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

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

Use of Zenith TX2 endografts in endovascular abdominal aortic aneurysm repair for large-diameter aortic necks

The purpose of this case report is to describe the use of thoracic endografts in endovascular repair of abdominal aortic aneurysms (AAAs) with large-diameter aortic necks. We present four patients who underwent elective repair of AAAs. Preoperative imaging demonstrated all to have large aortic necks (35-37 mm) precluding treatment with standard abdominal aortic devices. All underwent endovascular treatment, which included the use of a Zenith TX2 endograft (Cook Medical Incorporated, Bloomington, IN, USA) as a proximal aortic cuff. There was 100% technical success. One patient developed gastrointestinal bleeding and a myocardial infarction. All were subsequently discharged home. On follow-up, there was one aneurysm-related death at three months. The remaining three patients are alive at a mean of 25.7 months after their operation. In conclusion, large proximal aortic necks preclude endovascular treatment with standard abdominal endograft components. The use of a thoracic endograft as a proximal aortic cuff is a feasible technique for patients unable to tolerate open aortic reconstruction.     

腔内人造血管移植术治疗腹主动脉瘤

目的 评价腔内人造血管移植术治疗腹主动脉瘤早期临床疗效。方法 总结对14例腹主动脉瘤患者采用经腹股沟切口腹主动脉瘤腔内人造管移植术的经验。结果 12例选用分叉型腔内人造血管,2例选用直型腔内人造人管,术后即刻DSA造影显示动脉瘤消失,近远端人造血管与宿主动脉结合处均未见渗漏,11例患者术后生命体征平稳,1例术后24h出现小面积急性心肌梗塞,经溶栓和抗凝治疗后缓解,术后死亡2例,技术成功率85.7%。12例患者术后1周随访螺旋CT,其中有4例术后3个月、1例术后12个月再次做螺旋CT,显示人造血管无移位,2例有渗漏,但动脉瘤腔无增大。结论 腔内人造血管移植术是一种创伤小、恢复快的治疗腹主动脉瘤新方法,但远期疗效有待随访。     

Conformational changes associated with proximal seal zone failure in abdominal aortic endografts

OBJECTIVE: Endovascular aneurysm repair (EVAR) has become a popular treatment for abdominal aortic aneurysm (AAA). This study examines conformational changes in the infrarenal aortas of patients in whom proximal seal zone failures (PSF) developed after EVAR. METHODS: All 189 patients with aortic endograft underwent routine post-EVAR computed tomographic scan surveillance. Patients identified with proximal type I endoleaks, type III endoleaks, or proximal component separation without demonstrable endoleak underwent three-dimensional reconstruction of the computed tomographic scans from which measurements of the migration, length, volume, and angulation of the infrarenal aorta were made. RESULTS: Five patients (3%) had PSF develop, four of whom had aortic extender cuffs. Although changes in the AAA volume and aortic neck angle were slight or variable, the mean AAA length increased 34 mm and the mean aortic body angulation increased 17 degrees (P =.03 and.01, respectively). Lengthening and migration caused proximal component separation in four patients, with concomitant migration in two patients. Two patients underwent endovascular repair, two patients needed explantation of the endograft, and one patient awaits endovascular repair. Proximal component separation and type III endoleak recurred in one patient and were repaired with a custom-fitted graft. CONCLUSION: PSF of aortic endografts is associated with proximal angulation and lengthening of the infrarenal aorta. These findings reinforce the importance of proper initial deployment to minimize the need for aortic extender cuffs, which pose a risk of late endoleak development.     

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

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

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.     

Treatment of Type III Endoleak with an Aortouniiliac Stent Graft

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

Management of a large intraoperative type IIIb endoleak in a bifurcated endograft-a case report

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.     

