Endoluminal stent grafts for aortic diseases: experience at a major teaching hospital in Hong Kong

Background: The purpose of the present paper was to review the initial experience of an endovascular aortic stent graft program at a major teaching hospital in Hong Kong. Methods: Demographics, operative details, complications and follow‐up data of all the patients receiving endovascular repair for aortic disease were recorded prospectively. Results: Between July 1999 and December 2001, endovascular repairs were attempted in 39 patients with aortic disease. The procedural success rate was 97.4%. Thirty‐three procedures were for abdominal aorto‐iliac aneurysms. Graft configuration was bifurcated in 28 patients (85%) while an aorto‐uni‐iliac device with a femoro‐femoral bypass was carried out in the remaining five patients. Thoracic procedures were carried out for one thoracic aortic aneurysm, two traumatic thoracic aortic injuries, one thoracic aortic dissection, and one thoracic aortic pseudoaneurysm with aorto‐oesophageal fistula. There was one hospital mortality (2.6%) from a type A thoracic aortic dissection with cardiac tamponade. Postoperative complications were seen in seven patients (18%). With a mean follow‐up of 11.6 ± 8.1 months, there was no open conversion or rupture. The endoleak rate was 27% at discharge, 15% at 6 months and 5% at 12 months postoperatively. For aneurysm endografts, the aneurysm sac decreased in size in 21 patients (62%), and remained static in 13 patients (38%). Conclusions: The endoluminal stent graft appears to be a promising device that can be used safely in selected patients with aortic disease. Continued follow‐up is required to monitor the presence of endoleak and the size of the aneurysm sac.     

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.     

Transluminal iliac angioplasty with distal bypass surgery in patients with critical limb ischaemia

Transluminal balloon angioplasty of the iliac artery was combined with a distal bypass graft procedure in 25 patients with critical ischaemia of the lower limb. Eleven patients had angioplasty in the operating theatre before a vascular graft and the remaining 14 patients had percutaneous transluminal angioplasty performed in the X-ray department before bypass surgery. The distal bypass grafts were 20 femoropopliteal and five femorofemoral grafts. Two patients died in the immediate postoperative period. Follow-up of patients ranged from 2 to 26 months with a graft patency of 63% at 12 months and 50% at 24 months but successful limb salvage rate of 75% at 12 and 24 months. Six patients required major amputations for failure of limb salvage. Transluminal iliac angioplasty is a valuable adjunct to distal bypass surgery by improving arterial inflow without the requirement for major aorto iliac surgery.     

Endovaskuläre Therapie bei aneurysmatischer Allograftdegeneration

Graft infections following aortic vascular procedures are rare, but they are life threatening. Orthotopic vascular restoration with allogenic grafts is a therapeutic option following removal of the infected material. However, graft degeneration is a well-known drawback during follow-up. We present a case of prosthetic infection (bifurcated graft) managed by orthotopic reconstruction with cryopreserved allografts. During follow-up of 27 months without infection, aneurysmal degeneration of the iliac femoral part of the allograft developed. Bilateral endovascular aneurysm exclusion was performed by a homemade device (ePTFE and Palmaz^® stent). According to the results of follow-up, the endovascular approach might become the therapy of choice in cases of aortic allograft degeneration.     

Predicting iliac limb occlusions after bifurcated aortic stent grafting: anatomic and device-related causes

