Combining open and endovascular surgery for the treatment of infrarenal abdominal aortic aneurysm: a case report using a hybrid vascular graft

Migration and endoleaks after endovascular exclusion of an infrarenal abdominal aortic aneurysm may lead to long-term failure of the stent graft. We report a successful case of a novel technique that combined open and endovascular surgery to address the issues of migration and endoleak in the repair of an abdominal aortic aneurysm. The hybrid graft, consisting of a proximal, conventional Dacron graft and two distal endoprosthesis limbs, was designed to reduce aortic cross-clamp time in aortic procedures. This is the first reported clinical experience with this new hybrid vascular graft for the treatment of an abdominal aortic aneurysm.     

Simultaneous endovascular exclusion of thoracic aortic aneurysm with open abdominal aortic aneurysm repair.

BACKGROUND: The treatment of aneurysms at multiple sites within the aorta is problematic. METHODS: Between March 2002 and June 2003 in the Department of General, Vascular and Transplant Surgery, Medical University of Warsaw six patients with coexisting abdominal and descending thoracic aortic aneurysms underwent simultaneous open abdominal aortic aneurysm (AAA) repair and endoluminal thoracic aortic aneurysm (TAA) repair. The indication for a combined procedure was a diagnosed descending TAA and AAA with no significant risk factors for open aortic surgery or technical contraindications for endovascular treatment of TAA. RESULTS: One patient died in the peri-operative period while the other five patients all recovered well after surgery and were discharged with both aneurysms excluded. CONCLUSION: Endovascular treatment of TAA combined with a simultaneous open AAA repair is an efficient and relatively safe treatment modality in patients with TAA and AAA disqualified from endovascular repair. The fact that thoracotomy is not a necessity significantly lowers the complication rate in these patients.     

Staged endourologic and endovascular repair of an infrarenal inflammatory abdominal aortic aneurysm presenting with forniceal rupture

We present the case of a 79-year-old female who presented with severe left flank pain and a pulsatile abdominal mass. She was diagnosed with left peripelvic urinary extravasation and forniceal rupture secondary to an intact infrarenal inflammatory abdominal aortic aneurysm with extensive periaortic fibrosis. Successful operative repair was performed with staged ureteral and endovascular stenting with subsequent resolution of periaortic inflammation and ureteral obstruction, and shrinkage of the aneurysm sac. Inflammatory abdominal aortic aneurysms (IAAAs) represent 5% to 10% of all abdominal aortic aneurysms. The distinguishing features of inflammatory aneurysms include thickening of aneurysm wall, retroperitoneal fibrosis, and adhesions to adjacent retroperitoneal structures. The most commonly involved adjacent structures are the duodenum, left renal vein, and ureter. Adhesions to the urinary system can cause hydronephrosis or hydroureter and result in obstructive uropathy. An unusual case of IAAA presenting with forniceal rupture is presented, with successful endovascular and endourologic repair.     

Combined thoracic aortic dissection and abdominal aortic fusiform aneurysm.

Certain clinical and autopsy findings are described in 13 patients who had both aortic dissection (AD) and fusiform abdominal aortic aneurysm (AAA). All 13 patients had severe and extensive aortic atherosclerosis. The AAA was diagnosed clinically in 9 patients, and 5 had the AAA resected. The AD was diagnosed clinically in 5 patients, and 2 underwent attempted operative repair. Two patients who had the AAA resected because of suspected rupture were found later to have ruptured a more proximal AD. Thus, AD occurs occasionally in patients who have AAA. In older persons with suspected rupture of an AAA, a more proximal rupture of an AD should be ruled out. When both AAA and AD are present in the same patient, the AD is more likely the cause of cardiovascular collapse than is rupture of the AAA.     

Midterm results of endovascular infrarenal abdominal aortic aneurysm repair in high-risk patients

Short-term and midterm clinical outcomes after endovascular repair of abdominal aortic aneurysms (AAAs) have been well documented. Evaluation of longer term outcomes is now possible. Here we describe our initial 100 high-risk patients treated with endovascular aneurysm repair (EVAR), all with a minimum of 5 years of follow-up. A retrospective review of prospectively recorded data in a departmental database was undertaken for the first 100 consecutive EVAR patients with a minimum of 5 years (range, 60-105 months) of follow-up performed between December 1997 and June 2001. Information was obtained from surgical follow-up visits and family doctors' offices. Endovascular repair of AAA in high-risk patients can be achieved with acceptably low postoperative mortality and morbidity. Longer term results in this high-risk cohort suggest that EVAR is effective in preventing aneurysm-related deaths at 5 years and beyond. All late mortalities were due to patients' comorbid diseases.     

