腔内修复术治疗孤立性髂动脉瘤14例

目的探讨腔内治疗孤立性髂动脉瘤的疗效。方法回顾性分析2004年10月至2006年5月腔内修复孤立性髂动脉瘤14例的临床资料。其中,右髂总动脉瘤8例,左髂总动脉瘤5例,左髂内动脉瘤破裂1例。髂动脉瘤腔内修复的标准是瘤体直径〉3．0cm。结果14例均取得技术成功。8例右髂总动脉瘤,钢圈栓塞右髂内动脉后选用分叉支架型人工血管行腔内修复术。其中1例右髂总动脉瘤累及腹主动脉下端,选用AUl支架型人工血管腔内修复加股．股动脉旁路术。5例左髂总动脉瘤栓塞同侧髂内动脉后选用直型支架型人工血管。1例左髂内动脉瘤破裂急诊行钢圈栓塞后选用直型支架覆盖左髂内动脉开口。术后即刻数字减影血管造影显示动脉瘤消失,远近端支架型人工血管与宿主动脉结合处均未见明显渗漏。1例术后出现急性左心功能不全和肺水肿,经抢救痊愈,其余13例无手术并发症。术后CTA随访10．2个月（3～19个月）,瘤体无增大,支架无移位,无内漏,旁路人工血管通畅。结论腔内修复术治疗孤立性髂动脉瘤具有可行、安全、微创等特点,近期疗效较好,远期效果需进一步随访。     

Endovascular management of isolated iliac artery aneurysms

OBJECTIVE: We reviewed our experience with endovascular treatment of isolated iliac artery aneurysms (IAAs). METHODS: Medical records for consecutive patients undergoing endovascular IAA repair from 1995 to 2004 were reviewed. Computed tomography (CT) angiograms were used to assess IAA location, size, and presence of endoleaks after endovascular repair. Rates of primary patency and freedom from secondary interventions were estimated using the Kaplan-Meier life-table method. RESULTS: From July 1995 to November 2004, 45 patients (42 men), with a mean age of 75 years, underwent endovascular repair of 61 isolated IAAs: 41 common iliac, 19 internal iliac, and one external iliac. Five patients (11%) were symptomatic, although none presented with acute rupture. The mean preoperative IAA diameter was 4.2 +/- 1.7 cm. Fifteen patients (33%) had prior open abdominal aortic aneurysm repair. Local or regional anesthesia was used in 28 cases (62%). Thirty-four patients (75%) were treated with unilateral iliac stent-grafts, eight (18%) with bifurcated aortic stent-grafts, and three (7%) with coil embolization alone. Perioperative major complications included one early graft thrombosis that eventually required conversion to open repair and one groin hematoma that required operative evacuation. On follow-up, late complications included one additional graft thrombosis and one late death after amputation. No late ruptures occurred after endovascular repair, with a mean follow-up of 22 months (range, 0 to 60 months). The mean postoperative length of stay was 1.3 +/- 1.0 days. On postoperative CT scans obtained at 1, 6, 12, 24, and 36 months, aneurysm shrinkage was noted in 18%, 29%, 57%, 67%, and 83% of IAAs, respectively, compared with the baseline diameter. One hypogastric aneurysm enlarged in the presence of a later identified type II endoleak. Five endoleaks were noted (4 type II, 1 indeterminate) at 1 month, with four other endoleaks (1 type II, 1 type III, 2 indeterminate) identified on later CT scans. At 2 years, primary patency was 95%, and freedom from secondary interventions was 88%. CONCLUSIONS: Endovascular repair of isolated IAAs appears safe and effective, with initial results similar to those after endovascular abdominal aortic aneurysm repair.     

