Final Results of the Prospective European Trial of the Endurant Stent Graft for Endovascular Abdominal Aortic Aneurysm Repair

Objectives

The Endurant Stent Graft System (Medtronic Vascular, Santa Rosa, CA) is specifically designed to treat patients with abdominal aortic aneurysm, including those with difficult anatomies. This is the 1-year report of a prospective, non-randomised, open-label trial at 10 European centres.

Methods

Between November 2007 and August 2008, 80 patients were enrolled for elective endovascular aneurysm repair (EVAR) with the Endurant; 71 with moderate (≤60°) and nine with high (60–75°) infrarenal aortic neck angulation. Safety and stent-graft performance were assessed throughout a 1-year follow-up period.

Results

The device was successfully delivered and deployed in all cases. All-cause mortality was 5% (4/80), with one possibly device-related death. Serious adverse events were comparable between the high and moderate angulation groups. There were no device migrations, stent fractures, aortic ruptures or conversions to open repair. Maximal aneurysm diameter decreased >5 mm in 42.7% of cases. A total of 28 endoleaks were observed (26 type II, two undetermined). Three secondary endovascular procedures were performed for outflow vessel stenosis, graft limb occlusion and iliac extension, resulting in a secondary patency rate of 100%. No re-interventions were required in the high angulation group.

Conclusions

The Endurant Stent Graft was successfully delivered and deployed in all cases and performed safely and effectively in all patients, including those with unfavourable proximal neck anatomy.     

腹主动脉瘤腔内修复与开腹切除术的麻醉管理比较

目的比较腹主动脉瘤腔内修复与开腹切除术的麻醉管理特点。方法 2010年2月~2011年1月,70例ASAⅡ~Ⅳ级,肾下型腹主动脉瘤行腔内修复术52例（腔内修复组）,开腹切除术18例（开腹切除组）。开腹切除组采用气管内插管全身麻醉。腔内修复组采用的麻醉方法包括气管内插管全身麻酔、全凭静脉麻醉（喉罩通气）和监护麻醉。气管内插管全身麻醉采用快速顺序静脉诱导,气管插管后机械控制呼吸,静吸复合方式维持麻醉;全凭静脉麻醉（喉罩通气）采用丙泊酚靶控静脉输注,经喉罩行机械通气控制呼吸;监护麻醉保留自主呼吸,适当镇静镇痛。结果开腹切除组在气管内插管全身麻醉下完成手术,术中均需要使用血管活性药物控制血压。腔内修复组有57.7%（30/52）的患者采用气管内插管全身麻醉、34.6%（18/52）的患者采用全凭静脉麻醉（喉罩通气）和7.7%（4/52）的患者在监护麻醉下完成手术。与开腹切除组相比,腔内治疗组术中血压较平稳,麻醉时间[（90±27）min vs.（210±44）min,t=13.668,P=0.000]、手术时间[（45±22）min vs.（187±36）min,t=-19.811,P=0.000]、术中输注晶体液[（750±178）ml vs.（1896±367）ml,t=17.486,P=0.000]、胶体液[（349±147）ml vs.（1257±266）ml,t=18.034,P=0.000]、异体血[（50±34）ml vs.（898±154）ml,t=-37.615,P=0.000]、术后返ICU患者比例（15.4%vs.66.7%,χ2=17.231,P=0.000）及术后住院时间[（8.5±2.1）d vs.（15.2±4.3）d,t=8.700,P=0.000]均明显降低。结论腹主动脉瘤腔内修复术的麻醉手术时间、液体出入量及血管活性药物应用水平远低于腹主动脉瘤开腹切除术,且监护麻醉、全凭静脉麻醉适用于该术式。     

Prevalence of Thoracic Aortic Aneurysms in Patients with Degenerative Abdominal Aortic Aneurysms: Results from the Prospective ACTA Study

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Surgery for Ruptured Abdominal Aortic Aneurysm with an Aortocaval and Iliac Vein Fistula

