Long-term single-center results with AneuRx endografts for endovascular abdominal aortic aneurysm repair.

PURPOSE: To evaluate the long-term single-center results with the AneuRx stent-graft in endovascular abdominal aortic aneurysm (AAA) repair (EVAR). METHODS: Between December 1996 and August 2003, 212 patients (197 men; mean age 71.3+/-7.0 years) were treated with the AneuRx stent-graft for an infrarenal AAA. Postoperatively, patients were enrolled in a fixed surveillance protocol, and data were prospectively captured into a database. RESULTS: Graft deployment was successful in 98.6% (209/212). Thirty-day mortality was 2.4%. Median hospital stay was 4.3+/-5.5 days. Median follow-up was 52.0 months (range 1-109); only 1 patient was lost to follow-up. At 9 years, patient survival was 56% and freedom from secondary interventions was 48%. In 68% of cases, these reinterventions were needed for a fixation-related complication, and most of these complications (75%) encompassed the area of the proximal aneurysm neck. Primary clinical success was 37% at 9 years. After secondary interventions, the assisted primary clinical success improved to 73% at 9 years. Freedom from aneurysm-related death was 97% at 1 year and 90% at 9 years. CONCLUSION: As an alternative to open repair, EVAR with the AneuRx device has low perioperative mortality. Reinterventions are mostly due to fixation-related complications. While the overall mortality risk in this population was 5% per year, annual aneurysm-related death was only 1%. The focus should be on surveillance and reducing the rate of long-term complications, which might be possible with improved proximal stent-graft fixation.     

Experience with endovascular abdominal aortic aneurysm repair in nonagenarians.

PURPOSE: To report a single-institution experience with endovascular abdominal aortic aneurysm (AAA) repair (EVAR) in nonagenarians. METHODS: A retrospective review was performed of all patients >90 years old undergoing EVAR over an 8-year period at a major academic medical center. The patient population was investigated for the presence of various comorbidities, initial aneurysm size, successful aneurysm exclusion, perioperative complications, disposition, endoleaks, secondary interventions, and overall survival. RESULTS: EVAR was performed in 18 male nonagenarians (mean age 92.4 years, range 90- 95). Mean aneurysm diameter was 7.3 cm (range 5.5-9.8). The cohort had an average of 3.2 comorbid conditions. Sixteen patients were treated electively, while 2 patients underwent emergent repair for contained rupture and bleeding aortoenteric fistula, respectively. Immediate technical success was 100%. Perioperative local/vascular complications occurred in 4 (22%) patients. Perioperative systemic complications occurred in 3 (17%) patients. There were 2 (11%) perioperative (<30 days) deaths. Three (17%) patients required secondary interventions. Mean survival in patients who expired during the follow-up period beyond the first 30 days was 34 months (range 8-78). Mean survival in 8 patients who are still alive is 17.4 months (range 9-39). CONCLUSION: Endovascular AAA repair in nonagenarians is associated with a high rate of technical success and relatively low morbidity rate. Survival times following successful hospital discharge are significant. Suitable patients over 90 years of age may benefit from an endovascular AAA repair.     

腹主动脉瘤腔内修复技术在90岁以上老年患者中应用的评价

目的探讨年龄逾90岁的腹主动脉瘤（AAA）患者行腔内修复术治疗的安全性和有效性。方法 2003年5月至2011年3月,12例年龄逾90岁的AAA患者接受主动脉腔内修复技术（EVAR）治疗,其中急诊手术2例。平均年龄（91.7±1.5）岁,其中11例为男性（91.7%）。统计技术成功率、围手术期并发症、死亡率;术后3,6,9,12个月及每年进行随访,进行CT或超声检查。结果 7例行全身麻醉,5例行局部麻醉,技术成功率为100%,无中转开刀手术患者;2例采用Endurant支架,4例采用Talent支架,6例采用Zenith支架;手术时间（3.4±1.3）h,出血量（220.5±60.5）ml,术后住院时间（8.4±2.3）d;30d死亡率为8.3%,1年死亡率为16.7%,3年死亡率为41.7%,5年死亡率为75%;11例术后30d仍存活的患者,平均术后生存时间为28.5个月（9～73个月）。结论对于年龄逾90岁的AAA患者,EVAR手术成功率高,围手术期死亡率和并发症发生率低,但从中远期结果来看部分患者的手术获益是有限的,因此术前个体化评估十分重要。     