Endovascular treatment for para-anastomotic abdominal aortic and iliac aneurysms following aortic surgery

AIM: The aim of this study was to report our experience with endovascular repair of anastomotic aneurysms occurring after graft replacement for abdominal aortic aneurysms or aorto-iliac obstructive disease. METHODS: Between January 2000 and April 2006, 19 consecutive male patients (median age 73 years) underwent endovascular repair for 22 anastomotic aneurysms [proximal aortic (n=15), iliac (n=4), concomitant aortic and iliac (n=3)], occurring 3 months to 18 years (mean 8.6 years) after open surgery. Three patients (15.7%) underwent emergency treatment for rupture. No patient had symptoms or positive blood tests for infection of the original graft. Twelve patients were treated with a bifurcated stent-graft, 4 patients with a proximal stent-graft cuff, 2 patients with a tube iliac stent-graft, and 1 patient with a mono-iliac stent-graft. RESULTS: Stent-grafts were successfully deployed in all patients. Procedure-related complications or death were not observed; open conversion was never required. Median hospitalisation was 9 days (range 3-45). During a median follow-up of 16 Euro-months (range, 2-44) all anastomotic aneurysms maintained excluded: 4 patients (21%) died. We observed 1 major complication (5.2%): an iliac branch occlusion occurred 1 month after the procedure, successfully treated with catheter-directed thrombolysis. Overall, survival rates at 6, 12, 18 and 36-months were 92.8%, 84.4%, 72.3%, and 57.8% respectively. CONCLUSION: Our experience confirms that endovascular stent-grafts can be used successfully to exclude anastomotic aortic aneurysms after open surgery. Endovascular repair seems to be effective at mid-term follow-up.     

Endovascular repair of para-anastomotic aneurysms of the aorta and iliac arteries: preferred treatment for a complex problem

PURPOSE: Standard surgical repair of para-anastamotic aneurysms (PAAs) of the abdominal and thoracic aorta and the iliac arteries has been associated with high morbidity and mortality rates. We reviewed our continuing experience with endovascular repair of these lesions to determine whether this approach is favorable and durable. METHODS: All patients with PAAs of the aorta or iliac arteries who underwent endovascular treatment of their lesions between August 1993 and July 1999 were prospectively followed up, and data on age, previous aortic pathology and surgery, size of PAA, time to diagnosis, and symptoms at presentation were recorded. Preoperative, intraoperative, and postoperative imaging studies were analyzed. All patients had endovascular stent-grafts placed under digital fluoroscopic guidance in the operating room. Data on intraoperative and postoperative complications, mortality, and endoleaks were reviewed. RESULTS: From August 1993 to July 1999, 28 patients (20 men, 8 women) had 35 PAAs of the aorta or iliac arteries. There were 5 thoracic aortic, 12 abdominal aortic, and 18 iliac artery PAAs. Three patients had a contained rupture of their PAA. All patients who had originally undergone reconstruction for occlusive disease had lesions consistent with false aneurysms, whereas 73% of the aortic or iliac PAAs in patients originally treated for aneurysm disease appeared to be true aneurysms. Thirty-four of 35 PAAs were successfully excluded with stent-grafts (97%). There was one death at 30 days (3.6%) in a patient who was successfully treated endovascularly for a contained rupture of a thoracic PAA. There were four major postoperative complications (14.2%) in the 28 patients who were treated. One patient had continued perfusion of a thoracic aortic PAA (type I endoleak). The in-hospital length of stay after endovascular repair of PAA was 4 days (range, 1-18 days). The mean follow-up period was 21 months (range, 1-68 months). CONCLUSION: Endovascular repair of aortic and iliac artery PAAs is technically feasible and provides a high rate of lesion exclusion. Morbidity and mortality rates appear lower than those reported for open surgical repair. These patients can typically be discharged by the second postoperative day. Endovascular therapy for stable ruptured PAAs can be successfully performed and should be considered as an option only when appropriate devices and expertise are available. For uncomplicated PAAs of the aorta and iliac arteries, endovascular therapy may be more favorable than surgical repair.     

A comparison of AneuRx aortic cuff and zenith distal flare exclusion of common iliac artery ectasia for endovascular aneurysm repair

