was accomplished without any technical or clinical complication. There were no permanent neurological deficits consequent to stent graft placement. CONCLUSION: Stent grafts are a useful tool for the endovascular treatment of head and neck aneurysms and direct arteriovenous fistulae in selected patients. The major disadvantage of the currently available stent grafts is their lack of mechanical flexibility. Maneuvering stent grafts in the intracranial arteries carries the risk of iatrogenic vessel dissection and may require supportive measures and protection of the target site by conventional stents.     

Application of covered stent grafts for intracranial vertebral artery dissecting aneurysms

OBJECT: Utilization of covered stent grafts in treating neurovascular disorders has been reported, but their efficacy and safety in vertebral artery (VA) dissecting aneurysms needs further investigation. METHODS: Six cases are presented involving VA dissecting aneurysms that were treated by positioning a covered stent graft. Two aneurysms were located distal to the posterior inferior cerebellar artery, and 4 were located proximal to the posterior inferior cerebellar artery. Aspirin as well as ticlopidine or clopidogrel were administered after the procedure to prevent stent-related thrombosis. All patients were followed up both angiographically and clinically. RESULTS: Five of the 6 patients underwent successful placement of a covered stent graft. The covered stent could not reach the level of the aneurysm in 1 patient with serious vasospasm who died secondary to severe subarachnoid hemorrhage that occurred 3 days later. Patient follow-up ranged from 6 to 14 months (mean 10.4 months), and demonstrated complete stabilization of the obliterated aneurysms, and no obvious intimal hyperplasia. No procedure-related complications such as stenosis or embolization occurred in the 5 patients with successful stent graft placement. CONCLUSIONS: Although long-term follow-up studies using a greater number of patients is required for further validation of this technique, this preliminary assessment shows that covered stent graft placement is an efficient, safe, and microinvasive technique, and is a promising tool in treating intracranial VA dissecting aneurysms.     

Repair of juxtarenal para-anastomotic aortic aneurysms after previous open repair with fenestrated and branched endovascular stent grafts

Three patients with juxtarenal para-anastomotic aortic aneurysms after previous open abdominal aortic aneurysm repair were treated with custom-designed fenestrated and branched Zenith endovascular stent grafts. Six renal arteries and two superior mesenteric arteries were targeted for incorporation by graft fenestrations and branches. The fenestration/renal ostium interface was secured with balloon-expandable Genesis stents (n = 5) or Jostent stent grafts (n = 1). Completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. During follow-up, one patient developed asymptomatic renal artery occlusion and underwent further endovascular intervention for type I distal endoleak. Computed tomography at 12 months demonstrated complete aneurysm exclusion in all patients with antegrade perfusion in the remaining target vessels. Fenestrated and branched endovascular stent grafts may be an acceptable alternative to conventional open repair in this group of patients.     

A new technique for the surgical creation of aneurysms in an in vivo tortuous vessel model to test neurovascular devices.

The purpose of this study was to develop an aneurysm model that mimics the tortuous anatomy of the cerebrovasculature for the evaluation of endovascular devices. This model is an adaptation of the carotid siphon model of Georganos et al. The common carotid artery trunks in 10 swine were surgically elongated using an EXXCEL Soft ePTFE vascular graft and then sutured into position to form an S-curve, with each bend having a 5- to 10-mm radius. Following a 3- to 4-week healing period, aneurysms were surgically created from jugular vein grafts along or distal to the tortuous segment and immediately embolized with coils. In a subset (n = 6) of the arteries, a stent was also placed across the aneurysm neck. Animals were allowed to survive for 30 days. Clinical relevance and utility of the model were evaluated based on comparison to human angiographic images, physician feedback, and histopathological assessment. Tortuous anatomy was successfully created in all 10 animals, and aneurysms were added at various locations within or distal to the tortuous segment in a subset of 8 animals, creating 11 aneurysms in total. At 30 days, 18/20 vessels were patent and the bend radius was maintained. Endovascular access to aneurysms and placement of embolization coils and/or stents was successful in 10 of 11 attempts. Physician feedback indicated this tortuous model was more clinically relevant in terms of endovascular device delivery and deployment compared to established, nontortuous aneurysm models.     

