Infected aortic aneurysms: aggressive presentation, complicated early outcome, but durable results.

OBJECTIVE: Infected aortic aneurysms are rare, difficult to treat, and associated with significant morbidity. The purpose of this study was to review the management and results of patients with infected aortic aneurysms and identify clinical variables associated with poor outcome. METHODS: The clinical data and early and late outcomes of 43 patients treated for infected aortic aneurysms during a 25-year period (1976-2000) were reviewed. Variables were correlated with risk of aneurysm-related death and vascular complications, defined as organ or limb ischemia, graft infection or occlusion, and anastomotic or recurrent aneurysm. RESULTS: Infected aneurysms were infrarenal in only 40% of cases. Seventy percent of patients were immunocompromised hosts. Ninety-three percent had symptoms, and 53% had ruptured aneurysms. Surgical treatment was in situ aortic grafting (35) and extra-anatomic bypass (6). Operative mortality was 21% (9/42). Early vascular complications included ischemic colitis (3), anastomotic disruption (1), peripheral embolism (1), paraplegia (1), and monoparesis (1). Late vascular complications included graft infection (2), recurrent aneurysm (2), limb ischemia (1), and limb occlusion (1). Mean follow-up was 4.3 years. Cumulative survival rates at 1 year and 5 years were 82% and 50%, respectively, significantly lower than survival rates for the general population (96% and 81%) and for the noninfected aortic aneurysm cohort (91% and 69%) at same intervals. Rate of survival free of late graft-related complications was 90% at 1 year and 5 years, similar to that reported for patients who had repair of noninfected abdominal aortic aneurysms (97% and 92%). Variables associated with increased risk of aneurysm-related death included extensive periaortic infection, female sex, Staphylococcus aureus infection, aneurysm rupture, and suprarenal aneurysm location (P <.05). For risk of vascular complications, extensive periaortic infection, female sex, leukocytosis, and hemodynamic instability were positively associated (P <.05). CONCLUSION: Infected aortic aneurysms have an aggressive presentation and a complicated early outcome. However, late outcome is surprisingly favorable, with no aneurysm-related deaths and a low graft-related complication rate, similar to standard aneurysm repair. In situ aortic grafting is a safe and durable option in most patients.     

True juxta-anastomotic aneurysms in the residual infra-renal abdominal aorta.

INTRODUCTION: abdominal aortic dilatation can occur above the graft following repair of infra-renal abdominal aortic aneurysm (AAA). This study aimed to determine the incidence and possible aetiological associations of recurrent juxta-anastomotic aneurysms following open repair of AAA. METHODS: the diameter of the infra-renal aorta above the graft of 135 patients who had previously undergone open AAA repair was determined using ultrasound. In those where the diameter was greater than 40 mm a CT scan was undertaken. Co-morbid and operative details were determined from the patients and their clinical notes. RESULTS: seven patients had true juxta-anastomotic aneurysms (>40 mm) in the residual infra-renal abdominal aorta, the occurrence of which was associated with tobacco smoking and hypertension. There was no association with other co-morbid factors, surgical operative details or the development of iliac aneurysms (which occurred in 3% of patients). CONCLUSIONS: true juxta-anastomotic aneurysms develop in the residual infra-renal neck of patients following open repair of abdominal aortic aneurysm. Tobacco smoking and hypertension are significant factors associated with the development of these aneurysms. This group of patients may warrant surveillance to prevent aneurysm rupture.     