高危胸降主动脉瘤腔内修复治疗

目的总结高危患者行胸降主动脉瘤(descending thoracic aortic aneurysm,DTAA)腔内修复治疗(endovascular aneurysm repair,EVAR)的经验。方法回顾分析2001年1月至2007年7月我科24例高危DTAA患者行EVAR诊治经过、结果和并发症。所有患者因动脉瘤部位、破裂、高龄或严重合并症而不适合行开放手术。EVAR术后1个月、3个月、6个月、12个月和每年行螺旋CT血管造影、三维重建随访。结果所有患者均获技术成功(100%)。围手术期死亡2例(8.3%),分别死于多系统器官功能衰竭和急性心肌梗死。2例(8.3%)术后发生严重并发症(1例缺血性脑卒中和1例急性肾功能不全)。11例(46%)术后即时造影显示近端Ⅰ型内漏,其中3例内漏量大,行球囊扩张后内漏消失;另8例随访观察。19例患者获随访,随访时间为1~60个月(平均18.6±4.2个月)。1例患者术后4年发生支架型人工血管移位并发Ⅰ型内漏,1例术后2年出现迟发性Ⅲ型内漏,均成功行EVAR。1例死于结肠癌。其余患者术后3个月CT证实瘤腔内完全血栓形成,无支架移位和内漏。随访期间动脉瘤最大直径缩小0~18 mm(平均6.3±3.1 mm),4例辅助性动脉旁路在随访期间人工血管均通畅。结论EVAR治疗高危DTAA早期死亡率和并发症发生率尚可接受,对某些病例可能是首选治疗方法。     

Renal consequences of endovascular abdominal aortic aneurysm repair.

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysm (AAA) is less invasive and has a lower operative mortality than conventional surgery. The relationship between renal function and outcome following open AAA repair has been extensively investigated, but less work has been undertaken with respect to renal function and outcome after EVAR. We reviewed the literature (Medline and PubMed databases) between 1991 and 2007 to investigate the relationship between EVAR and renal dysfunction. Our review found that perioperative renal dysfunction is attenuated by EVAR. However, dialysis rates after EVAR are similar to those after open surgery. EVAR patients develop progressive deterioration in renal function over time. The etiology is unclear and probably multifactorial, involving embolization, contrast media, and graft misplacement. The effect of transrenal endograft fixation on long-term renal function is unknown, but the technique may be associated with a significantly increased risk of renal infarction. The etiology of the renal injury during and after EVAR needs further evaluation, and techniques aimed at renal preservation should be pursued.     

Abdominal pulsatile tumor after endovascular abdominal aortic aneurysm repair

A 70 years old patient was successfully treated for infrarenal aortic aneurysm by an endovascular bifurcated prosthesis. Three months later, because of dysuria, he underwent urological examination revealing an abdominal pulsatile tumor. Thereafter, the patient was sent to our emergency ward with suspected symptomatical endoleak. Radiological screening by computer tomography and magnetic resonance angiography showed good post-operative results without endoleak. Patient was treated with antispasmodic medication and is doing well today. Because endovascular repair of aortic aneurysm, in contrast to an open approach, does not eliminate the aneurysm itself, post-operative abdominal palpation can be ambiguous. Magnetic resonance angiography--without the need of nephrotoxic contrast medium--compares favourably to CT and provides excellent pictures with less artefacts for post-operative screening of endoleak. If reperfusion can be excluded, pulsation is due to the transmission of the blood-pressure wave to the thrombosed aneurysm.     

