Endovascular management of ruptured, mycotic abdominal aortic aneurysm

Patients with mycotic aneurysms have a high mortality rate. The standard surgical approach can be exceptionally difficult and fraught with complications. There has been reluctance to insert an endograft into an infected field. We believe that this thought should be challenged and present a case of a successful endovascular repair of a ruptured, mycotic abdominal aortic aneurysm. The patient is a 63-year-old man with severe medical comorbidities and methicillin-sensitive Staphylococcus aureus. He required 6 units of red blood cells on admission. Magnetic resonance angiography (MRA) showed a contained rupture of his distal abdominal aorta, and he underwent emergent endovascular repair. An aortomono-iliac device (12 mm x 10 cm iliac extension limb) was inserted along with coil embolization of his right common iliac artery and a femoral-femoral bypass. He did not require additional transfusions after the procedure and was discharged in good condition. He is on antibiotics and doing well 1 year post-op. Endovascular management of ruptured, mycotic aneurysms is feasible. In fact, it is an attractive approach for a medically compromised patient subset that would carry an exceptionally high mortality rate with traditional surgical repair. Further follow-up is necessary to determine its long-term efficacy.     

Patient fitness and survival after abdominal aortic aneurysm repair in patients from the UK EVAR trials

BACKGROUND: The aim was to use a validated fitness score to determine whether fitter patients with a large abdominal aortic aneurysm (AAA) benefited from having open rather than endovascular repair. METHODS: The Customized Probability Index (CPI) was applied to patients in the Endovascular Aneurysm Repair (EVAR) I and II trials. Interaction tests between CPI and randomized group assessed the effect of fitness and type of AAA repair on elective 30-day mortality and 4-year survival. RESULTS: The mean(s.d.) CPI scores were 3.6(9.3) for 1252 EVAR I patients and 10.0(11.3) for 404 EVAR II patients (range - 25 to + 43) (P < 0.001). The fitness of EVAR I patients was classified as good (579 patients, mean CPI - 4.2), moderate (331 patients, mean CPI 5.7) or poor (338 patients, mean CPI 15.1). Only in the good fitness group did 30-day mortality convincingly favour endovascular repair (odds ratio 0.24, P = 0.030), but overall the test of interaction was not significant (P = 0.363). For 4-year all-cause and aneurysm-related mortality, there was no benefit for either treatment across all fitness scores (P = 0.281 and P = 0.371 respectively). CONCLUSION: The benefit of endovascular repair was most convincing in the fittest patients. There was no evidence that the fittest patients benefited more from open surgery.     

Meta-analysis of randomized controlled trials on safety and efficacy of exercise training in patients with abdominal aortic aneurysm

Objective

Low exercise capacity preoperatively leads to increased postoperative complications, perioperative mortality, length of stay, and inpatient costs among patients going through elective abdominal aortic aneurysm (AAA) surgery. Therefore, exercise training may be extremely important for reducing perioperative adverse events in AAA patients. This paper aimed to perform a meta-analysis of randomized controlled trials to evaluate the safety of exercise training and its effects on exercise capacity in AAA patients.

Endovascular abdominal aortic aneurysm repair: a community hospital's experience

Endovascular abdominal aortic aneurysm repair (EVAR) has become the first-line approach for the treatment of abdominal aortic aneurysms. Outcomes outside of tertiary care settings remain unknown. The purpose of this study is to report the midterm outcomes of EVAR in a community hospital. A retrospective review of 75 elective, consecutive EVARs performed at a single nonacademic community hospital was performed. There were no conversions to open repair during or after endovascular repair. The mean follow-up was 18 months. There were no postoperative ruptures or aneurysm-related deaths. At 24 months, freedom from aneurysm-related death was 100%, freedom from secondary interventions was 91%, and freedom from endoleak was 69%. EVAR in the community setting is a safe and durable procedure, even in a medically high-risk population. Comparable outcomes can be achieved to tertiary care centers, in carefully selected patients with favorable anatomy.     