The purpose of this study was evaluate the operative procedure and outcome of abdominal aortic aneurysm (AAA) patients with aortocaval fistula (ACF) and iliac vein fistula. From 1982 through 2004, we experienced five AAA patients associated with spontaneous aortocaval and aortoiliac venous fistula who underwent repair of AAA. Three patients were in hypovolemic shock, including one patient with cardiopulmonary arrest on admission who required cardiopulmonary resuscitation before surgery. These three ACF patients with hypovolemic shock underwent emergency operation and two patients with stable hemodynamic state underwent urgent operation. One of two ACF patients with stable condition was associated with unstable angina. One AAA patient with ACF-complicated angina underwent AAA repair with coronary artery bypass grafting; the remaining four patients underwent 3 bifurcated graft and 1 tube graft implantation. All surgical treatment of the fistula included direct closure within the aorta under digital compression in four patients and inferior vena cava clamp in one. The mortality rate was 25%. One ACF patient with retroperitoneal hematoma died of bleeding. Survival for ACF depends on early diagnosis and prompt surgical repair. Aortocaval fistula complicated with a rupture of aneurysm into retroperitoneal space had a severe fatal prognosis compared with uncomplicated ACF.     

腹主动脉瘤72例诊断和外科治疗分析

目的总结分析腹主动脉瘤的诊断和外科治疗经验。方法回顾性分析自1995年1月至2004年2月我科收治的72例腹主动脉瘤患者的临床资料。术前根据患者症状和体征，分别采用彩色多普勒超声、CT、MRA和DSA检查明确诊断和拟定手术方案。其中肾动脉下型腹主动脉瘤行择期腹主动脉瘤切除、人造血管移植术58例；肾动脉上型假性腹主动脉瘤行择期囊内修复术1例；肾动脉上型腹主动脉瘤行择期腹主动脉瘤切除人造血管移植术1例；腹主动脉瘤破裂行急诊腹主动脉瘤切除、人造血管移植术12例。结果彩色多普勒超声、CT、MRA和DSA检查均能确诊腹主动脉瘤；58例肾动脉下型腹主动脉瘤切除、人造血管移植择期手术，术后死于多器官功能衰竭2例，死亡率为3．45％，其余病例和2例肾动脉上型腹主动脉瘤均获临床治愈。12例腹主动脉瘤破裂者临床治愈7例，5例术后死于多器官功能衰竭，死亡率为41．67％。结论加强腹主动脉瘤手术患者围手术期评估和管理，尤其是保证术中内环境稳定，减少术中失血，可使腹主动脉瘤手术更为安全、有效。     

Implications of Attendance Patterns in Northern Ireland for Abdominal Aortic Aneurysm Screening

Introduction

Evidence supports the introduction of an abdominal aortic aneurysm (AAA) screening programme. The aims of this study were to estimate future disease patterns and to determine the effect of the proportion attending on the programme’s cost-effectiveness.

Patients and methods

The results of the local AAA screening programme were reviewed. Ultrasonic infrarenal aortic diameter of 30 mm was considered aneurysmal. Projected population numbers from the Department of Health and current disease prevalence were used to estimate future number of potential patients. The Multi-centre Aneurysm Screening Study (MASS) Markov model was used to calculate an incremental cost-effectiveness ratio (ICER) and 95% uncertainty intervals (UI), using a 30-year time horizon and 3.5% per annum discount, to determine the effect of attendance.

Results

Men were recruited from August 2004 to May 2010. 13316 were invited for a scan and 5931 (44.5%) attended. 321 AAA were diagnosed, giving a prevalence of 5.4%, while 27 large AAA (0.46%) were repaired. The annual incidence of AAA until 2021 will range from 441 to 526, with an incidence of 40–48 large AAA, with both showing a gradual increase with time. Using this attendance rate, the ICER was calculated at £2350 per life-year gained (95% UI: £1620–£4290), or £3020 per quality-adjusted life-year gained (95% UI: £2080–£5500).

Conclusions

The prevalence of disease in this local AAA screening was similar to other studies. The low attendance will result in many AAA being missed, but will not impact greatly on the long-term cost-effectiveness.     

Elective Resection of Pheochromocytoma with Concomitant Abdominal Aortic Aneurysm Repair: Report of a Case

We report a rare case of coexistent pheochromocytoma and abdominal aortic aneurysm (AAA). The patient was a 72-year-old man who presented to the Emergency Department with severe dyspnea and hypertension. Physical examination revealed a pulsatile mass in his abdomen. A computed tomography scan, done after pharmacological treatment of his symptoms, showed a thoraco-AAA and a left adrenal mass. His urinary vanylmandelic acid and metanephrine levels were found to be elevated, strongly indicative of a diagnosis of pheochromocytoma. We gave the patient phenoxybenzamine, an α-blocker, preoperatively, then resected the adrenal mass and repaired the AAA. The patient had an uneventful recovery. The diagnosis of pheochromocytoma was confirmed histologically. To our knowledge, this is the first reported case of elective resection of both these lesions.     