Influence of endograft oversizing on device migration, endoleak, aneurysm shrinkage, and aortic neck dilation: results from the Zenith Multicenter Trial

BACKGROUND: Generous endograft oversizing has been associated with propensity for aortic neck dilation and subsequent device migration in endografts without suprarenal fixation. Effects of variable oversizing of endografts with suprarenal fixation have been poorly studied. METHODS: Three hundred fifty-one patients underwent endovascular AAA repair (EVAR) in a prospective multicenter trial using the Zenith AAA Endovascular Graft, a fully supported bifurcated 3-piece endograft with barb-enhanced suprarenal stent fixation. Blinded core-laboratory measurement of variables was prospectively recorded at predischarge and at 1, 6, 12, and 24 months after the procedure. Potential influence of endograft oversizing on subsequent aortic neck dilation (minor axis), aneurysm shrinkage (major axis), device migration, endoleak, rupture, open conversion, and death were retrospectively studied. Data are given as mean +/- SEM. RESULTS: Risk of endograft migration (>5mm) at 12 months was 2.3% (6/261). However, patients with endograft oversizing of >30% had a 14% (4/29) migration risk compared with those oversized < or =30% (0.9%, 2/232), P <.002. There was zero device migration by the SVS definition (>10 mm or clinical event). Device oversizing >30% was associated with decreased AAA sac shrinkage (48% vs 77%) and with increased sac enlargement (9.5% vs 0.6%) at 24 months when compared with oversizing of < or =30%, respectively (P =.001). Incidence rate of any endoleak at 12 and 24 months was 8.2% (21/256) and 7.1% (12/169), respectively. Oversizing of endografts by >30% was associated with an increased type II endoleak rate (11 vs 4.7%) that failed to reach statistical significance (P =.27). Aortic neck diameters increased significantly by 6 months (P <.001) but then stabilized through 24 months; the absolute changes at 1 (n = 298), 6 (n = 278), 12 (n = 264), and 24 months (n = 171) were 0.66 +/- 0.10 mm (3.0%), 1.32 +/- 0.11 mm (5.6%), 1.38 +/- 0.12 mm (5.9%), and 1.44 +/- 0.16 mm (6.1%), respectively. Linear regression analysis demonstrated no correlation between endograft oversizing and aortic neck dilation at 12 (P =.86) or 24 months (P =.64). CONCLUSIONS: Device migration and endoleaks were very infrequent after treatment with the Zenith AAA Endovascular Graft. However, endograft oversizing of >30% was associated with an approximately 14-fold increase in device migration (>5 mm) at 12 months and with a approximately 16-fold increased risk of AAA expansion at 24 months. Although further follow-up will be essential to assess whether these early associations continue, avoidance of excessive endograft oversizing is recommended.     

高外科风险腹主动脉瘤腔内修复术的近远期结果

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

Endovascular stent grafting in the presence of aortic neck filling defects: early clinical experience

OBJECTIVE: Although endovascular grafts have been increasingly applied to the treatment of abdominal aortic aneurysms, their use in clinical trials is limited by well-defined anatomical exclusion criteria. One such criterion is the presence of thrombus within the infrarenal neck of an aneurysm, which is thought to (1) prevent the creation of a permanent watertight seal between the graft and the vessel wall, resulting in an endoleak; (2) contribute to stent migration; and (3) increase the risk of thromboembolism. This article summarizes our experience with endovascular abdominal aortic aneurysm exclusion in 19 patients with large aortic aneurysms, significant medical comorbidities, and apparent thrombus extending into the pararenal aortic neck. METHODS: Of 268 patients undergoing abdominal aortic aneurysm repair, 19 (7%; 17 men; mean age, 71 years) demonstrated computed tomographic and angiographic evidence of intramural filling defects at the level of the aortic neck. In no instance did these filling defects extend above the renal arteries. Endovascular grafting was performed through use of a balloon-expandable Palmaz stent and an expanded polytetrafluoroethylene graft, delivered and deployed under fluoroscopic guidance. Follow-up at 3, 6, and 12 months and annually thereafter was performed with computed tomography and duplex ultrasound scan. RESULTS: Spiral computed tomography and aortography revealed an irregular flow-limiting defect, occupying up to 75% of the aortic circumference, in every case. The mean aneurysm size, aortic neck diameter, and neck length before the procedure were 6.1, 2.43, and 1.4 cm, respectively; the mean aortic neck diameter after the procedure was 2.61 cm. No primary endoleaks were observed after graft insertion, and no delayed endoleaks have been detected during follow-up, which ranged from 7 to 48 months (mean, 23 months). In one patient, an asymptomatic renal artery embolus was detected on immediate follow-up computed tomography, and in another patient, an asymptomatic posterior tibial embolus occurred. CONCLUSION: No primary endoleaks, endograft migration, or significant distal embolization were observed after endografting in patients with aortic neck thrombus. The deployment of the fenestrated portion of the stent, above the thrombus and across the renal arteries, allows for effective renal perfusion, graft fixation, and exclusion of potential mural thrombus from the circulation. The presence of aortic neck thrombus may not necessarily be a contraindication to endovascular repair in select patients.     