Endovascular Repair of Paraanastomotic Aneurysms after Previous Open Aortic Prosthetic Reconstruction

The aim of this study was to evaluate the effectiveness of endovascular repair of anastomotic and true aortic and iliac aneurysms occurring after prior polyester graft repair for abdominal aortic aneurysms (AAA) or aortoiliac obstructive disease. Between July 1999 and January 2003, 14 patients underwent endovascular treatment of aortic pseudoaneurysms (n = 6) or iliac aneurysms (2 patients with pseudoaneurysms and 6 patients with true aneurysms) occurring 4 to 18.4 years (mean, 8.8 years) after open aortic surgery. No patient had symptoms or positive parameters for infection of the original polyester graft. Eleven patients, including one patient with both a proximal anastomotic and a true iliac aneurysm, were treated with AneuRx (n = 8), Talent (n = 2), or Quantum LP (n = 1) bifurcated stent grafts. Three patients with an infrarenal anastomotic pseudoaneurysm were treated with a tube stent graft (Talent [n = 2] and AneuRx [n = 1]). Endovascular stent grafts were successfully inserted in all patients. Procedure-related complications or death was not seen. During a median follow-up of 12 months (range, 3-40) all anastomotic and/or true aneurysms treated with bifurcated stent grafts maintained excluded. However, two out of three patients, treated with a tube graft for proximal aneurysm exclusion, were converted. In both patients the tube stent graft did not migrate from the level of the renal arteries but fixation failed between the stent graft and the previous polyester graft, creating endotension in the thrombus of the aneurysm sac. In one of these patients the old anastomotic aneurysm ruptured 16 months after stent graft placement and the patient died 1 day after conversion because of mesenterial ischemia. At 1 year follow-up the second patient was converted successfully after enlargement of his anastomotic aneurysm due to similar disconnection between the stent graft and the polyester graft. From this experience with endovascular stent grafts, we conclude that these can be used successfully to exclude anastomotic or true aneurysms after open aortic surgery. Exclusion of aneurysms at the proximal anastomosis with tube stent grafts is apparently not durable because of the insecure distal fixation in polyester grafts. Endovascular repair with bifurcated stent grafts, however, seems to be effective at midterm follow-up.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, II, June 7, 2003.     

Stent-graft treatment of a large internal carotid artery vein graft aneurysm

Aneurysm degeneration of internal carotid artery interposition vein grafts can occur, and their repair can be complicated by repeated neck dissection and difficulty in obtaining distal artery control. We used a covered stent graft to exclude a large internal carotid artery interposition vein graft aneurysm. Retrograde flow was induced in the internal carotid artery so that an embolization protection balloon could be placed through the aneurysm. The stent graft was then placed with embolization protection. The repair was performed without complication, and the aneurysm remained successfully excluded at 6-month follow-up.     

A New Technique for the Surgical Creation of Aneurysms in an In Vivo Tortuous Vessel Model to Test Neurovascular Devices

The purpose of this study was to develop an aneurysm model that mimics the tortuous anatomy of the cerebrovasculature for the evaluation of endovascular devices. This model is an adaptation of the carotid siphon model of Georganos et al. The common carotid artery trunks in 10 swine were surgically elongated using an EXXCEL Soft ePTFE vascular graft and then sutured into position to form an S-curve, with each bend having a 5- to 10-mm radius. Following a 3- to 4-week healing period, aneurysms were surgically created from jugular vein grafts along or distal to the tortuous segment and immediately embolized with coils. In a subset (n = 6) of the arteries, a stent was also placed across the aneurysm neck. Animals were allowed to survive for 30 days. Clinical relevance and utility of the model were evaluated based on comparison to human angiographic images, physician feedback, and histopathological assessment. Tortuous anatomy was successfully created in all 10 animals, and aneurysms were added at various locations within or distal to the tortuous segment in a subset of 8 animals, creating 11 aneurysms in total. At 30 days, 18/20 vessels were patent and the bend radius was maintained. Endovascular access to aneurysms and placement of embolization coils and/or stents was successful in 10 of 11 attempts. Physician feedback indicated this tortuous model was more clinically relevant in terms of endovascular device delivery and deployment compared to established, nontortuous aneurysm models.     