Transluminally placed endovascular graft indications: thoracic aortic aneurysm and abdominal aortic aneurysm]

In 1991, Parodi et al described the first clinical use of a new technique for abdominal aortic aneurysm (AAA) repair using transluminally placed endovascular grafts (TPEG). Subsequently, in 1994 Dake et al reported the use of this new technique for the treatment of patients with aneurysms of the descending thoracic aorta. Since then, TPEG for the treatment of aneurysms have been clinically investigated in a number of centers. Initially, TPEG appeared to be an attractive alternative to standard surgical open repair, since they are less invasive and thereby reduce the operative risk in high-risk patients. The effectiveness and safety of TPEG have been reported by many investigators, and indications for this technique are increasing. However, the placement of TPEG within the artery by insertion via a remote site and fixation by attachment systems, such as various types of expandable stents, is completely different from conventional graft replacement. The long-term durability of TPEG is not yet known, and therefore we must remain cautious in patient selection. The cause and morphology of each aortic aneurysm determine whether TPEG are indicated. At present, TPEG is used to treat patients with aneurysms below the distal arch, and infrarenal abdominal aorta. However, indications in patients with aortic dissections are not clearly defined, because though the procedure is technically feasible, the effectiveness is not yet known and further investigation is required.     

Extensive spinal cord ischemia following endovascular repair of an infrarenal abdominal aortic aneurysm: a rare complication

Postoperative paraplegia secondary to spinal cord ischemia (SCI) is an extremely rare and devastating complication of endovascular repair in abdominal aortic aneurysm (AAA) surgery. The reported incidence is only 0.21 % worldwide. This case of postoperative paraplegia occurred in a 60-year-old man immediately following endovascular repair of an infrarenal AAA. Postoperative magnetic resonance imaging showed multiple foci of SCI involvement from C5 to L1. However, neither cerebral spinal fluid drainage nor steroid therapy was effective; he was eventually admitted with no improvement in his neurological status. The mechanism remains multifactorial until now and needs more attention in perioperative management. We report the first case involved in the most significantly extensive SCI after endovascular repair of an infrarenal AAA.     

Spinal cord ischemia after endovascular treatment of infrarenal aortic aneurysm. Case report and literature review

Spinal cord ischemia is a rare but catastrophic complication after endovascular treatment of infrarenal aortic aneurysm: only 14 cases are reported in the literature. A patient with a 6 cm infrarenal aortic aneurysm extending to both common iliac arteries and high surgical risk was submitted to endovascular repair with exclusion of both hypogastric arteries and surgical revascularization of the right hypogastric artery. The patient presented paraplegia, apallesthesia and superficial hyposensitivity immediately after the procedure. A spinal cord drainage was positioned with little improvement of superficial sensitivity. We undertook a systematic review of the literature on this topic.     

腔内修复术治疗肾下型腹主动脉瘤的内漏防治：附43例报告

目的：总结应用腔内修复术治疗腹主动脉瘤的经验,探讨内漏的防治策略。方法：回顾性分析齐鲁医院及莱钢医院2007年1月—2012年12月接受腔内治疗的43例肾下型腹主动脉瘤患者临床资料,分析内漏的发生原因、预防和处理。结果：术后发生原发性内漏11例,其中I型8例,III型2例;植入分叉型支架发生9例,植入直管型支架发生2例。1例II型因漏血量小未处理;经一期经过球囊扩张、植入支架型血管或裸支架等处理后,除2例I型内漏仍有残留,其余I,III型内漏均消失。39例患者获随访4~50个月,发现迟发性Ib型、II型内漏各2例,继续随访1~2年,未见瘤体明显增大。3例残留原发性内漏自愈,术后半年复发Ia型内漏1例,导致动脉瘤复发破裂而再次接受腔内治疗。结论：内漏的发生与动脉瘤的解剖学条件、移植物缺陷和操作技术有关;防治内漏需要把握好手术适应证、合理选择支架,并有成熟的操作经验。

     

Complex thoracic aortic aneurysm: a combined open and endovascular approach

The authors wish to describe a combined open and endovascular approach to repair a complex thoracic aortic aneurysm. A 72-year-old man with chronic obstructive pulmonary disease, aortic valvular insufficiency and diffuse thoracic aortic aneurysm underwent aortic valve and ascending aorta replacement by a Bentall-procedure and replacement of arch aneurysm using the elephant trunk technique, performed in a first procedure. During the second procedure, endovascular stenting of the descending thoracic aorta was done. Only a few similar case reports have been presented. Endovascular repair after an elephant trunk procedure for complex thoracic aortic aneurysms is an elegant approach to deal with such mega aortas. Further research is necessary to compare open and endovascular repair and to determine long-term follow-up with regard to endoleaks and mortality.     

胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理

目的探讨胸主动脉瘤及夹层腔内修复术中左锁骨下动脉的处理方法。方法2000年6月至2005年12月,54例胸主动脉瘤及夹层患者的近端锚定区小于15mm,需处理左锁骨下动脉。腔内修复术在X线透视下进行,支架型血管通过输送系统携带到病变部位,根据病变特点对左锁骨下动脉采取一期完全覆盖（40例）、部分覆盖（3例）、完全覆盖后腔内重建（1例）、完全覆盖前外科重建（10例）等方法处理,观察治疗后效果。结果所有患者术中均应用数字减影血管造影进行脑循环评估。40例一期完全覆盖左锁骨下动脉;10例腔内覆盖前行右锁骨下动脉．左锁骨下动脉或左颈总动脉-左锁骨下动脉旁路术;3例覆盖左锁骨下动脉开口1／2～4／5后再通过球囊扩张、支架植入重建左锁骨下动脉;1例完全覆盖左锁骨下动脉后应用腔内人造血管开窗技术重建左锁骨下动脉。所有辅助技术均取得成功,未出现严重脑及上肢并发症。腔内修复术后近端Ⅰ型内漏发生率17％（9／54）。一期完全覆盖左锁骨下动脉患者术后早期窃血综合征发生率20％（8／40）,左肱动脉平均收缩压（63±24）mmHg（1mmHg=0．133kPa）。结论通过辅助腔内或腔外技术,可对短颈胸主动脉瘤及夹层病变进行有效的腔内修复术;对左锁骨下动脉的处理方式根据椎基底动脉、Willis环及双侧颈动脉状况来确定。     

Evaluation of the effect of endovascular options on infrarenal abdominal aortic aneurysm repair

Endovascular devices designed to exclude flow to infrarenal abdominal aortic aneurysms (AAA) were approved by the Food and Drug Administration in the United States in 1999. This action allowed widespread use of this technology for AAA exclusion. The purpose of this report is to examine trends for use of these modalities, rates of rupture of AAA, and to compare results of open AAA repair with endovascular repair. Results were collected for all hospitals, except for Veterans Administration hospitals, by a state-wide repository. Data for the years 1996 through 1998 and 2001 through 2002 were evaluated, and data from 1999 through 2000 were excluded because no separate codes were available to distinguish between open and endovascular repair. The information gathered is based on the All Patient Refined Diagnostic Related Group (APRDRG; 3M, St. Paul, MN). An average of 718 open, elective AAA was performed between 1996 and 1998. This dropped to 503 open repairs from 2001 to 2002 (P < 0.005). During that same interval, 308 endovascular elective AAA repairs were performed, therefore the total rate of elective repair increased by 100. The average rate of ruptured AAA repairs from 1996 to 1998 was 121 per year, and this dropped to 89 from 2001 to 2002 (P < 0.005). The mortality of open AAA repair during the 1996 to 1998 and 2001 to 2002 intervals was unchanged (4.7%). Mortality from endovascular AAA repair between 2001 and 2002 was 1.9 per cent (P = 0.003). Major morbidity was 14.5 per cent for open, elective AAA repair and 6.3 per cent for endovascular elective repair from 2001 to 2002 (P < 0.001). These data suggest that the advent of endovascular AAA repair has contributed to a reduction in the rate of ruptured AAA repairs, an increase in total procedures performed, and a significant decrease in perioperative deaths and major complications when compared with open AAA repair.     

Acute retrograde aortic dissection during endovascular repair of a thoracic aortic aneurysm

Endovascular aneurysm exclusion represents a valuable alternative treatment for descending thoracic aortic aneurysms. Although the minimally invasive character of this procedure is obvious, major complications are possible. We report a 77-year-old male who developed acute retrograde dissection of the aortic arch and ascending aorta during endovascular stent-grafting of a descending aortic aneurysm. Emergent open surgical repair provided a successful outcome.     

Hemopericardium from retrograde dissection of an abdominal aortic aneurysm

Atherosclerotic abdominal aortic aneurysms rarely result in significant aortic dissection, and it is even more unusual to see marked proximal extension of such a dissection. We report the case of an 82-year-old man whose fatal dissection and hemopericardium originated in an atherosclerotic abdominal aortic aneurysm. This is apparently the third such case to be reported. Accurate angiographic identification of the site of intimal disruption, whether intrathoracic or intra-abdominal, is essential for planning proper therapy.