Lessons learned from midterm follow-up of endovascular repair for traumatic rupture of the aortic isthmus

OBJECTIVE: The aim of this study was to evaluate the short- and midterm results following endovascular repair of a traumatic rupture of the aortic isthmus. METHODS: Between January 2001 and January 2007, 27 patients underwent endovascular repair for acute traumatic rupture of the aortic isthmus (8 women, 19 men, mean age 40.2 +/- 16.7 years [19-78]). All patients underwent a computed tomography scan resulting in the preoperative diagnosis of aortic disruptions. Twenty-one patients were treated within the first 5 days following diagnosis. Follow-up computed tomography scans were performed at 1 week, at 3 and 6 months, and annually thereafter. The median follow-up was 40 months. RESULTS: All endografts were successfully deployed (Excluder-TAG [16], Talent [10], Zenith [2]). Three patients required common iliac artery access. The morbidity rate was 14.8%: two cases of inadvertent coverage of supra-aortic trunks occurred peroperatively, a proximal type I endoleak was successfully treated by a proximal implantation of a second endograft, and one collapse of an endograft was successfully treated by open repair and explantation. No patient suffered transient or permanent paraplegia, cerebral complication, endograft migration, or secondary endoleak. The overall mortality rate was 3.7%. CONCLUSIONS: Short and midterm results following endovascular treatment for traumatic rupture of the aortic isthmus favor the proposition of endovascular repair as the first-line treatment in hemodynamically unstable patients. In hemodynamically stable patients, the preoperative morphological evaluations aim to assess aortic anatomy and thereby detect possible technical limitations (aortic diameter <20 mm, severe aortic isthmus angulation, short proximal aortic neck <20 mm, conical aorta). In the presence of any one of these technical restrictions, open surgical treatment should be discussed to avoid major per- or postoperative complications related to endovascular repair. Further studies and long-term survival studies are mandatory to determine the efficacy and durability of this technique.     

Primary endovascular repair of juxtarenal aneurysms with fenestrated endovascular grafting.

PURPOSE: To evaluate outcomes of an endovascular graft incorporating the visceral aortic segment with graft material in the setting of juxtarenal aneurysms. MATERIALS AND METHODS: A prospective analysis of patients undergoing implantation of an endovascular device with graft material proximal to the renal arteries was conducted. All patients were deemed unacceptable candidates for open surgical repair and had proximal neck length=<10 mm, or =<15 mm with a compromising morphology (funnel or thrombus). Fenestrations were customized to accommodate aortic branch anatomy based upon CT and intravascular ultrasound data. Selective visceral ostia were treated with balloon expandable stents following endograft deployment. All patients were evaluated with CT, duplex ultrasound, and abdominal radiograph at discharge, 1, 6, 12 and 24 months. RESULTS: A total of 32 patients were enrolled in the trial. Short proximal necks (3-10 mm) were present in 22, and 10 had necks 10-15 mm in length with concomitant angulation or thrombus compromising neck quality. Endograft design included bifurcated (30) and aortic tube (2) systems. A total of 83 visceral vessels were incorporated (mean of 2.6 per patient). These most commonly included both renal arteries and the SMA. All prostheses were implanted successfully without the acute loss of any visceral arteries. The mean follow-up was 9.2 months (range 0-24 months). One patient died within 30 days of device implantation and hypogastric bypass following the development of aspiration pneumonia. Three early (<30 days) and three late secondary interventions were performed. The 30-day endoleak rate was 6.5%. The aneurysm sac decreased greater than 5 mm in 58% of patients at 6 months and in 75% of patients at 12 months. One patient, with a persistent type II endoleak had 5 mm of sac growth over 12 months. Six patients had transient or permanent elevation of serum creatinine (>30% from baseline), with one requiring hemodialysis. Of the 83 vessels incorporated, three late stenoses (all successfully treated with an endovascular approach) and two renal occlusions were detected during follow-up. Three patients died of unrelated causes during the follow-up period. CONCLUSIONS: The placement of endovascular prostheses with graft material incorporating the visceral arteries is technically feasible. The incidence of endoleaks is exceptionally low. It remains critical to follow the status of stented visceral vessels, and establish the long-term efficacy of this type of repair.     