Covered stent treatment for traumatic cervical carotid artery aneurysms--two case reports

A 37-year-old man and a 23-year-old man with cervical carotid artery aneurysms were treated with covered stents. The covered stent was constructed from a Palmaz stent covered with an expanded polytetrafluoroethylene graft. Angiography showed the aneurysms had disappeared immediately after the procedure. Patency of the covered stents was confirmed at 18 and 34 months after intervention by three-dimensional computed tomography angiography. The covered stent allows relatively noninvasive reconstruction of the parent artery that immediately brings about complete thrombosis of the aneurysm. However, delivering the covered stent to the carotid artery may be difficult.     

白塞病并发动脉瘤12例的外科治疗体会

目的总结白塞病并发动脉瘤的外科手术和腔内治疗经验。方法对1977年6月至2006年3月收治的12例白塞病患者并发21个动脉瘤进行回顾性分析。腹主动脉瘤3个,升主动脉瘤1个,髂动脉瘤4个,髂动脉吻合口假性动脉瘤1个,股总动脉瘤3个,股浅动脉瘤2个,腘动脉瘤2个,椎动脉瘤1个,锁骨下动脉瘤2个。颈动脉瘤1个和肠系膜上动脉瘤1个。21个动脉瘤中,行外科手术14个,包括动脉瘤切除、人工血管或自体大隐静脉移植术12个,动脉瘤切除、病变动脉结扎术2个;行支架型人工血管腔内修复术6个;1个升主动脉瘤因患者全身情况差,行保守治疗。结果围手术期死亡患者2例,其中1例行外科手术,1例行腔内修复术。术后吻合口假性动脉瘤1例（1个）,其他部位新动脉瘤形成7个,下肢血管移植物闭塞2例,但患肢无明显缺血坏死。6例患者随访3-293个月,随访中位时间28个月,1例死于肺癌。结论白塞病动脉瘤一旦发生,需积极处理。术前、术后积极免疫抑制治疗可降低外科手术和腔内修复术后并发症发生。因术后有吻合口和其他部位假性动脉瘤复发及血管移植物闭塞可能,需长期随访、及时处理。     

Midterm results of endovascular stented grafts for the treatment of isolated iliac artery aneurysms.

PURPOSE: Isolated aneurysms of the iliac arteries are uncommon lesions that require surgical repair to prevent rupture. METHODS: During a 4-year period, we used endovascular stented grafts (EGs) to treat 28 iliac artery aneurysms that were not associated with aortic aneurysms. Twenty-five patients, with a total of 24 common iliac (15 right, nine left) and four internal iliac (two right, two left) artery aneurysms, underwent endovascular grafting. There were 24 men and 1 woman, with a mean age of 74 years (range, 51 to 88 years). Combined common and internal iliac artery aneurysms were present in three patients. Nineteen patients who underwent treatment with EGs were administered epidural anesthesia (22 epidural, two local, one general). Before surgery, one patient had lower extremity embolization and ischemia from the aneurysm, three had abdominal or back pain, and the remaining were asymptomatic. The EGs were constructed of polytetrafluoroethylene grafts and balloon expandable stents. RESULTS: Four procedure-related complications (12%) occurred (distal extremity embolization, n = 1; wound complications, n = 2; colonic mucosal ischemia, n = 1). Only a minimal reduction in the aneurysmal diameter was seen in 90% of the iliac artery aneurysms treated. The remaining lesions showed no change in size, and no aneurysm had an increase in cross-sectional diameter on computed tomographic images enduring a follow-up period up to 4 years (mean, 24 months). One aneurysm ruptured after successful endovascular exclusion, and the patient underwent treatment with open repair. The 3-year primary patency rate of iliac EGs was 86%. CONCLUSION: EGs appear to show satisfactory safety and efficacy for the repair of isolated aneurysms of the iliac arteries.     