OBJECTIVE: Graft limb occlusion may complicate endovascular abdominal aortic aneurysm repair. The precise etiologic factors that contribute to the development of these graft limb thromboses have not been defined. We evaluated our experience with bifurcated aortic endografts to determine factors that may predict subsequent limb thrombosis. The management of the thrombosed limbs and the results after treatment were also investigated. METHODS: During a 4-year period, 351 patients with aortic aneurysms underwent treatment with bifurcated endografts (702 graft limbs at risk). These 351 bifurcated devices included AneuRx (Medtronic, Minneapolis, Minn; n = 35), Ancure (Guidant, Menlo Park, Calif; n = 8), Gore (W.L. Gore & Associates, Sunnyvale, Calif; n = 25), Talent (World Medical, Sunrise, Fla; n = 255), Teramed (Teramed, Minneapolis, Minn; n = 10), and Vanguard (Boston Scientific Vascular, Natick, Mass; n = 18). Details regarding the type of device, mechanism of deployment, and aortoiliac artery anatomy were collected prospectively and analyzed. Graft limbs were analyzed for diameter, use of additional endograft iliac extensions, deployment in the external iliac artery, and endograft to vessel oversizing. Follow-up included physical examination, duplex ultrasonography, and spiral computed tomographic scans at 1 month, 6 months, and 12 months and annually thereafter. The follow-up period ranged from 2 to 54 months, with a mean follow-up period of 20 months. RESULTS: Twenty-six of 702 limbs (3.7%) had an occlusion develop. The risk of limb thrombosis was associated with a smaller limb diameter. Mean graft limb diameter was 14 mm in the occluded population, and patent limbs had a mean diameter of 16 mm. Thrombosis occurred in 16 of 291 limbs (5.5%) that were 14 mm or less and in 10 of 411 limbs (2.4%) that were greater than 14 mm (P =.03). Extension of a graft to the external iliac artery was performed in 96 of the 702 limbs. Eight of these 96 limbs (8.3%) had thrombosis develop as compared with 18 of 606 (3.0%) that extended to the common iliac artery (P =.01). No significant association was present between limb thrombosis and the contralateral or ipsilateral side of a device, the configuration of the iliac graft limb end (closed web, open web, or bare spring), or the degree of iliac graft limb oversizing. AneuRx, Ancure, Vanguard, and Talent grafts each sustained limb occlusions, with no occlusions seen among the Gore and Teramed devices. No significant increased risk of graft limb thrombosis was observed in unsupported grafts (1/16; 6.3%) versus supported grafts (25/686; 3.6%; P = not significant). Thromboses occurred between 1 day and 23 months after surgery. Thirteen of the 26 thromboses (50%) occurred within 30 days of surgery. Presenting symptoms were mild to moderate claudication in eight patients (30.8%), severe claudication in 16 patient (61.5%), and paresthesia and rest pain in two patients (7.7%). Eighteen of 26 patients (69.2%) eventually needed intervention to reestablish flow to the occluded limb, including thrombolysis and stenting in two patients (7.7%), axillary femoral bypass in one patient (3.8%), femoral-femoral bypass in 13 patients (50.0%), and axillary-bifemoral bypass in two patients (7.7%). All patients with mild to moderate symptoms under observation had improvement in symptoms with no further interventions necessary. All revascularizations were successful in relieving symptoms. CONCLUSION: Graft limb occlusion is a recognized complication of endovascular treatment of abdominal aortic aneurysms that may be associated with smaller graft limb diameter and extension to the external iliac artery. Occlusions usually necessitate additional intervention for resolution of ischemic symptoms. The use of small diameter grafts should be avoided when possible to reduce the risk of graft limb occlusions.     

Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair

INTRODUCTION: Endovascular aneurysm repair (EVAR) with aortouniiliac prostheses extends the morphologic range of aneurysms that can be treated and is potentially a more rapid and simple operation than bifurcated endovascular repair. It may, however, be limited by durability of the femorofemoral extra-anatomic bypass graft required to revascularize the contralateral lower limb. Previous studies of femorofemoral bypass grafts were performed almost exclusively in patients with occlusive disease. An 8-year single center experience with use of the femorofemoral bypass graft in aneurysmal disease is reported. METHODS: All patients undergoing EVAR with an aortouniiliac endovascular stent graft over eight years (1994-2002) at a single institution were included in a retrospective study. Patient data were collected from a prospectively maintained local endovascular database. All patients gave informed consent and were part of an endovascular program approved by the local ethics committee. RESULTS: Over the 8 years, 231 patients underwent EVAR with an aortouniiliac endovascular stent-graft. Median follow-up was 22 months. Localized wound complications were observed in 25 patients (11%). Cumulative 3-year patency rate for the femorofemoral bypass graft was 91%. At the end of 5 years 83% of grafts remained patent. CONCLUSIONS: The femorofemoral bypass graft used during EVAR with aortouniliac stent grafts offers encouraging medium and long-term patency. When graft occlusion occurs, it is usually directly attributable to inadequate inflow from the endovascular stent graft itself or to endoluminal damage of the external iliac artery. Awareness and early detection of stent-graft distortion or complications in the external iliac artery may result in improved patency rates.     