腹主动脉瘤腔内修复术中髂内动脉的处理

目的总结肾下腹主动脉瘤腔内修复术中的髂内动脉的处理方法。方法自1997年7月至2007年3月实施的腔内修复术中有62例肾下腹主动脉瘤涉及髂内动脉的处理。其中C型腹主动脉瘤57例(包括单侧髂总动脉分叉受累者35例,双侧髂总动脉分叉受累者22例),髂总动脉分叉过高5例。手术方法采用髂内动脉单纯覆盖、髂内动脉栓塞并覆盖、髂内动脉重建,针对具体的病变情况,采用不同的组合处理方法。结果无中转开腹手术,手术结束时6例(9.7%)Ⅰ型内漏。术后出现臀肌跛行5例(8.1%)、单侧下肢麻木1例(1.6%),无褥疮及结、直肠坏死表现。结论腔内修复术中保留一侧髂内动脉是合理的,尽可能避免同时破坏双侧髂内动脉。     

Midterm results of a modified technique for implanting tube grafts during endovascular abdominal aortic aneurysm repair

PURPOSE: To retrospectively analyze the efficacy and midterm results of endovascular aneurysm repair (EVAR) with a tubular stent-graft using 2 different implantation techniques. METHODS: Between November 2004 and September 2007, 53 patients (49 men; mean age 68.5+/-8.6 years, range 40-80) were treated with the EndoFit tube stent-graft. The majority (45, 85%) were treated using the trombone technique, in which 2 tubular aortoaortic endografts were deployed with 4 to 8 cm of overlap. This subgroup was compared to the 8 patients who received single tube grafts. RESULTS: Technical and procedural success were 100%; perioperative mortality was 0%. Operative results were similar for patients treated with 1 graft versus those treated with the overlapping trombone technique. The overall device-related complication rate was significantly lower for patients treated with the trombone technique (11% versus 75%, p<0.001). Mean follow-up was 24 months (range 6-36). Endoleak type II occurred in 3 (5.7%) cases. Three (5.7%) patients died, 1 from an aortoduodenal fistula secondary to a proximal type I endoleak and 2 from acute myocardial infarction. CONCLUSION: The tubular EndoFit device appears both safe and effective in terms of midterm clinical outcome, especially when the trombone technique is utilized. It compares favorably with previously reported EVAR results.     

Midterm results of endovascular abdominal aortic aneurysm repair with Talent stent graft in a single center.

AIM: The aim of this study is to investigate the safety and efficacy of abdominal aortic aneurysm (AAA) repair with modular bifurcated Talent stent-graft. METHODS: Between September 2001 and September 2005, 85 patients with infrarenal AAA underwent treatment with Talent stent-graft. There were 83 men and 2 women with a median age of 69.3 years. Anatomy of the abdominal aorta and the iliac arteries was investigated with high resolution contrast CT together with digital subtraction angiography. The majority of patients had comorbid illnesses like arterial hypertension (60%), CAD (38%) and previous CABG (26%). Duration of follow-up period ranged from 1 to 48 months (median 18 months). RESULTS: Repair was performed with transrenal fixation of the bifurcated Talent stent-graft under regional anesthesia in 80% of all cases. Technical success rate was 97.6%. Aneurysm related mortality was 2.4% due to aneurysm rupture in the postoperative period. Overall mortality rate was 9.4%. Morbidity rate was 16.5%. Immediate conversion to open repair was necessary in 1 patient (1.2%). Endoleak rate was 4.8% at 1 month follow-up period. Secondary intervention was required in 1.2% of patients. Iliac limb occlusion was detected in 1 patient (1.2%). CONCLUSIONS: Talent stent-graft exhibits a high degree of technical success in AAA repair in patients with comorbid conditions with a low perioperative morbidity and mortality rate.     

Overview of techniques and devices for endovascular abdominal aortic aneurysm repair.

The endovascular treatment of abdominal aortic aneurysms (AAAs) is rapidly evolving. Since the onset of clinical investigations in 1990 there has been a rapid proliferation in the number of available devices, both surgeon-made and industry-made. This chapter reviews endovascular AAA repair with regard to available devices, patient selection for each device based on anatomic criteria, and techniques for graft deployment.     

Large iliac arteries: a high-risk group for endovascular aortic aneurysm repair.