Stent-assisted coil embolization of an intraparenchymal renal artery aneurysm in a patient with neurofibromatosis

True renal artery aneurysms are rare. They are generally asymptomatic, however, a few may present with hypertension, rupture, or renal dysfunction secondary to distal embolization. Indications for intervention include aneurysm of ≥ 2.0 cm in diameter, renovascular hypertension, enlarging aneurysm, associated dissection /rupture, and aneurysms in women of child-bearing age/ pregnancy. Endovascular therapy through coil embolization or stent graft exclusion is the recommended management. Coil embolization of the first and second order branch aneurysms is often associated with distal parenchymal loss and current stent graft technology prohibits use of these endoprostheses in the branch renal arteries. In this report, we describe successful stent-assisted coil embolization of an intraparenchymal aneurysm while preserving the distal parenchyma in a young woman with Neurofibromatosis type 1.     

Endovascular treatment of very small intracranial aneurysms

BACKGROUND: The treatment of very small cerebral aneurysms with maximal diameter less than 3 mm remains a challenge for endovascular and surgical treatment. Endovascular treatment of these lesions may be difficult and associated with high risk of complications because of their small size. Our purpose was to assess the feasibility and results of endovascular treatment of these lesions. METHODS: We conducted a retrospective review of our experience and results of endovascular treatments for a series of 11 consecutive patients with 11 very small aneurysms. Of 11 aneurysms, 10 were acutely ruptured, and 1 was unruptured with a previous subarachnoid hemorrhage from another aneurysm. Aneurysms were located at the internal carotid artery (n = 4), the anterior communicating artery (n = 6), and the vertebral artery (n = 1). Seven patients were treated with coil embolization, and remodeling technique was used in 1 case. Three cases underwent intravascular stent implantation. Coil packing was done after in 2 of 3 aneurysms, and stent implantation alone was used in the remaining aneurysm. RESULTS: Coil embolization and stent deployment were carried out without difficulty in all cases. Coil packing was not available after stent implantation in 1 case for unsuccessful navigation of microcatheter into the aneurysm sac. Immediate angiography demonstrated complete occlusion in 10 cases and nearly complete occlusion in 1 case with stent implantation alone. No stent thrombosis and aneurysmal rupture was encountered during treatment. With the exception of 1 patient (Hunt and Hess grade 4) who died of pneumonia 4 weeks after treatment, no clinical evidence of neurologic deterioration and hemorrhagic complication was seen during the follow-up period in the remaining 10 patients. Follow-up angiography for 3 to 12 months (mean, 5.3 months) was available in 6 (60%) of 10 surviving patients, and no aneurysm recanalization was found. CONCLUSIONS: Endovascular treatment may be a feasible and effective therapeutic alternative for very small aneurysms. The long-term efficacy and durability of endovascular treatment for these lesions remains to be determined in a large series.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.     