Selective use of retroperitoneal aortic exposure in the emergency treatment of ruptured and symptomatic abdominal aortic aneurysms

Emergency surgery is the only effective treatment of ruptured abdominal aortic aneurysms, even though morbidity and mortality rates remain high. We have studied the feasibility of left retroperitoneal aortic exposure in these cases in an effort to reduce postoperative complications. Over a 33 month period, 29 patients underwent emergency surgery for either a ruptured or symptomatic infrarenal abdominal aortic aneurysm. Of 13 patients with ruptured aneurysms, 4 underwent repair through a midline transperitoneal approach (3 deaths) whereas the remaining 9 were repaired through the retroperitoneal exposure (1 death). Supraceliac aortic clamping through the same incision prior to aneurysm exposure maintained hemodynamic integrity. The remaining 16 patients with symptomatic aneurysms were all treated through the retroperitoneal exposure (3 deaths). In the retroperitoneal groups, the cause of death was cardiac in two patients, hypertensive stroke in one, and necrotizing pancreatitis in one. Morbidity consisted of prolonged intubation, respiratory distress syndrome, and thrombophlebitis in one patient each and acute tubular necrosis in two patients. We believe that the left retroperitoneal approach is a useful option in the emergent treatment of abdominal aortic aneurysms.     

Endovascular repair of abdominal aortic aneurysms and other arterial lesions

Purpose: This report describes our experience with endovascular stented graft repair of abdominal aortic aneurysms and other arterial lesions.Methods: Between September 1990 and April 1994, 57 patients were treated with endovascular stented grafts (50 with abdominal aortic aneurysms or iliac aneurysms; five with traumatic arteriovenous fistulas; one with an infected femoral false aneurysm; and one with a false aneurysm of the proximal right common carotid artery). The devices consist of either a Dacron or an autogenous vein graft sutured to a balloon-expandable stent. The stented grafts are placed through remote arteriotomies, advanced under fluoroscopic guidance to their predetermined sites, and secured into position.Results: Forty of the 50 endovascular stented graft procedures used to treat abdominal aortic aneurysms or iliac aneurysms were considered successful, even though some secondary treatment was required in six patients (two open operations; four secondary endovascular procedures). The 10 failures include four early procedural deaths, one late procedural death, and five leaks. All five arteriovenous fistulas and the two false aneurysms were successfully treated with endovascular stented grafts.Conclusions: Although our experience with endovascular stented grafts has been promising, remaining problems require resolution, and further follow-up is needed. However, the potential advantages of these endovascular grafts warrant their continued evaluation. (J VASC SURG 1995;21:549-57.)     

Treatment of mycotic aortic aneurysms with endoluminal grafts.

PURPOSE: To report the benefit of endoluminal repair of mycotic aortic aneurysms and highlight the need for a registry. METHODS: Nine patients (five female) were identified over 5 years (1998-2003) as having presumed mycotic aortic aneurysms (12 in total) suitable for endoluminal grafting. A total of nine thoracic and three abdominal were grafted and followed up for a median of 36 months. RESULTS: Six of the aneurysms have resolved and one was converted to an open repair. There was one early death from rupture of a second undiagnosed aneurysm and two late deaths from rupture due to persistent inflammation. Long-term antibiotics have not been mandatory to ensure survival. CONCLUSIONS: Mycotic aortic aneurysms of the thoracic and abdominal aorta do benefit from endoluminal repair, particularly when arising in previously normal aortic tissue. Endoluminal grafting also has a role in the palliation of secondarily infected aortas and so to prove its efficacy in the treatment of all these rare cases a registry is required.     

Perioperative cardiac complications of surgical repair of infrarenal aortic aneurysms

From 1985 to 1987, 261 patients (241 male, 20 female; mean age 66.5 years, range 38-90 years) were hospitalized for elective repair of infrarenal aortic aneurysms. One-hundred forty seven patients (56%) had coronary artery disease, attested to by past history of myocardial infarction or angina pectoris, electrocardiographic signs at rest, or abnormalities of dipyridamole thallium scintigraphy (performed in 72 patients). Ten patients had coronary arteriography and one patient then underwent aortocoronary bypass. Only two patients were not offered operation. All patients operated on had perioperative monitoring using Swan-Ganz catheters. Forty-five patients (17.5%) had a total of 62 postoperative events related to coronary artery disease. These included 40 cases of myocardial ischemia (15%), 16 cases of left heart failure (6%), and six myocardial infarctions (2%). There were nine (3.4%) postoperative deaths, four of which were due to cardiac causes (1.5%). In spite of the frequency of preexisting coronary artery disease and of intra- or postoperative myocardial ischemia, surgical repair of abdominal aortic aneurysm was not responsible for increased perioperative cardiac morbidity or mortality. In this population of aged patients, abdominal aortic aneurysm repair does not necessitate extending the indications for preoperative coronary arteriography or aortocoronary bypass.     