Stent-grafts are ideally terminated within the common iliac artery (CIA). However, CIA ectasia may require hypogastric artery occlusion, with stent-graft extension to the external iliac artery. Alternatively, the diameter of the distal stent-graft may be increased, or flared, to allow exclusion of the abdominal aortic aneurysm. This report details the authors' experience with this technique. Forty-one patients received bifurcated stent-grafts (BSG): 20 received an AneuRx device, and 21 received a Zenith device. CIA ectasia (diameter 15-25 mm) was treated with a distal flare of 2-4 mm greater than the CIA diameter. Patients were followed up with computed tomography scan at 1, 6, and 12 months. Statistical analysis was performed using ANOVA within groups and unpaired two-tailed t test between groups. A p value of < 0.05 was considered significant. Eight of 20 patients (40%) (11 CIA) received an AneuRx device and 13/21 (62%) (17 CIA) received a Zenith device, with a distal flare. Values are (n) mean (mm) +/- SE. There were no deaths, endoleaks, migrations, or conversions to open repair. Follow-up mean was 24.7 and 20.6 (range 15-28) months for AneuRx and Zenith groups, respectively. In comparing initial and 12-month CIA diameters, AneuRx grafts 20 +/-0.8 vs 21.5 +/-1.0 were not significantly different, p = 0.2, nor was the same comparison for Zenith, 17 +/-0.5 vs 19.1 +/-0.4, significant, p = 0.57. At a mean follow-up of 12 months, distal flare of iliac limbs with either AneuRx or Zenith devices affords a seal for CIA ectasia and/or aneurysms complicating EVAR.     

Endovascular repair for acute traumatic rupture of the thoracic aorta

BACKGROUND: We report endovascular treatment of acute traumatic rupture of the thoracic aorta as a potential alternative to open surgery for high-risk patients. METHODS: Between January 2001 and July 2002, 9 patients with acute traumatic rupture of the thoracic aorta were treated with a stent-graft. In all cases the endovascular management was selected because of age, associated polytrauma, or comorbidities. Preoperative workup included chest computed tomography scan, transoesophageal echography, and angiography. The devices used were the Excluder and the Talent stent-grafts. RESULTS: Eight patients underwent immediate repair and 1 patient was treated within 5 days of the accident because of delayed diagnosis of aortic rupture after surgical management of spleen rupture. The stent-graft was successfully expanded in all patients through the common femoral artery (n = 7) or the common iliac artery (n = 2). There was no perioperative death, renal failure, or neurologic complication (paraplegia or stroke). In 1 patient the computed tomography scan at 7 days postoperatively showed proximal endoleak requiring placement of a second stent-graft. Follow-up ranged from 4 to 20 months. All spiral computed tomography scans performed during follow-up revealed no evidence of endoleak, migration, or alteration of the stent-graft. CONCLUSIONS: Endovascular repair in the acute phase of traumatic rupture of the thoracic aorta is technically feasible and safe, and may represent an alternative to open surgery for high-risk patients.     

Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair

OBJECTIVE: Precise diameter changes in iliac artery aneurysms (IAAs) after endovascular graft (EVG) repair are yet to be determined. This report describes the midterm size changes in isolated IAAs 13 to 72 months after treatment with an EVG. METHODS: From January 1993 to April 1999, 31 patients with 35 true isolated IAAs (32 common iliac and 3 hypogastric) had these lesions treated with EVGs and coil embolization of the hypogastric artery or its branches. The EVG used in this study consisted of a balloon-expandable stent attached to a polytetrafluoroethylene graft. Contrast-enhanced spiral computed tomographic scans were performed at 3- to 6-month intervals to follow the aneurysms for change in diameter and endoleaks. RESULTS: Thirty patients had a decrease in the size of their iliac aneurysms with EVG repair. All EVGs remained patent. All patients, except for one, were followed up for 13 to 72 months (mean, 31 months). The pretreatment aneurysm size ranged from 2.5 to 11.0 cm in diameter (mean, 4.6 +/- 1.62 cm). After EVG treatment, the aneurysms ranged from 2.0 to 8.0 cm in diameter (mean, 3.8 +/- 1.36 cm). The change in aneurysm diameter ranged from 0.5 to 3.1 cm (mean, 1.1 +/- 0.62 cm) with an average change of -0.516 +/- 0.01 cm/y for the first year. Five patients died of their intercurrent medical conditions during the follow-up period. One of the patients had a new endoleak and an increase in common iliac aneurysm size 18 months after EVG treatment, despite an early contrast-enhanced computed tomographic scan that showed no endoleak. This patient's aneurysm ruptured, and a standard open surgical repair was successfully performed. Another patient had a decrease in hypogastric aneurysm size after EVG treatment and no radiographic evidence of an endoleak, but eventually the aneurysm ruptured. He was successfully treated with a standard open surgical repair. CONCLUSIONS: EVGs can be an effective treatment for isolated IAAs. Properly treated with EVGs, IAAs decrease in size. The enlargement of an IAA, even if no endoleak can be detected, appears to be an ominous sign suggestive of an impending rupture. IAAs that enlarge should be closely evaluated for an endoleak. If an endoleak is detected, it should be eliminated if possible. If an endoleak cannot be found, open surgical repair should be considered.     

Endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers of the descending thoracic aorta

OBJECTIVE: To report our initial experience with endovascular stent-graft repair of complicated penetrating atherosclerotic ulcers as an alternative to surgery in patients with increased risk of perioperative morbidity and mortality. METHOD: During a 2-year period, eight patients with complicated penetrating atherosclerotic ulcers of the descending thoracic aorta were treated with the Gore Excluder stent-graft. Patients (mean age, 70.6 years) presented with two to five comorbid conditions causing an increased risk for surgical repair. In addition to painful events, three patients presented with severe hemoptysis, one patient with shortness of breath, and one patient with dysphagia. All patients underwent emergency computed tomography, and diagnosis of contained rupture was confirmed in five patients. Computed tomographic findings included one to three penetrating ulcers per patient (n = 4), pseudoaneurysms (n = 5), additional intramural hematomas (n = 4), mediastinal bleeding (n = 2), and hematothoraces (n = 4). Through an iliac or femoral access site, a total of 11 stent-grafts were implanted under general (n = 5), epidural (n = 2), or spinal (n = 1) anesthesia. RESULTS: Deployment of stent-grafts was successful in all patients, and all sites of hemorrhage were sealed. The intramural hematoma resolved completely in three cases, and two pseudoaneurysms decreased in size. Intentional occlusion of the origin of left subclavian artery with the stent-graft in one patient was tolerated without left arm or cerebral symptoms. One patient experienced permanent paraplegia immediately after endovascular repair. There were no deaths during the hospital stay (range, 7-35 days; mean, 14.5 days). One patient was lost to follow-up after hospital discharge. The clinical observation period for the remaining seven patients was 38 to 99 weeks (mean, 60 weeks). CONCLUSIONS: Endovascular stent-graft repair in complicated penetrating atherosclerotic ulcers is an alternative therapeutic option to conventional thoracotomy, especially in patients at high risk of increased morbidity and mortality perioperatively and postoperatively.     

The midterm experience of tapered stent grafts in the endovascular management of iliac artery aneurysms with unfavorable anatomy

We report our experience and the midterm results of a modern technique for endovascular management of isolated iliac artery aneurysms (IAAs) with unfavorable neck anatomy, which involves the inversion of an iliac leg of a Zenith stent graft. Patients who underwent endovascular IAA repair from 2002 to 2010 were reviewed. A total of 12 patients, with a mean age of 77.6 years, underwent endovascular repair of 13 IAAs. Mean size of the aneurysms was 54.6 mm (range 34-133 mm). Mean proximal neck diameter was 18 mm (range 15-22 mm). In 7 patients, the length of the proximal neck was <15 mm (10-14 mm). Only 1 patient developed thrombosis of the stent graft immediately after the operation. Patients were followed up for a mean of 31.5 months (range 18-72 months). Our midterm results demonstrate the durability of this technique in the management of iliac aneurysms with unfavorable anatomy.     

多撕裂口主动脉夹层的一期或分期血管腔内治疗

目的总结一期或分期血管腔内治疗多撕裂口主动脉夹层的临床经验。方法在DSA监控下,通过一侧或双侧股动脉入路将多枚带膜支架植入主髂动脉,一期或分期封闭这些部位的多个撕裂口。结果从2001年1月至2004年6月,共有8例患者接受了一期或分期血管腔内治疗,其中5个撕裂口者1例,4个撕裂口者2例,3个撕裂口者2例,2个撕裂口者3例。降主动脉撕裂口11个,腹主动脉撕裂口11个,髂动脉撕裂口4个。一期血管腔内治疗6例,分期腔内治疗2例。共植入带膜支架23枚,其中直管型20枚,分叉型3枚。手术均获成功。术后3、6、12及24个月CT或MRA复查显示夹层均消失,假腔内血栓形成,无内漏发生,患者均健康生存。结论血管腔内多枚带膜支架一期或分期植入治疗多撕裂口主动脉夹层是一种可行,安全和有效的方法。     