Endovascular Treatment of Failed Prior Abdominal Aortic Aneurysm Repair

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

Endovascular stent-graft repair of failed endovascular abdominal aortic aneurysm repair

Despite high initial technical success, the long-term durability of endovascular abdominal aortic aneurysm repair (EVAR) continues to be a concern. Following EVAR, patients can experience endoleaks, device migration, device fractures, or aneurysm growth that may require intervention. The purpose of this study was to review all patients treated with secondary endovascular devices at our institution for failed EVAR procedures. Over an 8-year period, 988 patients underwent EVAR, of whom 42 (4.3%) required secondary interventions involving placement of additional endovascular devices. Data regarding patient characteristics, aneurysm size, initial device type, time until failure, failure etiology, secondary interventions, and outcomes were reviewed. The mean time from initial operation until second operation was 34.1 months. Failures included type I endoleaks in 38 patients (90.5%), type III endoleaks in two patients (4.8%), and enlarging aneurysms without definite endoleaks in two patients (4.8%). The overall technical success rate for secondary repair was 92.9% (39/42). Perioperative complications occurred in nine patients (21.4%), including wound complications (n = 6), cerebrovascular accident (CVA) (n = 1), foot drop (n = 1), and death (n = 1). Mean follow-up following secondary repair was 16.4 months (range 1-50). Eighty-six percent of patients treated with aortouni-iliac devices had successful repairs compared to 45% of patients treated with proximal cuffs. Ten patients (23.8%) had persistent or recurrent type I or type III endoleaks following revision. Of these, four had tertiary interventions, including two patients who had additional devices placed. Failures following EVAR occur in a small but significant number of patients. When anatomically possible, endovascular revision offers a safe means of treating these failures. Aortouni-iliac devices appear to offer a more durable repair than the proximal cuff for treatment of proximal type I endoleaks. Midterm results indicate that these patients may require additional procedures but have a low rate of aneurysm-related mortality. Longer-term follow-up is necessary to determine the durability of these endovascular revisions.     

Minimally invasive surgical solution in the treatment of an unusual distal type I endoleak after endovascular abdominal aortic aneurysm repair

Most distal type I endoleaks can be treated by endovascular techniques such as coil embolization of the hypogastric artery and additional stent or extension stent grafts. We report a case of a difficult type I endoleak located in the distal end of a monoiliac conical stent graft used to treat an abdominal aortic aneurysm extensively involving both common iliac arteries. Cranial migration of the endograft and incarceration in the contralateral iliac aneurysm were observed on the computed tomographic scan. The patient was submitted to a procedure that involves endovascular and limited open surgery techniques. A 26 mm balloon catheter was used to secure the proximal implantation site, and through a Gibson incision, the iliac arteries were controlled. An interpositional 8 mm regular Dacron graft was then sutured end to end between the endograft and the external iliac artery.     