Late cerebrovascular accidents after repair of abdominal aortic aneurysms

In this follow-up of 1,112 patients operated on for abdominal aortic aneurysm (AAA) it was noted that cerebrovascular accidents (CVAs) caused significant (8.2%) late mortality. Seventy-one patients developed non-fatal or fatal CVAs at 5.9 +/- 2.9 (mean +/- SD) years after the initial aneurysm repair. The incidence of CVA was 4.2% and 9.5% within five and ten years, respectively. In patients with preoperative evidence of both hypertension and heart disease, the incidence of CVA within five years was 9.1% compared to an incidence less than 4% in patients with either or neither of these risk factors (p less than 0.01). Multivariate analysis of individual risk factors revealed that only age (p less than 0.001), hypertension (p less than 0.001), angina pectoris (p less than 0.02) and other heart disease (p less than 0.001) were independently associated with a reduced survival free of CVA. Thus, cerebrovascular accidents are responsible for significant late morbidity after AAA repair. Patients at high age or with evidence of hypertension and heart disease carry a greater risk for this complication.     

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

Surgical treatment of aneurysms of the ascending aorta associated with severe aortic regurgitation

From January 1979 to June 1982 31 patients have had simultaneous ascending aortic aneurysm repair and aortic valve replacement. Fifteen patients (group 1) received a composite graft; seven patients (group 2) had separate aortic valve and supracoronary ascending aorta prostheses; and nine patients (group 3) had aortic valve replacement and "tailoring" of the ascending aorta. The mean age was 50 (SD 14) years. Nine patients had acute dissection, five with the coronary ostia affected. Emergency surgery was performed in 10 cases. There were six early deaths (19.4%), none of them due to technical complications during surgery. The mortality rate was 56% for patients with acute dissection operated on as an emergency and 4.5% for patients having elective operations. Appreciable haemorrhage occurred in four patients (12.9%). No neurological complications occurred. There was one late death. The survivors were followed up for one to four years. There was one case of recurrence of aneurysm. No ischaemic complications resulted from coronary reimplantation. There were no significant differences in the results of the three groups. Simultaneous ascending aortic aneurysm repair and aortic valve replacement can be accomplished with an acceptable mortality rate and little morbidity.     

Multiple aortic aneurysms: the results of surgical management

During the past 2 decades 102 consecutive patients (77 men and 25 women) with multiple aortic aneurysms underwent 201 aortic reconstructions. These procedures (174 elective and 27 emergent) represented 3.4% of the 5837 aortic aneurysm operations performed. Seventy-five (30.9%) of the 243 aneurysms occurred in the infrarenal aorta, 65 occurred in the descending aorta (26.7%), 56 occurred in the thoracoabdominal aorta (23.0%), and 47 occurred in the ascending aorta or arch (19.3%). Ages ranged from 20 to 81 years (mean 63.3 years). Smoking history and abnormal electrocardiographic tracings were present in 84.3% of the patients, hypertension was present in 77.5%, and obstructive lung disease was present in 60.8%. Multiple aortic aneurysms were present at the time of the first repair in 55 patients (53.9%). Twelve patients had one procedure, 81 had two, and nine had three. Sixteen (17.8%) of the 90 patients who had multiple operations had a subsequent operation for complications of the unrepaired aneurysm (rupture 12, symptoms 4). Fourteen perioperative deaths occurred among the 174 elective repairs (8.0%), and 11 occurred among the 27 emergent procedures (40.7%). Procedure mortality increased with the ordinal number of elective operations and was 4.4% for the first, 10.4% for the second, and 33.3% for the third. Seven of 21 patients (33.3%) who had simultaneous repair of at least two aortic aneurysms died in the perioperative period. Overall, 77 of the 102 patients (75.5%) survived all surgical procedures to repair their multiple aortic aneurysms; of these, 63 had complete resection of all known aneurysms. Follow-up was complete in all patients and averaged 6.3 years (ranges: 1 month to 19 years). There were 30 late deaths; the most frequent cause was myocardial infarction. Kaplan-Meier 5-year survival including perioperative deaths for all patients after the first operation was 76% and after the last operation 40%. We conclude that multiple aortic aneurysms can be safely managed, usually with staged repairs, and that long-term survival is probably. After the first aortic operation the presence of multiple aneurysms mandates close observation with timely surgical intervention.     