Successful treatment of endotension and aneurysm sac enlargement with endovascular stent graft reinforcement

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair because of endoleak, which is persistent blood flow within the aneurysm sac. In the absence of detectable endoleak, AAA may still expand, in part because of endotension, which is persistent pressurization within the excluded aneurysm. We report three patients who underwent successful endovascular AAA repair using the Excluder device (W. L. Gore & Associates, Flagstaff, Ariz). Although their postoperative surveillance showed an initial aneurysm regression, delayed aneurysm enlargement developed in all three, apparently due to endotension. Endovascular treatment was performed in which endograft reinforcement with a combination of aortic cuff and iliac endograft extenders were inserted in the previously implanted stent grafts. The endograft reinforcement procedure successfully resulted in aneurysm sac regression in all three patients. Our study underscores the significance of increased graft permeability as a mechanism of endotension and delayed aneurysm enlargement after successful endovascular AAA repair. In addition, our cases illustrate the feasibility and efficacy of an endovascular treatment strategy when endotension and aneurysm sac enlargement develops after endovascular AAA repair.     

Hypogastric preservation with Viabahn stent graft during endovascular aneurysm repair

The presence of bilateral iliac aneurysms extending to the iliac bifurcations, in conjunction with an abdominal aortic aneurysm, complicates endovascular repair because of the difficulty of preserving one or both hypogastric arteries. Several open techniques have been suggested for hypogastric preservation, but they usually involve some type of anatomic or extra-anatomic bypass. Endovascular techniques for hypogastric preservation include branch iliac grafts, chimney grafts, and bellbottom limbs. We report the use of a Viabahn stent graft (W. L. Gore and Associates, Flagstaff, Ariz) within the iliac limb of a Powerlink device (Endologix, Inc, Irvine, Calif) to preserve a hypogastric artery.     

Ancillary techniques to facilitate endovascular repair of aortic aneurysms.

PURPOSE: The ability to treat abdominal aortoiliac aneurysms and thoracic aortic aneurysms may be limited by coexisting arterial disease. Device deployment may be impaired by occlusive disease and tortuosity of the arteries used to access the aneurysm or by suitability of the implantation sites. In this study we describe the auxiliary procedures performed to circumvent these obstacles and thereby enable endovascular aneurysm repair. PATIENTS AND METHODS: Between January 1, 1993, and December 31, 1999, 390 patients treated for aneurysm of the aorta with endovascular devices were entered prospectively in a vascular registry. Fifty (12%) of the 390 patients required adjunctive surgical techniques to (1) create or extend the length of the proximal or distal device implantation site or (2) permit device navigation through diseased iliac arteries. Auxiliary techniques used to extend or enhance implantation sites were elephant trunk graft (n = 2), the construction of renovisceral bypass grafts (n = 1), and subclavian artery transposition (n = 2). Plication of the common iliac artery at its bifurcation was performed in conjunction with femorofemoral bypass graft in nine patients to allow preservation of pelvic circulation by avoiding internal iliac artery sacrifice. Construction of a bypass graft to transpose the internal iliac artery orifice was performed in one patient. The auxiliary techniques used to facilitate device navigation were iliac artery angioplasty or stenting (n = 8), external iliac artery endovascular endarterectomy or straightening (n = 14), endoluminal iliofemoral bypass conduit (n = 5), and the construction of an open iliofemoral bypass conduit (n = 8). RESULTS: Successful deployment of the endovascular devices was achieved in 49 (98%) of 50 patients. Auxiliary techniques were successful in providing access for endovascular device deployment in all 35 patients (100%). Mean follow-up for techniques to facilitate device navigation is 26 months for endovascular procedures and 42 months for the open bypass graft construction patients; no occlusions were observed at this moment. There were five patients with incisional hematomas that did not necessitate intervention. Fourteen (94%) of 15 patients underwent successful device implantation after the auxiliary maneuvers to enhance implantation site. Mean follow-up for implantation site manipulation is 28 months. One of the subclavian transpositions had a new onset of Horner's syndrome, two of nine patients who had common iliac artery ligated had retroperitoneal hematomas that did not necessitate interventions, and no colon ischemia was seen. The patient who underwent nonanatomic bypass grafting of viscero-renal arteries had a retroperitoneal hematoma that necessitated reexploration. CONCLUSIONS: Significant coexisting arterial disease may be encountered in patients with aortic or iliac aneurysms. Identification of coexisting arterial diseases is essential to help tailor the appropriate supplemental surgical procedure to allow the performance of endovascular aneurysm repair in patients who would otherwise require open surgical repair.     