Double-barrel technique for preservation of aortic arch branches during thoracic endovascular aortic repair

Thoracic endovascular aortic repair (TEVAR) may involve either planned or inadvertent coverage of aortic branch vessels when stent grafts are implanted into the aortic arch. Vital branch vessels may be preserved by surgical debranching techniques or by placement of additional stents to maintain vessel patency. We report our experience with a double-barrel stent technique used to maintain aortic arch branch vessel patency during TEVAR. Seven patients underwent TEVAR using the double-barrel technique, with placement of branch stents into the innominate (n = 3), left common carotid (n = 3), and left subclavian (n = 1) arteries alongside an aortic stent graft. Gore TAG endografts were used in all cases, and either self-expanding stents (n = 6) or balloon-expandable (n = 1) stents were utilized to maintain patency of the arch branch vessels. In three cases the double-barrel stent technique was used to restore patency of an inadvertently covered left common carotid artery. Four planned cases involved endograft deployment proximally into the ascending aorta with placement of an innominate artery stent (n = 3) and coverage of the left subclavian artery with placement of a subclavian artery stent (n = 1). TEVAR using a double-barrel stent was technically successful with maintenance of branch vessel patency and absence of type I endoleak in all seven cases. One case of zone 0 endograft placement with an innominate stent was complicated by a left hemispheric stroke that was attributed to a technical problem with the carotid-carotid bypass. On follow-up of 2-18 months, all double-barrel branch stents and aortic endografts remained patent without endoleak, migration, or loss of device integrity. The double-barrel stent technique maintains aortic branch patency and provides additional stent-graft fixation length during TEVAR to treat aneurysms involving the aortic arch. Moreover, the technique uses commercially available devices and permits complete aortic arch coverage (zone 0) without a sternotomy. Although initial outcomes are encouraging, long-term durability remains unknown.     

Explantation of aortic stent-grafts]

BACKGROUND: Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. METHODS AND RESULTS: Between 9/94 and 12/98, 150 patients (age = 69.6 +/- 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12 % of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914 +/- 220 d), rupture of the aorta (2, 452 d/802 d), recurrent thrombosis of the stent graft (3, 478 +/- 359 d), endoleak (3, 955 +/- 472 d), infection of the prosthesis (5, 798 +/- 495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. CONCLUSIONS: 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.     

Thoracic aortic aneurysms: treatment with endovascular self-expandable stent grafts

BACKGROUND: This study was performed to evaluate the safety and feasibility of endovascular stent graft placement in the treatment of descending thoracic aortic aneurysms. METHODS: Between November 1996 and February 1999, endovascular stent graft repair was used in 21 patients. There were 5 women and 16 men with a mean age of 67 years (range, 41 to 87 years). An atherosclerotic aneurysm with a diameter of more than 6 cm was the indication for intervention in 19 patients (90.5%). In 2 patients (9.5%), a localized aortic dissection with a diameter of more than 6 cm was treated. In 71.4% (15 of 21) of patients, multiple stents were necessary for aneurysm exclusion. To allow safe deployment of the stent graft, preliminary subclavian-carotid artery transposition was performed in 9 patients (42.9%). Vascular access was achieved through a small incision in the abdominal aorta (n = 6), an iliac artery (n = 8), or a femoral artery (n = 7). Talent and Prograft stent grafts were used. RESULTS: Successful deployment of the endovascular stent grafts was achieved in all patients. Two patients died postoperatively (mortality rate, 9.5%), 1 of aneurysmal rupture and the other of impaired perfusion of the celiac axis. Repeat stenting was done in 3 patients because of intraoperative leakage. CONCLUSIONS: Endovascular stent graft repair is a promising and less invasive alternative to exclude the aneurysm from blood flow. This technique allows treatment of patients who are unsuitable for conventional surgical procedures. An exact definition of inclusion criteria and technical development of stent grafts should contribute to further improvements in clinical results.     