EVAR reintervention management strategies in contemporary practice

It is known that following an endovascular aneurysm repair (EVAR) procedure, patients may experience endoleaks, device migration, stent fractures, graft deterioration, or aneurysm growth that might require a reintervention. In this review management strategies of reinterventions after EVAR in contemporary practice will be discussed. The current endovascular treatment options of Type I endoleak involve securing of the attachment site with percutaneous transluminal balloon angioplasty, stent-graft extension, or placement of a stent at the proximal attachment site. Moreover, the use of endostaples to secure the position of the proximal cuff to the primary endograft have been developed. Type II endoleaks can be managed conservatively if the aneurysm is shrinking or remains stable. Otherwise, reinterventions include transarterial embolization, translumbar embolization, transcaval embolization, direct thrombin injection, and endoscopic or open ligation of the lumbar and mesenteric arteries. There is little debate regarding the treatment of type III endoleaks, including deployement of additional stent graft components to bridge the defect. Endovascular treatment of endotension includes endovascular conversion stent or relining of the stent graft. Alternative options are puncture of the aneurysm sac and removal of the aneurysm sac content. In case of migration large balloon-expandable stents can be used to improve the seal between the components, or devices that deploy staples to secure endovascular grafts to the aortic wall to secure endovascular components together. In conclusion, the first treatment options for reinterventions after EVAR are catheter based nowadays.     

Endovascular abdominal aortic aneurysm repair with percutaneous transfemoral prostheses deployment under local anaesthesia. Initial experience with a new, simple-to-use tubular and bifurcated device in the first 27 cases.

BACKGROUND: Modification of endografts are required to simplify and improve the safety of the endovascular management of abdominal aortic aneurysms (AAA). OBJECTIVES: The aim of this study is to evaluate the efficacy of a new custom-made, tubular and bifurcated device. MATERIALS AND METHODS: The graft consisted of a continuous, self-expanding, stainless steel, Z-stent structure, covered with a thin wall PTFE tube. Bifurcated grafts were constructed in vivo from three PTFE tubes with a continuous Z-stent structure. Twenty-seven high risk patients with a mean age of 74 (62-86) years and AAA, mean diameter 5.9 cm, were treated in the last 26 months. Tube grafts were deployed in 13 aortic and one iliac cases, bifurcated grafts in nine cases and aorto-uni-iliac grafts with femorofemoral bypass in four cases. Grafts were deployed percutaneously under local anaesthesia. Patients were followed with contrast CT periodically. RESULTS: All grafts were deployed. There were no open conversions or other major complications. There were nine proximal and one distal postoperative endoleak. Four sealed spontaneously, three were treated successfully with endovascular techniques and three are under surveillance. In the 7 (2-23) months follow-up, one patient died due to heart failure 3 months post-procedure. CONCLUSIONS: Local anaesthesia and percutaneous graft introduction simplify and improve the efficacy of the procedure. Continuous aortic graft support provides stability and reduces the risk of migration. PTFE is a flexible, low-profile material for use in endovascular stent-grafts. The bifurcation concept used offers a simple technique for bifurcated grafts.     

Multicenter pivotal trial results of the Lifepath System for endovascular aortic aneurysm repair