Are familial abdominal aortic aneurysms different?

A 9-year prospective study of 542 consecutive patients undergoing operation by one of the authors for abdominal aortic aneurysms was undertaken to define the incidence, clinical behavior, and anatomic characteristics of familial abdominal aortic aneurysms. Eighty-two (15.1%) patients having surgery for abdominal aortic aneurysms were found to have a first-degree relative with an aneurysm, as compared to nine (1.8%) of a control group of 500 patients of similar age and sex without aneurysmal disease (p less than 0.001). Detailed analysis was next performed of the pedigree charts of patients with a positive family history of aneurysm who underwent repair of abdominal aortic aneurysms by all authors over the 9-year study period. This review identified a total study population of 86 families with 209 first-degree relatives with abdominal aortic aneurysms. Clinical and anatomic features of this familial group were compared to those of 460 patients operated on for abdominal aortic aneurysms who had no family history of abdominal aortic aneurysms. Patients with familial abdominal aortic aneurysms were more likely to be women (35% vs 14%), and men with familial abdominal aortic aneurysms tended to be about 5 years younger than the women. There was no significant difference between the patients with nonfamilial and familial abdominal aortic aneurysms in anatomic extent of aneurysmal disease, multiplicity of aneurysms, associated occlusive disease, or blood type. There was a history of aneurysm rupture in 35 of 86 (40.7%) families with familial abdominal aortic aneurysms.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgery for aortic aneurysms

Aortic aneurysms, the majority of which affect the infrarenal abdominal portion of the aorta, are responsible for 1–2% of all deaths in men aged over 65 years in the Western world. The disease most commonly represents a multifactorial degenerative process involving both genetic and environmental risk factors and is characterized pathologically by a reduction in elastic lamellae within the aortic wall. The natural history of the condition is one of progressive enlargement with an associated increase risk of aneurysm rupture. Although aneurysm rupture remains a catastrophic event, with an overall mortality of approximately 80%, the majority of patients are asymptomatic. Asymptomatic aneurysms are usually diagnosed as an incidental finding and management relies on an assessment of the risks of future aneurysm rupture weighed against the risks associated with elective surgical repair. Aneurysm repair may be accomplished by traditional open surgery or minimally invasive endovascular repair. Although the latter confers a short-and medium-term survival advantage in selected patients, long-term follow-up data suggest this benefit may not persist. Thoracoabdominal aortic aneurysm disease is considerably more complex, with intervention, even in specialist centres, associated with significant morbidity and mortality. Best medical management of aortic aneurysm disease requires control of blood pressure, smoking cessation together with aspirin and statin therapy. Screening has been introduced in an effort to identify a largely silent killer although with better medical management the overall prevalence may be in decline.     