Delayed Visceral Arterial Hemorrhage Following Whipple’s Procedure: Minimally Invasive Treatment with Covered Stents

Background Delayed visceral arterial hemorrhage caused by inflammatory vessel erosion represents a rare but life-threatening complication after pancreatic head resection. Therapeutic options include reoperation or endovascular minimally invasive techniques such as embolization or stent graft placement. The present article describes our experiences with implantation of newly developed low-profile stent grafts. Methods The findings of four patients with delayed visceral arterial hemorrhage are described. All patients were treated with placement of low-profile stent grafts. The patients’ medical records, radiological reports, and images were retrospectively reviewed. Technical success was defined as immediate cessation of hemorrhage. Clinical success was defined as hemodynamic stability. Results A total of seven stent grafts were implanted in four arteries. In detail, one stent graft was placed in the splenic artery of the first and second patients. In the third patient one stent graft was initially implanted in the common hepatic artery. The patient developed recurrent hemorrhages of the common hepatic artery, treated one time surgically and two times by deployment of a second and third stent graft. In the fourth patient two stent grafts were placed in the proper hepatic artery. Technical and clinical success was achieved at every procedure. Apart from recurrent hemorrhage of patient No. 3 there were no major complications. Conclusions Minimally invasive therapy using low-profile stent grafts is an effective and safe procedure for the treatment of delayed visceral arterial hemorrhage following Whipple’s procedure. The technique is a promising alternative to standard procedures such as surgical repair or embolization.     

Treatment of giant intracranial aneurysms with saphenous vein extracranial-to-intracranial bypass grafting: indications,operative technique,and results in 29 patients

OBJECTIVE: The treatment of giant intracranial aneurysms is a challenge because of the limitations and difficulty of direct surgical clipping and endovascular coiling. We describe the indications, surgical technique, and complications of saphenous vein extracranial-to-intracranial bypass grafting followed by acute parent vessel occlusion in the management of these difficult lesions. METHODS: Between January 1990 and December 1999, 29 patients with giant intracranial aneurysms underwent 30 saphenous vein bypass grafts followed by immediate parent vessel occlusion. There were 11 men and 18 women with a mean follow-up period of 62 months. Twenty-five patients harbored aneurysms involving the internal carotid artery, 2 had middle cerebral artery aneurysms, and 2 had aneurysms in the basilar artery. Serial cerebral or magnetic resonance angiograms were obtained to assess graft patency and aneurysm obliteration. RESULTS: All 30 aneurysms were excluded from the cerebral circulation, with 28 vein grafts remaining patent. Two patients had graft occlusions: one because of poor runoff and the other because of misplacement of a cranial pin during a bypass procedure on the contralateral side. Other surgical complications included one death from a large cerebral infarction, homonymous hemianopsia from thrombosis of an anterior choroidal artery after internal carotid artery occlusion, and temporary hemiparesis from a presumed perforator thrombosis adjacent to a basilar aneurysm. CONCLUSION: With appropriate attention to surgical technique, a saphenous vein extracranial-to-intracranial bypass followed by acute parent vessel occlusion is a safe and effective method of treating giant intracranial aneurysms. A high rate of graft patency and adequate cerebral blood flow can be achieved. Thrombosis of perforating arteries caused by altered blood flow hemodynamics after parent vessel occlusion may be a continuing source of complications.     

Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Hybrid endovascular repair with reconstruction of superior mesenteric and celiac arteries for thoracoabdominal and abdominal aortic aneurysms

A 79-year-old woman presented with sustained thoracolumbar back pain. Contrasted computed tomography (CT) showed a thoracoabdominal aortic aneurysm (TAAA: type I of Crawford classification) and an abdominal aortic aneurysm (AAA) that were not ruptured. Considering her age, the placement of an endovascular stent graft was performed for TAAA at the possible sacrifice of the celiac (CA) and superior mesenteric arteries (SMA). In order to prevent ischemic events, it was necessary that blood supply to the CA and SMA was maintained by placing a graft to each artery from the Y-shaped graft for replacement of AAA. Actually, only CA was sacrificed and coil embolization of CA was needed because of type 2 endoleak. The patient was discharged 17 days after surgery. A hybrid technique, endovascular repair with reconstruction of abdominal branches for TAAA and AAA, can be an alternative procedure for such high-risk operation with multiple aortic aneurysms including TAAA.