PURPOSE: This study was undertaken to assess the results of endovascular aortic aneurysm repair with the Lifepath abdominal aortic aneurysm (AAA) graft system. METHOD: In a prospective clinical trial, 23 centers used the Lifepath System balloon-expandable, modular bifurcated stent graft for elective endovascular aortic aneurysm repair. Stent grafts were sized according to computed tomographic angiography-based diameter measurements. All repairs were performed in the operating room through bilateral surgically exposed femoral arteries. Results were assessed with contrast agent-enhanced computed tomography scans and plain abdominal x-ray films at 1, 6, 12, 24, 36, and 48 months postoperatively. RESULTS: Over 52 months (mean follow-up, 11 months), 227 patients (206 men, 21 women) were enrolled. Technical implant success rate was 98.7%. There were five (2.2%) conversions to open surgery: two emergently because of aortic perforation; to treat refractory endoleak, immediate in one and at 12 months in one; and to replace a device with wireform fractures that had migrated at 12 months, resulting in a proximal endoleak. The perioperative mortality rate was 1.3%. There was one operative death during a secondary procedure to repair perforation of the aorta. There were two perioperative deaths, from postoperative myocardial infarction (n = 1) and pulmonary embolus (n = 1). There were 12 late deaths, from coronary artery disease (n = 4), cancer (n = 2), respiratory failure (n = 2), sepsis (n = 1), or unknown cause (n = 3). Median length of stay was 2 days (mean, 4 days). There have been no AAA ruptures after successful implantation of the device, no graft limb thromboses, and no limb dislocations. At the time of operation endoleak was noted in 43 (19%) patients, but by 6 months this was reduced to 8 (5.9%) patients (type I, n = 1; type II, n = 7). There were no type III or type IV endoleaks. Secondary interventions to treat endoleaks included open conversion (n = 2), placement of extension cuffs (n = 4), repeated balloon dilation (n = 3), and coil embolization (n = 6). The two remaining secondary interventions were emergent treatment of postoperative bleeding from a groin incision, and a colon resection because of postoperative colonic ischemia, for a 12-month secondary intervention rate of 7.5%. Wireform fractures were noted in the first generation Lifepath device in 37 of 79 (47%) patients. Graft migration (>10 mm) was observed in five patients (2.2%), each of whom also had two or more fractures of the proximal anchoring wireforms. Migration resulted in a proximal attachment endoleak in one patient. In response to wireform fractures, the device was modified after the initial 79 patients were enrolled. Wireform fracture has been observed in six patients since this modification (4%), and in only one patient did this involve fracture of a proximal anchoring wireform; none of these patients has had endoleak or graft migration. By 12 months, mean aneurysm diameter was noted to decrease by 9 mm (P <.0001), and mean aneurysm volume by 42 mL (P <.0001) from the preoperative visit. CONCLUSION: The Lifepath System demonstrates a low endoleak and secondary intervention rate and high sac regression rate, compared with other devices. The unique balloon-expandable design offers the advantages of precise placement and high radial force. The device appears to be highly resistant to limb thrombosis and modular component separation. Patients were protected from AAA rupture after successful device implantation, and demonstrated significant reduction in AAA diameter and volume. Fractures of the wireforms of the main body of the device have been observed. Careful long-term follow-up is necessary.     

Midterm outcomes of AFX2 endografts used in combination with aortic cuffs

ObjectiveType III endoleaks after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms (AAAs) with the Endologix unibody endograft remain a major concern, despite fabric, system, and instructional updates. The purpose of this study was to examine real-world outcomes of repairing AAAs using the current version of the AFX2 main body in combination with an aortic cuff, specifically focusing on type III endoleaks and morphological changes of the endograft.MethodsWe recruited facilities in Japan that used AFX2 combined with an aortic cuff for at least five cases between April 2017 and March 2018. A total of 175 cases in 24 facilities were analyzed. Patients’ background information, including anatomic factors, operative findings, device component variations, and midterm outcomes at 3 years after the EVAR were collected. The data on computed tomography scans from cases registered as types I and III endoleaks and migration from each institute were sent to our department for verification.ResultsThe mean patient age was 74.6 ± 8.1 years, and 48 cases (27%) were saccular aneurysms. The mean fusiform and saccular AAA diameters were 50.5 ± 5.8 mm and 43.5 ± 8.9 mm, respectively. No in-hospital deaths occurred. Data at 3 years, including computed tomography images, of 128 cases were analyzed. Overall survival, freedom from aneurysm-related mortality, and freedom from reintervention rates at 3 years were 85.8%, 99.3%, and 87.3%, respectively. There were three, one, and three cases of types I, IIIa, and IIIb endoleaks without sac dilatations, respectively. Among five migration cases, one case of aortic cuff migration presented as a type Ia endoleak, and four cases demonstrated sideways displacement, one of which presented as a type IIIa endoleak. The sac regression and enlargement rates at 3 years were 41.4% and 20.5% in the fusiform group and 44.2% and 16.7% in the saccular group, respectively. The proximal neck diameter slightly increased from 20.8 ± 2.7 mm before the EVAR to 22.2 ± 4.6 mm after the repair.ConclusionsMidterm outcomes of the AFX2 used in combination with an aortic cuff were acceptable, considering the rates of types I and III endoleaks. However, there were cases of sideways displacement that could cause future type IIIa endoleaks. When the AFX2 is used in combination with an aortic cuff, close surveillance for endograft deformations and subsequent adverse events, including type III endoleaks, is needed.