Ruptured descending and thoracoabdominal aortic aneurysms

BACKGROUND: Advances in end-organ protection have dramatically reduced the incidence of the life-threatening complications associated with the elective repair of thoracoabdominal and descending thoracic aortic aneurysms. However, in the setting of a ruptured thoracic aneurysm, one may not have the luxury of complex end-organ support. We analyzed our experience with ruptured thoracic aneurysms to define morbidity and mortality in the present era. METHODS: One hundred seventy-two patients with thoracoabdominal or descending thoracic aneurysms were operated on between July 1997 and October 2001. Forty presented with either a contained or free rupture. Three techniques were used for aortic reconstruction: clamp and sew, left heart bypass, and hypothermic circulatory arrest. Adjuncts for neurologic and renal support were used when circumstances and anatomy permitted. RESULTS: Seven of 40 patients died in the hospital (17.5%). Four patients died intraoperatively, all of acute myocardial infarction. Five of the seven deaths were in patients who presented in shock. Two patients (5%) experienced paraplegia, 3 (7.5%) had renal failure requiring hemodialysis, 8 (20%) required a tracheostomy, and 6 (15%) had recurrent nerve palsies. There was one stroke (2.6%). Mean diameter of ruptured aneurysms was 8.5 cm. CONCLUSIONS: Ruptured thoracic aneurysms can be repaired with a gratifying rate of salvage. Rapid diagnosis and triage for repair is necessary to avoid progressive deterioration into shock. The incidence of myocardial infarction, and the mortality associated with this event, underscores the need for aggressive cardiac evaluation in the elective thoracic aneurysm patient. The size at rupture also emphasizes the need for earlier referral for elective aneurysm repair.     

Late iliac artery aneurysms and occlusive disease after aortic tube grafts for abdominal aortic aneurysm repair. A 35-year experience.

Controversy continues over whether patients treated with straight Dacron aortic tube grafts for an abdominal aortic aneurysm remain at significant risk for subsequent development of iliac aneurysm or occlusive disease. To address this issue, the authors performed a population-based analysis of 432 patients who had an abdominal aortic aneurysm diagnosed between 1951 and 1984. Aneurysm repair was performed eventually in 206 patients (48%). To ascertain differences in late development of graft-related complications, iliac aneurysms, and arterial occlusions, the authors compared all tube-graft patients with similar numbers of bifurcated-graft patients matched for age and year of operation. In the tube-graft group, no subsequent clinically evident or autopsy-proven iliac aneurysms or iliac occlusive disease were noted. Over a mean follow-up of 6 years (range, 4 to 18 years), new aortic aneurysms occurred in the proximal aorta in both tube and bifurcated-graft patients (5.0% and 2.5%, respectively). In contrast the cumulative incidence of graft-related complications was higher with a bifurcated prosthesis (12.8%) compared with a straight graft (5.0%) (p = 0.15). These problems generally occurred 5 to 15 years postoperatively and emphasize the need for long-term graft surveillance. The authors conclude that straight tube-grafts for repair of abdominal aortic aneurysms provide excellent late patency with minimal risk of subsequent iliac aneurysm development.     

The prevalence and natural history of aortic aneurysms in heart and abdominal organ transplant patients

OBJECTIVE: The purpose of this study was to document the prevalence and clinical features of aortic aneurysms in heart and abdominal transplant patients. METHODS: We undertook a retrospective review of 1557 patients who had heart, liver, or kidney transplantation between January 1, 1987, and December 31, 2000. Aortic aneurysms were identified by computed tomographic scan, ultrasound scan, or at the time of surgery for rupture. An aortic diameter of 3.5 cm was used as the threshold for the definition of aneurysmal disease. We compared dichotomous variables with Fisher's exact test and continuous variables with the Wilcoxon rank-sum test. RESULTS: There were 296 heart, 450 liver, and 811 kidney transplants performed on adult patients during the study period. We identified 18 transplant patients who had an aortic aneurysm (13 heart, three liver, two kidney). Seven patients (41%) had rupture of the aortic aneurysm, and five of these patients died. There were no deaths from causes other than aortic aneurysm rupture. The rate of aneurysm rupture was 22.5% per year. Eight patients had the aortic aneurysm repaired electively with no deaths and no hospital stay greater than 15 days. The mean aortic aneurysm size at rupture was 6.02 +/- 0.86 cm, and the smallest aneurysm that ruptured was 5.1 cm. The pretransplant rate of aortic aneurysm expansion was 0.46 cm/y, but this increased to 1.00 cm/y after transplantation (P =.08). The rate of aortic aneurysm expansion among heart transplant patients and abdominal transplant patients was the same (P =.51). The prevalence of aortic aneurysm was 4.1% in cardiac transplant patients and 0.4% in abdominal transplant patients. Earlier in our series (1987 to 1996), 11% of the cardiac transplant patients were screened for aortic aneurysms, and the prevalence rate of diagnosis was 3.0%. Screening of cardiac transplant candidates became more frequent in 1997 (87% screened), with an associated increase in the aortic aneurysm prevalence rate to 5.8% in the patients who were screened. CONCLUSION: Aortic aneurysms in cardiac and abdominal transplant patients have an aggressive natural history with high expansion and rupture rates. Screening transplant patients for aortic aneurysms will increase detection and facilitate elective repair, which is generally well tolerated. These findings support programs for early detection and elective treatment of aortic aneurysms in organ transplant patients, particularly those having heart transplants.     