腔内治疗时代腹主动脉瘤传统开放手术的地位和意义

在过去30多年里,随着腹主动脉瘤腔内治疗(EVAR)技术的出现及其越来越广泛地应用,并逐步超越了开放手术治疗的病例数量,导致腹主动脉瘤的治疗方式发生了巨大变化。虽然EVAR成为目前腹主动脉瘤的主要治疗方式,但最新的长期随访结果显示开放手术可能带来更多的远期获益,尤其对于年轻、预期寿命长、围术期风险低的腹主动脉瘤患者。在此背景下,我们需要重新客观地审视开放手术和EVAR的价值和地位。无论是EVAR还是开放手术,均需要结合动脉瘤的解剖结构、患者特点、医生情况等因素综合评估,以实现动脉瘤的充分隔绝,提高远期生存率,降低远期并发症发生率及经济支出。因此,新生一代的血管外科医生不能过多地依赖EVAR,应同时具备腹主动脉瘤开放手术和EVAR的技能,充分发挥两种治疗方式的优势互补,为患者尽可能提供最佳的个体化治疗选择。     

腹主动脉瘤腔内修复术单中心治疗经验

目的 评价腔内修复术(endovascular aneurysm repair,EVAR)治疗肾下型腹主动脉瘤(abdominal aortic aneurysm,AAA)的围术期和中远期效果.方法 回顾性分析131例AAA行EVAR的临床资料,评价EVAR治疗AAA的安全性和中远期疗效.结果 手术时间(137±29) min,术中出血(142±20) ml、输血(46±26) ml、ICU恢复时间为(17±4)h.围术期主要并发症包括重度心功能不全8例、心肌梗死2例、肺部并发症5例,内漏4例等;随访中发现内漏15例,Ⅰ型8例,Ⅱ型5例,Ⅲ型和Ⅳ型各1例,死亡2例;Kaplan-Meier生存分析无并发症生存率及再次处理率提示60个月后仍有并发症发生,其中40％是需要再次处理的并发症.结论 EVAR是AAA的安全治疗方法,但需要长期严格随访并及时处理并发症.     

Endovascular repair of abdominal aortic aneurysm: current status

INTRODUCTION: Endovascular aneurysm surgery (EVAR) was introduced a decade ago. Early results are promising, however, there remain concerns regarding the longer-term durability of this technique. Consequently, the national multi-centre EVAR trial has been commenced to define the role of endovascular surgery in the management of abdominal aortic aneurysm. DISCUSSION: Successful EVAR requires accurate pre-operative assessment of aneurysm morphology. Current stent-grafts allow 60% of all infra-renal AAA to be treated. Reduced physiological stress and low peri-operative morbidity and mortality rates have been demonstrated with this technique when compared to open repair. Endoleak is an Achilles heel of EVAR, although in itself does not accurately predict outcome. First and second generation devices are estimated to have a 1% per year risk of rupture. CONCLUSIONS: Increased understanding of the issues surrounding aneurysm morphology and successful stent-grafting have allowed a major reduction of early type I endoleak. Late endoleak and graft migration remain problematic. Type I and III endoleaks are risk factors for subsequent rupture although the significance of type II endoleak remains uncertain. More robust indicators of outcome success/failure are required so that follow-up may be rationalised.     

Outcomes following endovascular abdominal aortic aneurysm repair (EVAR): an anatomic and device-specific analysis