Doxycycline Treatment in a Model of Early Abdominal Aortic Aneurysm

Purpose. To evaluate the effects doxycycline (Dox) in animal models of early abdominal aortic aneurysm. Methods. Of 43 male Wistar rats, 33 underwent intraluminal perfusion of the abdominal aorta with thioglycolate plus plasmin to reproduce early aortic aneurysm. These rats then were treated for 7 days with subcutaneous injections of Dox or saline. The 10 remaining rats underwent intra-aortic perfusion with saline and were injected subcutaneously with saline. On day 7, the rats were killed after abdominal aortic diameters were measured. Some aortic specimens were examined microscopically after elastica van Gieson (EVG) and hematoxylin–eosin (H&E) staining. In other specimens, the matrix metalloproteinase (MMP) activity in tissue extracts was evaluated by gelatin zymography. Results. Among the thioglycolate plus plasmin-perfused rats, the degree of aortic dilation was less in Dox–treated than in saline-treated rats. EVG staining indicated that Dox maintained a nearly normal pattern of elastic lamellae and normal medial elastin thickness. The aortic inflammatory response was not suppressed by Dox in H&E staining. In gelatin zymography, Dox reduced the MMP-9 activity, but did not significantly change either MMP-2 or the percentage of activated MMP-2. Conclusions. Dox inhibited experimental aneurysmal dilation by preserving medial elastin. This effect involved the suppression of MMP-9 but not of the MMP-2 activity. Received: February 8, 2002 / Accepted: July 2, 2002 RID="*" ID="*" Reprint requests to: K. Kaito Acknowledgments. We gratefully acknowledge the helpful suggestions of Hiroshi Ohtake, M.D., Fuminari Kasashima, M. D., and Mrs. Yoko Tanaka.     

The Role of Cell Salvage Autotransfusion in Abdominal Aortic Aneurysm Surgery

Objective

Abdominal aortic aneurysm (AAA) repairs, both elective and rupture, are associated with significant blood loss often requiring transfusion. Cell-salvage autotransfusion has been developed to reduce the need for allogeneic blood. We review the literature to delineate the role of cell salvage in reducing allogeneic blood use in open AAA repairs.

Methods

A systematic search of the English-language literature was performed using the PubMed, Embase and Cochrane databases up to August 2010.

Results

Twenty-three studies were identified. Whilst some data are conflicting, cell salvage appears to reduce overall use and exposure to allogeneic blood, and reduces length of intensive care unit and hospital stay after elective AAA repairs. There may be additional benefit by combining cell salvage with other blood-conservation techniques. Use of cell salvage in ruptured AAA repairs consistently reduced blood-product requirements.

Conclusions

Cell salvage appears to reduce blood-product use in both elective and rupture AAA repairs. Owing to the heterogeneity in methodology of published data, further study may be required before cell salvage becomes standard practice in open AAA repairs.     

Management of an Abdominal Aortic Aneurysm in a Patient with End-Stage Liver Disease

Concomitant abdominal aortic aneurysms and cirrhosis that need surgical attention are rare. Currently there are no guidelines with regards to the appropriate timing of the repair of these aneurysms and transplantation. In addition it also raises the issue of which procedure takes precedence. With the advent of endovascular repairs, this issue was resolved with relative ease, by doing the orthotopic liver transplantation (OLT) first and subsequent endovascular stenting on post-operative day 7 during the same hospitalization. This is the first case report of stenting an abdominal aortic aneurysm (AAA) in a liver transplant recipient. The rationale for the OLT and then AAA repair are discussed and formal guidelines are offered.     