The impact of walking impairment,cardiovascular risk factors,and comorbidity on quality of life in patients with intermittent claudication

PURPOSE: This study assessed the cardiovascular disease, perioperative results, and survival after surgical abdominal aortic aneurysm repair in young patients (< or = 50 years) compared with randomly selected older patients who also underwent abdominal aortic aneurysm repair. METHODS: We reviewed hospital records to identify young and randomly selected control patients (3 for each young patient, > or = 65 years, matched for year of operation) with degenerative (atherosclerotic) abdominal aortic aneurysms undergoing repair between Jan 1, 1988, and Mar 31, 2000. Patients with congenital aneurysms, pseudoaneurysms, aortic dissections, post-coarctation dilations, aortic infection, arteritis, or aneurysms isolated to the thoracic aorta were excluded. Mortality data and cause of death were obtained from medical records and the National Death Index RESULTS: Among 1168 patients who underwent abdominal aortic aneurysm repairs, 19 young patients (1.6%) and 57 control patients were identified. The mean age was 48.4 years in the young group and 72.2 years in the control group. There were no differences in sex or race between the two groups. When comparing existing cardiovascular disease between the groups, there were no differences in the incidence of earlier coronary revascularization (26% vs 16%) or non-cardiac vascular surgery (5% vs 9%), but aneurysms were more commonly symptomatic in young patients (53% vs 21%; P <.01). Aneurysmal disease was limited to the infrarenal aorta in similar proportions of patients (89% vs 88%). No statistically significant differences were seen in the incidence of perioperative deaths (16% young vs 9% control; P =.40) or postoperative complications (37% young vs 26% control; P =.38). The estimated survival rate of the young group was not different from that of the control group (3-year survival rate, 73% vs 69%; P =.32) or the entire cohort of patients (older than 50 years; n = 1101) who underwent repair of abdominal aortic aneurysms during the study period (3-year survival 73% vs 75%; P =.63) CONCLUSION: After abdominal aortic aneurysm repair, young patients had perioperative results and follow-up mortality rates similar to those of control patients. Cardiovascular disease was the predominant cause of death after abdominal aortic aneurysm repair in the young patients. When compared with an age older than 50 years at the time of abdominal aortic aneurysm repair, young age alone was not associated with increased survival.     

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

OBJECTIVE: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. METHODS: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. RESULTS: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. CONCLUSION: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.     

Inflammatory aneurysms of the abdominal aorta

Inflammatory aneurysms of the abdominal aorta (IAAAs) have distinctive clinical and physical characteristics that separate them from typical atherosclerotic aneurysms. They were identified in 19 (7.2%) of 265 patients undergoing abdominal aortic aneurysm repair. Symptoms were present in 12 (63%) of 19, with one patient presenting with rupture, and multiple symptoms were present in six (32%). Intraoperatively, all aneurysms exhibited dense periaortic inflammation. Adjacent structures most frequently involved were the duodenum in 15 (79%) of 19 patients, the left renal vein in six (32%) of 19, and the ureter in five (26%) of 19. Seventeen (94%) of the 18 patients who underwent elective aneurysm resection survived. The involvement of retroperitoneal structures varied in number and severity, demonstrating that a wide spectrum of inflammation is present in IAAAs, making diagnosis and definition difficult.     