OBJECTIVE: We performed a device-specific comparison of long-term outcomes following endovascular abdominal aortic aneurysm repair (EVAR) to determine the effect(s) of device type on early and late clinical outcomes. In addition, the impact of performing EVAR both within and outside of specific instructions for use (IFU) for each device was examined. METHODS: Between January 8, 1999 and December 31, 2005, 565 patients underwent EVAR utilizing one of three commercially available stent graft devices. Study outcomes included perioperative (< or =30 days) mortality, intraoperative technical complications and need for adjunctive procedures, aneurysm rupture, aneurysm-related mortality, conversion to open repair, reintervention, development and/or resolution of endoleak, device related adverse events (migration, thrombosis, or kinking), and a combined endpoint of any graft-related adverse event (GRAE). Study outcomes were correlated by aneurysm morphology that was within or outside of the recommended device IFU. chi2 and Kaplan Meier methods were used for analysis. RESULTS: Grafts implanted included 177 Cook Zenith (CZ, 31%), 111 Gore Excluder (GE, 20%), and 277 Medtronic AneuRx (MA, 49%); 39.3% of grafts were placed outside of at least one IFU parameter. Mean follow-up was 30 +/- 21 months and was shorter for CZ (20 months CZ vs 35 and 31 months for GE and MA, respectively; P < .001). Overall actuarial 5-year freedom from aneurysm-related death, reintervention, and GRAE was similar among devices. CZ had a lower number of graft migration events (0 CZ vs 1 GE and 9 MA); however, there was no difference between devices on actuarial analysis. Combined GRAE was lowest for CZ (29% CZ, 35% GE, and 43% MA; P = .01). Graft placement outside of IFU was associated with similar 5-year freedom from aneurysm-related death, migration, and reintervention (P > .05), but a lower freedom from GRAE (74% outside IFU vs 86% within IFU; P = .021), likely related to a higher incidence of graft thrombosis (2.3% outside IFU vs 0.3% within IFU; P = .026). The differences in outcome for grafts placed within vs outside IFU were not device-specific. CONCLUSION: EVAR performed with three commercially available devices provided similar clinically relevant outcomes at 5 years, although no graft migration occurred with a suprarenal fixation device. As anticipated, application outside of anatomically specific IFU variables had an incremental negative effect on late results, indicating that adherence to such IFU guidelines is appropriate clinical practice.     

腹主动脉瘤腔内修复面临的挑战和远期疗效研究

腹主动脉瘤(abdominal aortic aneurysm,AAA)治疗的目的在于重建主动脉管腔和血流,防止瘤样病变继续发展和破裂发生,改善与疾病自然病程有关的预后。然而传统的开腹手术存在着创伤大、恢复时间长、并发症发生率和死亡率高等诸多不利因     

Single-center experience of endovascular abdominal aortic aneurysm repair (EVAR) in patients not participating in the U.K. EVAR trials

The objective was to evaluate outcomes of a high-risk patient cohort following endovascular abdominal aortic aneurysm repair (EVAR) treatment not entered into the U.K. endovascular stent-graft aortic aneurysm repair trials (EVAR-1 or -2) because of equipoise absence but where EVAR was judged to be the most appropriate intervention option on compassionate grounds. A single-center retrospective analysis was performed involving all patients undergoing compassionate EVAR treatment during the EVAR-1 and -2 trial period. Over an 8-year period, 34 patients underwent compassionate EVAR procedure. The mean (SD) age was 76 (79) years. The mean (SD) preoperative physiology score (P-POSSUM) was 25 (8.3) with a mean (SD) predicted early mortality of 9.9% (16%). The actual early mortality in our study was 2.9% and morbidity was 35%. There were 8 cases of endoleak: type I (n = 2), type II (n = 5), and type IV (n = 1). Aneurysm-related mortality and all-cause mortality after 8 years were 5.8% and 23.5% respectively. Satisfactory outcome with low mortality (2.9%) and morbidity can be achieved in patients with compassionate indications, where clinicians judge EVAR to be an advantage over open abdominal aortic aneurysm repair. Based on our study, the early mortality (2.9%) in our compassionate EVAR group is comparable to EVAR-1 outcomes (1.7%) and better than EVAR-2 mortality results (9%). EVAR should therefore not be denied to a significant number of high-risk abdominal aortic aneurysm patients who fall between the EVAR-1 and EVAR-2 criteria.     

腹主动脉瘤的腔内治疗（附2例报告）

目的探讨腹主动脉瘤腔内治疗的效果。方法对２例行腔内治疗的腹主动脉瘤患者的临床资料进行回顾性分析。结果２例患者均获得技术上的成功,分别随访２周和１年,经超声检查证实置入的支架型人工血管没有移位且保持通畅。结论在腹主动脉瘤的治疗中,如果病例选择得当,与传统的手术治疗比较,腔内治疗操作简单,创伤小,且可大大缩短病人住院时间。