Percutaneous Endoprosthesis for Treatment of Aortic Aneurysms

The purpose of this study was to define the clinical utility of stent-grafts for endoluminal treatment of infrarenal abdominal aortic aneurysms (AAAs). In a prospective study involving three centers, bifurcated stent-grafts for endovascular repair of infrarenal AAAs were implanted in 295 patients. Patient selection was based on anatomic suitability. For analysis of the initial and follow-up results the patients were divided in three subgroups. Group 1 included patients treated between August 1994 and April 1996 with use of the original stent-graft device; group 2 comprised patients treated between May 1996 and December 1997 with the refined stent-graft device, and group 3 comprised patients treated with a newly designed bifurcated stent-graft device. In group 1 (n = 111) the primary technical success was 82%. The procedure had to be converted to surgery in four patients. Endoleaks immediately after the procedure were observed in 16 patients. The initial technical success in subgroup 2 (n = 159) was 96%. One patient required surgical repair, and five others had immediate perigraft flow due to reperfusion via lumbar arteries. For group 3 (n = 28) the primary technical success rate was 89%. Endoleaks due to back-bleeding via lumbar arteries were demonstrated in three patients. Minor and major complications related to the intervention, including two perioperative deaths, were observed in 24 patients (8%). Serious problems such as distal migration or disconnection of the stent-graft were detected during follow-up in five patients. Delayed aortic rupture occurred in three patients who survived after successful surgical repair. Based on the initial results and a limited follow-up of 35 months, we believe endoluminal repair of infrarenal AAA with use of bifurcated endografts may be a feasible alternative to conventional surgery, especially for patients at high surgical risk. However, at the present time there are major concerns with respect to the structural integrity of stent-graft material and the fate of the proximal aortic cuff in the long-term time frame.     

Midterm results of endovascular stented grafts for the treatment of isolated iliac artery aneurysms.

PURPOSE: Isolated aneurysms of the iliac arteries are uncommon lesions that require surgical repair to prevent rupture. METHODS: During a 4-year period, we used endovascular stented grafts (EGs) to treat 28 iliac artery aneurysms that were not associated with aortic aneurysms. Twenty-five patients, with a total of 24 common iliac (15 right, nine left) and four internal iliac (two right, two left) artery aneurysms, underwent endovascular grafting. There were 24 men and 1 woman, with a mean age of 74 years (range, 51 to 88 years). Combined common and internal iliac artery aneurysms were present in three patients. Nineteen patients who underwent treatment with EGs were administered epidural anesthesia (22 epidural, two local, one general). Before surgery, one patient had lower extremity embolization and ischemia from the aneurysm, three had abdominal or back pain, and the remaining were asymptomatic. The EGs were constructed of polytetrafluoroethylene grafts and balloon expandable stents. RESULTS: Four procedure-related complications (12%) occurred (distal extremity embolization, n = 1; wound complications, n = 2; colonic mucosal ischemia, n = 1). Only a minimal reduction in the aneurysmal diameter was seen in 90% of the iliac artery aneurysms treated. The remaining lesions showed no change in size, and no aneurysm had an increase in cross-sectional diameter on computed tomographic images enduring a follow-up period up to 4 years (mean, 24 months). One aneurysm ruptured after successful endovascular exclusion, and the patient underwent treatment with open repair. The 3-year primary patency rate of iliac EGs was 86%. CONCLUSION: EGs appear to show satisfactory safety and efficacy for the repair of isolated aneurysms of the iliac arteries.     