Aortoiliac surgery concomitant with kidney transplantation: a single center experience

Abstract: Introduction: Aortoiliac pathology in kidney allograft recipients is not rare but treatment timing is controversial. As most publications on this topic are case reports it’s difficult to evaluate long‐term outcomes of those clinical challenges. Herein we report long‐term results of these procedures. Methods: From 1970 to 2006, 1544 kidney transplants were performed in our center. Thirty patients underwent aortoiliac surgery simultaneously with kidney transplantation. We analyzed their clinical records to come up with outcomes of these complex clinical challenges. Results: Vascular pathology was distributed as following: 19 stenoses treated with endarterectomy (15), aortoiliac bypass (two), aorto‐bi‐iliac bypass (one) and aorto‐bifemoral bypass (one); and 11 aneurysms treated with arterioplasty (four), aorto‐bi‐iliac bypass (four) and iliac‐iliac bypass (three). In 24 cases (80%) the necessity of vascular surgery was established intraoperatively as vessels’ conditions did not permit safe anastomoses and jeopardized graft survival. Mean follow‐up was 59 months (12–125). Five (16.7%) grafts were lost and three (10%) patients died in the first post‐operative month: acute myocardial infarction (two) and non‐viable kidney (one). Three patients died six, seven and 10 yr after the procedure. Nineteen patients are currently well with functioning grafts. Conclusions: Surgical correction of aortoiliac pathology may be performed simultaneously with kidney transplantation with acceptable outcome. This complex surgery can be performed in centers with experienced vascular surgeons. Specific vascular imaging should be performed regularly on patient at risk of aortoiliac disease before insertion and while on waiting list.     

Initial experience with endovascular aortic aneurysm repair without cardiologists or radiologists--do vascular surgeons really need them?