PURPOSE: To examine if the presence of large iliac arteries is a potential risk factor for the development of a type Ib endoleak (iliac sealing zone) or need for iliac artery-related secondary intervention in patients undergoing endovascular abdominal aortic aneurysm repair. METHODS: The medical notes and all preoperative and postoperative plain abdominal radiographs and computer tomographic scans were reviewed for a consecutive series of 100 patients (89 men; mean age 75 years, range 56-91) with large iliac arteries (mean 19.7 mm, range 16-22) who had Zenith endovascular stent-grafts inserted for management of aortoiliac aneurysmal disease from January 1999 until September 2002. Endpoints were all-cause mortality, aneurysm-related death, endoleak, secondary intervention, secondary interventions, and stent-graft migration. RESULTS: Mean follow-up was 30.1+/-8.3 months; at the last follow-up, 30% of patients were dead, 3% were aneurysm-related. Seven (7%) patients developed a type Ib endoleak, with the remainder being type II (29%), type Ia (2%), type III (1%), and type V (endotension, 1%). Eight (27.5%) type II endoleaks persisted, with the remainder closing spontaneously with sac shrinkage. The iliac artery-related secondary intervention rate was 10%, and the overall secondary intervention rate was 16%. CONCLUSION: Iliac arteries between 16 and 22 mm in diameter may be treated with a cuff to the iliac limb with an expectation of 90% efficacy. Surveillance is required, with a high index of suspicion for type 1b endoleaks. Early secondary iliac intervention with extension to the external iliac artery is recommended if there is an increase in sac size after 6 months.     

Preliminary results of endovascular abdominal aortic aneurysm exclusion with the AneuRx stent-graft

OBJECTIVES: This study evaluated the clinical effectiveness of the Medtronic AneuRx stent-graft in patients with infrarenal abdominal aortic aneurysms (AAAs) who were treated in an endovascular suite. BACKGROUND: The use of endovascular stent-graft prosthesis for the treatment of AAAs is receiving increasing attention as an alternative to standard surgical repair. Endovascular treatment of AAAs offers the potential to avoid the significant morbidity and mortality associated with surgical repair. METHODS: In this series, 215 patients have undergone AAA exclusion with the AneuRx stent-graft. Six-month follow-up is available in 132 patients; one-year follow-up is available in 84 and two-year follow-up in 22. RESULTS: Of the patients, one hundred ninety-two (89%) were male; 87% had hypertension, and 58.6% were American Society of Anesthesiologists grade IV or higher. The procedural success was 99.5%; we were unable to place the device in one patient. There was no procedural or one-month mortality. There were no acute conversions to surgical repair. One patient had a non-Q-wave myocardial infarction 24 h after the procedure. Endoleaks were present in 82 patients (42%) at discharge, 15 patients (11.3%) at six months and 10 patients (11.9%) at one year. Twenty-two patients had a secondary procedure for endoleak repair of which three were conversions to surgical repair. Twelve late deaths have occurred, none due to device failure or AAA rupture. Mean hospital stay was 1.9 days. CONCLUSIONS: These results reveal that infrarenal AAAs can be safely and successfully treated in an endovascular suite with the AneuRx stent-graft. Further follow-up is needed to determine the long-term efficacy of endoluminal treatment to prevent rupture and death due to AAAs.     

腹主动脉瘤开腹手术与腔内修复术后心肌损伤比较

目的：比较腹主动脉瘤开腹手术与腔内修复术后心肌损伤程度.方法：收集75例腹主动脉瘤开腹切除手术和67例腔内修复手术患者的临床资料,根据患者冠状动脉CT造影（CTA）检查结果所示狭窄程度将所有病例分为轻、中、重三组,CTA示至少一处≥75％狭窄者为重度狭窄组,至少一处≥50％狭窄者为中度狭窄组,狭窄均＜50％者为轻度狭窄组.以肌钙蛋白I（cTnI） ≥0.01 μg/L为升高.每组进行两种术式病史资料及术后24h cTnI升高情况的比较.结果：中度狭窄组腔内介入13例,共6例术后cTnI升高,发生率46％;开腹手术15例中13例术后cTnI升高,发生率87％,两者比较,差异有统计学意义（P =0.042）.轻度狭窄及重度狭窄组腔内介入与开腹手术术后cTnI升高发生率差异无统计学意义（P＞0.05）.结论：冠状动脉中度狭窄患者腔内修复术较开腹手术术后心肌损伤发生率低.