腹主动脉瘤大小对腔内隔绝术及其疗效的影响

目的 探讨腹主动脉瘤大小对腔内隔绝术及隔绝后治疗结果的影响.方法 回顾性分析1997年3月至2007年6月共429例腹主动脉瘤的临床资料,依腹主动脉瘤直径将患者分为＜55 mm组(A组,n=274)及≥55 mm组(B组,n=155).根据术前影像学资料研究两组动脉瘤大小、瘤颈长度、瘤颈直径、瘤颈扭曲程度及髂动脉是否受累等,并探讨动脉瘤大小对腔内隔绝术及治疗结果的影响.结果 A组平均年龄71.1岁,B组73.7岁(P＜0.05).B组有冠心病史者(36.1%)明显多于A组(18.6%)(P＜0.05),B组伴高血压病、糖尿病、慢性阻塞性肺疾病者多于A组,但两组间差异无统计学意义.A组腹主动脉瘤平均直径为(46.6±6.8)mm,B组为(66.8±11.2)mm(P＜0.05);B组腹主动脉瘤较A组近端瘤颈短、瘤颈直径大、瘤颈扭曲、易累及髂动脉(P＜0.05);B组患者应用腹膜外径路、髂内动脉重建或髂内动脉栓塞等附加手术、术中牵张导丝均多于A组,术中发生内漏数及使用移植物个数均高于A组(P＜0.05).围手术期并发症发生率B组高于A组,病死率无明显差异.术后B组内漏率及二次干预率均高于A组.结论 腔内隔绝术治疗腹主动脉瘤获得了较好的临床效果,而腹主动脉瘤的大小对腔内隔绝术存在一定影响,较小腹主动脉瘤无论在术中操作、围手术期并发症、术后随访等方面均优于较大腹主动脉瘤.     

Isolated iliac artery aneurysms: a contemporary comparison of endovascular and open repair

OBJECTIVE: Iliac artery aneurysms are rare but associated with significant morbidity and mortality when ruptured. This study compares recent open and endovascular repairs of iliac aneurysms at a single institution. METHODS: Patients were identified and charts reviewed using ICD-9 and CPT codes for iliac artery aneurysm and open or endovascular repair performed between January 2000 and January 2006. Baseline characteristics, procedure-related variables, and follow-up data were retrospectively reviewed. RESULTS: A total of 71 patients were treated with isolated iliac artery aneurysms. There were 19 open and 52 endovascular repairs. Seven presented with acute ruptures and were treated by open (4) or endovascular (3) repair. Preoperative comorbidities were similar between the two groups. Major perioperative (30 day) complications included three deaths in the open group from cardiovascular complications, all after ruptured aneurysm repair, and one death in the endovascular group (after rupture; one additional perioperative death occurred after 30 days due to colonic infarction) (P = NS). Postoperative complications were less frequent in the endovascular group, although this did not reach statistical significance. The mortality was 50% in the open group and 33% in the endovascular group for patients presenting with a ruptured aneurysm (P = NS). Transfusion requirement was significantly higher in the open group (47%) than in the endovascular group (6%) (P = .03). The mean follow-up was 20 +/- 5 months in the open group and 17 +/- 2 months in the endovascular group (P = NS). Long-term complications included two limb thromboses following repair with a bifurcated stent graft that were treated with thrombolysis plus stenting or a fem-fem bypass. Three endoleaks were identified on postop CT scans, all of which were successfully managed with endovascular techniques. There were no postoperative ruptures or aneurysm-related death. The mean postoperative length of stay was 5.2 +/- 2.3 days (open) and 1.3 +/- 1.0 days (endovascular) (P = .04). CONCLUSIONS: This is the first large, case control study comparing open vs endovascular repair of isolated iliac artery aneurysms. Endovascular repair of iliac artery aneurysms is safe and results in decreased length of stay, lower requirement for perioperative blood transfusion, and similar intermediate term outcomes as open repair.     