Endovascular abdominal aortic aneurysm repair (EVAR) has been predominantly accomplished by teams of multidisciplinary interventionalists, frequently under the primary direction of cardiologists and radiologists. The purpose of this paper was to examine the feasibility and safety of an initial experience of EVARs performed by vascular surgeons at a single institution without other interventionalists. The authors reviewed the first 50 EVARs performed solely by vascular surgeons at our hospital, which we believed represented a fair and sizable enough learning curve for this new procedure. The operations were performed in an endovascular operating room and the surgeons had prior endovascular experience. The EVAR protocol included preoperative abdominal computed tomography (CT) scans and aortograms, same-day admissions, epidural anesthesia, transfer to the ward the day of surgery, and discharge the first postoperative day. CT scans were performed on postoperative day 1 and then annually, unless duplex ultrasound (DU) suggested an endoleak. DU was performed 1 week postoperatively, every 3 months for the first year, and then every 6 months thereafter. Of the first 23 patients, 3 required immediate conversion to open repair because of device malfunction (all in a Phase III FDA trial) and 1 underwent conversion 3 weeks after initial graft placement during treatment of a failing endograft limb as diagnosed by duplex ultrasonography. None of the next 27 cases required conversion. In 2 (4%) patients, graft limb occlusions occurred postoperatively and were treated with femorofemoral crossover grafts. There were 5 (10%) endoleaks: 2 were treated endovascularly, 1 closed spontaneously, and 2 were followed. Several advanced adjunctive endovascular procedures were performed concomitantly during EVAR including internal iliac artery coil embolization using aortic crossover catheters in 16% (8/50) of patients, proximal or distal extension cuff placement in 16% (8/50), and graft limb stenting in 50% (25/50). The average length of stay for patients who underwent uncomplicated aortic stent grafts was 1.9 days (range, 1-4 days) compared to 2.3 days for all patients (range 1-13 days). In no case were other interventionalists necessary for intraoperative assistance. These results of EVAR performed solely by vascular surgeons are comparable to reports by multidisciplinary teams and support the premise that vascular surgeons with endovascular skills have the knowledge and capability to begin performing EVAR independently of other specialists.     

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.)     

Hypogastric artery preservation during aortoiliac aneurysm repair

Hypogastric artery (HA) embolization with iliac limb extension is often performed for patients with concomitant aorta and common iliac artery aneurysms at the time of standard endovascular aneurysm repair. However, symptomatic pelvic ischemia following HA exclusion can be debilitating. In this study, we described two cases of HA preservation using commercially available stent grafts. The techniques that we described enable patients with concurrent aorta and iliac aneurysms to undergo endovascular aneurysm repair without increasing the risk of pelvic ischemia. Although the long-term durability of these trifurcated graft configurations remains to be determined, the short-term results are superb. Technical considerations of these two different approaches have also been compared.     

Incidence and treatment of intraoperative technical problems during endovascular repair of complex abdominal aortic aneurysms

PURPOSE: The purpose of this study was to assess the incidence and management of intraoperative technical problems during endovascular repair (EVR) of complex abdominal aortic aneurysms (AAA). METHODS: From February 1995 to March 1999, 204 EVRs of nonruptured AAA were performed at our institution. One hundred seventy-six patients had an in-house custom-made graft; 172 were aorto-uni-iliac grafts, and four were aortoaortic grafts. Twenty- eight patients had a bifurcated graft. One hundred fourteen patients (56%) were high risk for conventional open repair. One hundred nine patients (53%) were not suitable for most commercially available devices. RESULTS: Intraoperative technical problems occurred in 81 patients (40%). There were 37 endoleaks (27 proximal, 10 distal), 15 graft stenoses, one failure of graft deployment, two graft thromboses, three aortoiliac ruptures, five renal artery occlusions (one bilateral, four unilateral), and 18 internal iliac occlusions (five bilateral, 13 unilateral). Endovascular management of these problems was successful in 37 of the 81 patients (46%) and included 15 balloon dilatations, 21 additional stent placements, and one graft thrombectomy. Fifteen of the 81 patients (19%) had open procedures (four periaortic ligature placements, six open aneurysm repairs, three common iliac ligations, and two extra-anatomic bypass grafts). In the remaining 29 patients, the on-table problem was managed expectantly. During follow-up, two of 37 patients (5%) who were treated successfully with endovascular procedures experienced recurrence. There were five deaths (33%) among the 15 patients who underwent open procedures. CONCLUSION: Intraoperative problems occur frequently during the endovascular management of complex aneurysms. Many of these problems can be managed with additional endovascular techniques without an increased risk of recurrence or procedure-related complications. Open procedures in high-risk patients carry a high mortality rate. The team performing EVR of AAA should be skillful in advanced endovascular and open surgical procedures.     

Internal iliac artery revascularization as an adjunct to endovascular repair of aortoiliac aneurysms.