Technical tips for endovascular repair of common iliac artery aneurysms

Isolated common iliac artery aneurysms are rare, comprising <2% of all aneurysm disease. These aneurysms present as either isolated disease, .03% of the population, or, in conjunction with abdominal aortic aneurysm, in approximately 20% to 25% of such cases. Common iliac artery aneurysms are defined as any localized dilatation of the common iliac artery >1.5 cm in diameter. Elective repair for isolated common iliac artery aneurysms is generally not undertaken for aneurysms <3 cm in diameter unless they are part of an abdominal aortic aneurysm repair. Most common iliac artery aneurysms are found incidentally during abdominal/pelvic diagnostic imaging studies or at the time of pelvic or abdominal surgery. As with abdominal aortic aneurysms, endovascular repair of common iliac artery aneurysms follows techniques similar to those used for endovascular repair of abdominal aortic aneurysm. Management includes aneurysm exclusion with an endograft, which seals at sites within the proximal and distal common iliac artery and may involve coil occlusion of the hypogastric artery with extension of the reconstruction into the proximal external iliac artery, or use a "bell-bottom" endograft limb placed at the common iliac bifurcation. Technical tips for successful outcome are described here, and all US Food and Drug Administration approved endografts have been used for repair. There were no statistically significant differences in outcomes that correlated with device or repair techniques used for management of common iliac artery aneurysms. Mid-term 54-month outcome has been excellent, with no common iliac artery ruptures or aneurysm-related deaths and the need for secondary interventions was gratifyingly small.     

Endovascular management of mycotic aortic aneurysms and associated aortoaerodigestive fistulas

We evaluated the short- and intermediate-term results of endovascular aneurysm repair (EVAR) for mycotic aneurysms. We reviewed all patients undergoing EVAR for mycotic aneurysms at our institution. To be consistent with the existing literature, patients with associated aortoaerodigestive fistulas were included. Aneurysm location, demographics, clinical findings, EVAR success, morbidity, and short- (<30 days) and long-term mortality were reviewed. From 2000 to 2007, 326 patients underwent EVAR. Nine of these (3%) had treatment of a mycotic aneurysm. The average age was 72 years (range 53-86), and seven patients were male. Four of the aneurysms were located in the thoracic aorta, two in the abdominal aorta, and three in the thoracoabdominal aorta. Four patients presented with gastrointestinal bleeding, two with hemoptysis, one with hemothorax, and two with fever. Etiologies included bacteremia from endocarditis and central catheter infection, erosion of anastomotic aneurysms from a previous aortic repair or endograft, erosion of a penetrating ulcer with pseudoaneurysm, infected aortic repair, left chest empyema, and unknown in one patient. Methicillin-resistant Staphylococcus aureus was the only bacteria isolated in 56% of the patients. EVAR successfully excluded the aneurysm or fistula in all nine patients; however, five patients experienced at least one postoperative complication. Two patients expired within 30 days. After 30 days, four additional patients expired; three of these deaths were procedure/aneurysm-related. Of the three survivors, over a mean follow-up of 257 days (range 60-417), one has required excision of an infected endograft with extra-anatomic bypass grafting but is now alive and well. All three surviving patients and two out of four patients expiring after 30 days had received long-term postoperative antibiotics. Despite an in-hospital mortality of 22.2%, EVAR can be used to treat acute complications from mycotic aneurysms and associated aortoaerodigestive fistulas, such as gastrointestinal bleeding, hemoptysis, or hemodynamic instability. As a definitive treatment, EVAR remains suspect and therefore should be considered a bridge to open surgical repair.