Hypogastric artery embolization in endovascular abdominal aortic aneurysm repair

PURPOSE: Iliac artery anatomy is a central factor in endoluminal abdominal aortic aneurysm therapy. It serves as the conduit for graft deployment and as the region of distal graft seal. Thirty-eight percent of iliac vessels in our patients require special treatment because of aneurysms, tortuosity, or small size. Bilateral hypogastric artery exclusion has been avoided because of concerns of colorectal ischemia, hip/buttock claudication, and impotence. We suggest that elective, staged, bilateral hypogastric embolization can be performed safely with reasonably low morbidity and can expand the anatomic boundaries for stent-graft abdominal aortic aneurysm repair. METHODS: This study was performed as a retrospective chart review of patients requiring hypogastric artery embolization for endovascular repair of abdominal aortic aneurysms between June 1998 and June 2000. Patients with otherwise appropriate anatomy and common iliac artery aneurysms were informed of the option for stent-graft repair with internal iliac artery embolization with its risks of impotence, hip/buttock claudication, and bowel ischemia. Patients underwent unilateral or staged bilateral coil embolizations of their proximal hypogastric arteries with an approximate 1-week interval between procedures. Hospital and office records were reviewed; phone interviews were performed. Follow-up ranged from 1 to 12 months. RESULTS: During a 24-month period, 65 patients underwent endovascular abdominal aortic aneurysm repair; 18 patients (28%) required hypogastric artery embolization. Seven (39%) of these patients underwent bilateral embolization. There were no episodes of clinically evident bowel ischemia. Lactate levels were normal in all measured patients. Postoperative fevers (> 101.0 degrees F) were documented in 10 (56%) of 18 patients. The average white blood cell count was 12.8 x 10(9)/L (range, 8.5-22.9). There were no positive blood culture results. The return to the full preoperative diet occurred in 1 to 3 days. Hip/buttock claudication occurred in approximately 50% of patients with persistent but improved symptoms at 6 months. Eighty-seven percent of patients had preoperative erectile dysfunction. Only two patients noted worsening of erectile function postoperatively. CONCLUSIONS: Preliminary results indicate that bilateral hypogastric artery embolization can be performed, when necessary, with reasonable morbidity in patients undergoing stent-graft abdominal aortic aneurysm repair.     

Combined surgical and endovascular treatment of aortic arch aneurysms

BACKGROUND: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia, and circulatory arrest and is associated with considerable morbidity and mortality. Endovascular stent-graft placement has developed as a safe and effective treatment for various diseases of the descending aorta and, recently, even in delicate anatomic regions such as the aortic arch. The aim of this study is to review our clinical experience with endovascular treatment of aortic arch aneurysms after surgical transposition of supra-aortic vessels. METHODS: Fifteen patients received thoracic stent-graft implants after aortic debranching for repair of aortic arch aneurysms during the 3-year period ending December 31, 2005. All patients were not candidates for standard endovascular repair due to inadequate proximal landing zones on the aortic arch. Device design and implant strategy were determined by an evaluation of aortic morphology with angiography and computed tomography (CT) scanning. Stent-grafts were used to repair the arch after supra-aortic vessel transposition was performed. The endografts were implanted transfemorally or via an iliac Dacron conduit graft using standardized endovascular techniques. Follow-up was 100% complete (mean, 18 +/- 2.5 months; range, 12 to 36 months). Outcome variables included death and treatment failure (endoleak, aortic rupture, reintervention, or aortic-related or sudden death). Follow-up included clinical examination, chest radiograph, and CT at discharge, 6 months after stent-graft placement, and yearly thereafter. RESULTS: Stent-graft deployment success was 100% after staged supra-aortic vessel transposition. Patency of all endografts and conventional bypasses was 100%. No endoleak or graft migration was observed. There were no neurologic complications. One patient died 2 months after the procedure from pulmonary complications. CONCLUSION: Repair of aortic arch aneurysms by sequential transposition of the supra-aortic branches and endovascular stent-graft placement is feasible. Extended application of this technique will enable safe and effective treatment of a highly selected subgroup of patients with aortic aneurysms by avoiding conventional arch aneurysm repair in deep hypothermia and circulatory arrest.     

Endovascular treatment of popliteal artery aneurysms: is the technique a valid alternative to open surgery?