PURPOSE: Endovascular repair of aortoiliac aneurysms may be limited by extension of the aneurysm to the iliac bifurcation, necessitating endpoint implantation in the external iliac artery. In such cases the circulation to the internal iliac artery is interrupted. Bilateral internal iliac artery occlusion during endovascular repair may be associated with significant morbidity, including gluteal claudication, erectile dysfunction, and ischemia of the sigmoid colon and perineum. We have employed internal iliac artery revascularization (IIR) to allow endograft implantation in the external iliac artery while preserving flow to the internal iliac artery in patients with aneurysms involving the iliac bifurcation bilaterally. METHODS: A total of 11 IIR procedures were performed in 10 patients undergoing endovascular abdominal aortic aneurysm (AAA) repair (9 men, 1 woman; mean age, 74 years). IIR was accomplished via a retroinguinal incision in 9 cases and a retroperitoneal incision in 2 cases. Six-mm polyester grafts were used for external-to-internal iliac artery bypass in 10 cases and internal iliac artery transposition onto the external iliac artery was used in one case. Endovascular AAA repair was performed using a modular bifurcated device (Talent-LPS, Medtronics, Minneapolis, Minn) after IIR. Bypass graft patency was determined immediately after the surgery, at 1 month, and every 3 months thereafter, using duplex ultrasound scanning and computed-tomography angiography. Mean aneurysm diameters were as follows: AAA, 6.4 +/- 0.7 cm; ipsilateral common iliac, 3.7 +/- 1.0 cm; contralateral common iliac, 3.9 +/- 0.8 cm. RESULTS: Successful IIR and endovascular AAA repair were accomplished in all cases. No proximal, distal, or graft junction endoleaks occurred. Two patients demonstrated retrograde aneurysm side-branch endoleaks originating from the lumbar arteries. One thrombosed spontaneously within 3 months. One perioperative myocardial infarction occurred. Reduction in aneurysm size was documented in 5 aortic, 5 ipsilateral iliac, and 3 contralateral iliac aneurysms. Gluteal claudication, erectile dysfunction, colon and perineal ischemia, and mortality did not occur. All IIRs have remained patent during a follow-up period of 4 to 15 months (mean, 10.1 months). CONCLUSIONS: IIR may be used with good short-term to intermediate-term patency to prevent pelvic ischemia in patients whose aneurysm anatomy requires extension of the endograft into the external iliac artery. This may allow endovascular AAA repair to be performed in patients who might otherwise be at risk for developing complications associated with bilateral internal iliac artery occlusion.     

Endovascular Repair of Paraanastomotic Aneurysms after Previous Open Aortic Prosthetic Reconstruction

The aim of this study was to evaluate the effectiveness of endovascular repair of anastomotic and true aortic and iliac aneurysms occurring after prior polyester graft repair for abdominal aortic aneurysms (AAA) or aortoiliac obstructive disease. Between July 1999 and January 2003, 14 patients underwent endovascular treatment of aortic pseudoaneurysms (n = 6) or iliac aneurysms (2 patients with pseudoaneurysms and 6 patients with true aneurysms) occurring 4 to 18.4 years (mean, 8.8 years) after open aortic surgery. No patient had symptoms or positive parameters for infection of the original polyester graft. Eleven patients, including one patient with both a proximal anastomotic and a true iliac aneurysm, were treated with AneuRx (n = 8), Talent (n = 2), or Quantum LP (n = 1) bifurcated stent grafts. Three patients with an infrarenal anastomotic pseudoaneurysm were treated with a tube stent graft (Talent [n = 2] and AneuRx [n = 1]). Endovascular stent grafts were successfully inserted in all patients. Procedure-related complications or death was not seen. During a median follow-up of 12 months (range, 3-40) all anastomotic and/or true aneurysms treated with bifurcated stent grafts maintained excluded. However, two out of three patients, treated with a tube graft for proximal aneurysm exclusion, were converted. In both patients the tube stent graft did not migrate from the level of the renal arteries but fixation failed between the stent graft and the previous polyester graft, creating endotension in the thrombus of the aneurysm sac. In one of these patients the old anastomotic aneurysm ruptured 16 months after stent graft placement and the patient died 1 day after conversion because of mesenterial ischemia. At 1 year follow-up the second patient was converted successfully after enlargement of his anastomotic aneurysm due to similar disconnection between the stent graft and the polyester graft. From this experience with endovascular stent grafts, we conclude that these can be used successfully to exclude anastomotic or true aneurysms after open aortic surgery. Exclusion of aneurysms at the proximal anastomosis with tube stent grafts is apparently not durable because of the insecure distal fixation in polyester grafts. Endovascular repair with bifurcated stent grafts, however, seems to be effective at midterm follow-up.Presented at the Twenty-eighth Annual Meeting of the Peripheral Vascular Surgery Society, Chicago, II, June 7, 2003.     