Minilaparotomy Abdominal Aortic Aneurysm Repair Versus the Retroperitoneal Approach and Standard Open Surgery

Purpose We evaluated the surgical results of minilaparotomy abdominal aortic aneurysm (AAA) repair in comparison with those of standard open repair and retroperitoneal approach repair.Methods Between February 2000 and January 2003, 30 patients with AAA underwent minimal incision laparotomy repair (MINI) through an abdominal incision 7–12cm long. Their clinical characteristics and in-hospital outcome were then compared with those of patients who had undergone repair of AAA by a standard open technique (OPEN) or retroperitoneal approach technique (RETRO).Results There were significant differences between the MINI, OPEN, and RETRO groups in the time until the patient was able to resume eating (2.4 ± 1.0 vs 4.4 ± 2.4* vs 2.8 ± 1.9 postoperative days [PODs], respectively; *P < 0.05), the time until ambulation outside the room (2.1 ± 0.7 vs 3.5 ± 1.3* vs 2.5 ± 1.9 PODs, respectively; *P < 0.05), and the operation times (188 ± 43* vs 256 ± 77 vs 238 ± 59min, respectively; *P < 0.05).Conclusion Minilaparotomy repair is a feasible technique, which combines the benefits of a small incision with those of conventional open repair. With the exception of patients with an iliac artery aneurysm extending to the external or internal iliac artery, MINI repair should be considered for the elective treatment of patients with aortic disease.     

The Fate of Small Aneurysms of the Internal Iliac Artery Following Proximal Ligation in Abdominal Aortic Aneurysm Repair

To assess the natural history of small internal iliac artery aneurysms (IIAA) measuring 2.0–3.0 cm in diameter, proximally ligated in association with abdominal aortic aneurysm (AAA) repair, we examined 9 of 12 patients who underwent this type of surgery. Postoperative computed tomography scanning demonstrated that three IIAAs were still patent and the other six were thrombosed. An increase in the maximum diameter from that at the time of surgery was seen in four IIAAs. One patient suffered serious complications in that a dilated IIAA caused right ureteral obstruction and subsequent hydronephrosis accompanied by unilateral renal dysfunction. This was successfully treated by resection of the IIAA. The findings of this analysis led us to conclude that small IIAAs associated with AAA repair should be treated by either endoaneurysmorrhaphy or resection of the aneurysm after both proximal and distal ligation. Received: July 21, 1999 / Accepted: May 30, 2000     

Left Renal Vein Anomaly Associated with Abdominal Aortic Aneurysm Surgery: Report of a Case

Retroaortic left renal vein occurs infrequently and poses potential hazards to the surgeon during abdominal aortic surgery. We herein report the case of a 77-year-old man with a retroaortic left renal vein who underwent an abdominal aortic aneurysm (AAA) repair. The retroaortic left renal vein was diagnosed preoperatively by contrast-enhanced computed tomography (CT). The patient underwent a successful abdominal aortic replacement with an uneventful postoperative course without any renal complications. The CT scan was useful for both evaluating the AAA and for establishing the presence of the venous anomaly. Major venous anomalies (retroaortic left renal vein, left renal vein collar, left-sided inferior vena cava, and caval duplication) should thus be taken into consideration in AAA operations.     

破裂腹主动脉瘤的外科治疗体会(附20例报道)

目的探讨破裂腹主动脉瘤的诊断和外科治疗方法。方法回顾性分析2000年1月至2010年12月期间新疆维吾尔自治区人民医院收治的20例破裂腹主动脉瘤患者的临床资料。结果男18例,女2例;年龄31～82岁,平均65.4岁。所有患者中突发性腹或腰背部疼痛20例,血压下降和(或)休克11例,发病前有明确腹主动脉瘤病史7例。所有患者均经彩超、CTA或手术探查确诊。19例患者采用传统开腹手术,1例行腔内支架人工血管置入术。20例患者中围手术期死亡4例,死亡率为20%,死亡原因为循环衰竭1例,多器官功能障碍综合征3例。存活的16例患者恢复顺利。结论手术治疗破裂腹主动脉瘤有效,早期诊断,急诊外科手术,是降低病死率的关键。     

Superior Mesenteric Artery Syndrome in Association with an Abdominal Aortic Aneurysm

Superior mesenteric artery (SMA) syndrome, also known as Wilkie syndrome, is a rare condition characterised by compression of the third part of the duodenum against the aorta by the SMA. This can cause symptomatic duodenal obstruction. It is rarely associated with an abdominal aortic aneurysm (AAA). We report the case of a male patient presenting with an AAA and recurrent upper gastrointestinal symptoms. SMA syndrome was diagnosed with imaging and was then successfully treated by aneurysm repair. This is the smallest AAA associated with SMA syndrome in the literature. We propose an anatomical mechanism for SMA syndrome in this case.