AIM: Feasibility of endovascular repair of popliteal artery aneurysms has been established. The results of this technique and the effect of the learning curve on the occurrence of complications were evaluated in a prospective cohort. METHODS: Between June 1998 and February 2007, 73 popliteal aneurysms were treated by endovascular means. Primary outcome was stent-graft patency. Secondary outcome was a combined end-point of stent-graft related complications, including occlusion, migration, stent-graft fracture, and stenosis. To study the learning curve, the cohort of patients was divided into 2 groups (group A from 1 to 23; group B from 24 to 73). Cut-off point chosen was the introduction of the more aggressive postoperative anticoagulation protocol with clopidogrel. RESULTS: Eighteen (25%) stent-grafts occluded. This resulted in a reintervention in 11 patients. Migration, fracture, and stenosis were diagnosed in 9, 3 (2 leading to occlusion), and 2 limbs, respectively; these 14 complications accounted for reinterventions in 8 additional patients. In total, 19 of the 73 limbs (26%) required 20 reinterventions. Overall 3-and 5-year patency rates were 77% and 70% for primary patency, and 86% and 76% for secondary patency, respectively. There were more occlusions in group A (8/23, 35%) versus group B (10/50, 20%) (P= 0.22). With regard to the combined endpoint, there were more events in group A (14/23, 61%) than in group B (16/50, 32%) (P= 0.016). CONCLUSION: Results of endovascular repair of popliteal artery aneurysms are improving and in range with those of open repair.     

巨大和长段胸主动脉瘤的血管腔内修复术治疗

目的探讨巨大和长段胸主动脉瘤行带膜支架主动脉腔内修复治疗的可行性。方法对3例10．6～28．0cm长真性胸主动脉瘤的男性患者,采用多个带膜支架相连接成一条长段支架型人工血管,行主动脉腔内修复治疗。对瘤体全长28．0cm、最大直径7．3cm的病例,采用4个长度为130mm的不同直径的带膜支架相连接覆盖胸主动脉;另2例分别用2枚、3枚带膜支架治疗。2例术中先行颈总动脉-颈总动脉和颈总动脉-锁骨下动脉旁路术。结果3例手术过程顺利,术后恢复良好。2例术后无内漏,分别随访1,2个月,瘤腔内血栓形成;1例在支架连接处有少量内漏,术后1年消失,瘤腔内血栓形成。1例术后出现短暂脑缺血表现,1个月后消失。结论采用多个带膜支架相连接对巨大和长段胸主动脉瘤行主动脉腔内修复治疗,安全、微创,疗效良好,远期效果有待观察。     

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.     

External iliac artery-to-internal iliac artery endograft: a novel approach to preserve pelvic inflow in aortoiliac stent grafting.

PURPOSE: To describe four patients with abdominal aortic aneurysm and bilateral common iliac artery aneurysms repaired by coil embolization of the ipsilateral internal iliac artery, aortouniiliac endograft extended to the ipsilateral external iliac artery, femorofemoral bypass grafting, and a contralateral external iliac to internal iliac stent graft to preserve pelvic perfusion. METHODS: Four patients with multiple risk factors, abdominal aortic aneurysm (mean diameter, 6.6 cm), and bilateral common iliac artery aneurysms were evaluated with contrast-enhanced computed tomography scanning, arteriography, and intravascular ultrasonography. Aortobiiliac endovascular abdominal aortic aneurysm repair was not feasible because of extension of the common iliac artery aneurysms to the iliac bifurcation bilaterally. RESULTS: The abdominal aortic aneurysms were repaired with an aortouniiliac endograft. The ipsilateral common iliac artery aneurysms were treated by coil embolization of the internal iliac artery and extension of the endograft to the external iliac artery. The contralateral common iliac artery aneurysms were excluded by a custom-made stent graft (n = 2) or a commercial stent graft (n = 2) from the external iliac artery to the internal iliac artery, which preserved pelvic inflow via retrograde perfusion from the femorofemoral bypass. Mean length of stay was 3.5 days. One patient had hip claudication. Follow-up (mean 10 months, range 6 to 17) demonstrated exclusion of the abdominal aortic aneurysm and common iliac artery aneurysms with no endoleak and patent external iliac artery-to-internal iliac artery endografts in all patients. CONCLUSION: Patients with bilateral common iliac artery aneurysms that extend to the iliac bifurcation may be excluded from endovascular abdominal aortic aneurysm repair because of concerns regarding pelvic ischemia after occlusion of both internal iliac arteries. External iliac artery-to-internal iliac artery endografting is a feasible alternative to maintain pelvic perfusion and still allow endograft repair of the abdominal aortic aneurysm in these patients.