Midterm experience with the endovascular treatment of isolated iliac aneurysms.

PURPOSE: This report describes our 5-year experience with the endovascular repair of isolated iliac aneurysms and pseudoaneurysms. METHODS: Between June 1993 and July 1998, 40 isolated iliac aneurysms and pseudoaneurysms were treated with endovascular grafts in 39 patients. Thirty-seven aneurysms were treated with endovascular grafts composed of polytetrafluoroethylene grafts and balloon expandable stents, and the other three underwent repair with a polycarbonate urethane endoluminal graft. RESULTS: All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and pseudoaneurysms and were followed from 1 to 51 months (mean, 18 months). The 4-year primary patency rate was 94.5% +/- 10%. The perioperative complications included one episode of distal embolization, an episode of colonic ischemia, five episodes of kinking or compression of the endovascular graft, and one early postoperative graft thrombosis. There was only one perioperative death in a patient whose aneurysm ruptured in the operating room just before endovascular repair. The median postoperative length of hospital stay was 3.0 +/- 1.3 days in this group of patients at moderate and high risk. The long-term complications included one graft thrombosis and two endoleaks. One small endoleak was followed until the patient died of unrelated causes, and the other one led to aneurysm rupture in the only patient temporarily lost to follow-up examination. This patient successfully underwent treatment in the standard open surgical fashion. To date, all the other aneurysms have remained stable or have decreased in size during the follow-up examinations with duplex or contrast-enhanced computed tomographic scans. CONCLUSION: Endovascular repair of iliac aneurysms and pseudoaneurysms is a safe and effective technique with good midterm results in patients at standard and high risk. These grafts are particularly beneficial for patients with medical, surgical, or anatomic contraindications for open surgical repair.     

Modular component separation and reperfusion of abdominal aortic aneurysm sac after endovascular repair of the abdominal aortic aneurysm: A case report

Transluminal placement of a stent graft in patients with an abdominal aortic aneurysm is a new endovascular technique that offers a potentially less invasive and less risky alternative to open surgery. Complications after stent graft placement are not infrequent, but in most cases secondary endovascular intervention is successful. We describe a late major leak in the aneurysmal sac caused by a distal migration of the iliac limb of a bifurcated graft. This late complication was successfully treated by covered stent placement, excluding and thrombosing completely the reformed aneurysm. (J Vasc Surg 1998;28:349-352)     

一体式覆膜支架在腹主动脉腔内修复中的应用

目的:总结一体式覆膜支架在腹主动脉以及髂动脉病变中的应用效果。方法:回顾性分析应用一体式腹主动脉覆膜支架腔内修复腹主动脉瘤15例、髂动脉瘤5例及腹主动脉或髂动脉夹层5例的临床资料。结果:平均时间42.4 min,手术成功率100%(25/25)。术后无I、III型内漏,发生髂动脉血栓形成1例,围术期无死亡病例。随访3~16个月复查无动脉瘤复发和II型内漏。结论:一体式覆膜支架是腹主动脉瘤和夹层动脉瘤腔内治疗方法的一种较好选择,具有快速、简单、有效的优点;其远期疗效需进一步观察。