Aortoenteric fistula arising as a complication of endovascular treatment of abdominal aortic aneurysm

Estimates of the incidence of aortoenteric fistula as a sequela of surgery of the aorta range 1-2%. This complication is less common in patients who have had an aortic endograft implanted for aortoiliac aneurysm. We present three cases of aortoenteric fistula complicating endovascular treatment of abdominal aortic aneurysm (3/423 patients, 0.7% in our series).     

Endovascular repair of late abdominal aortic aneurysm rupture owing to mixed-type endoleak following endovascular abdominal aortic aneurysm repair

We report the successful endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 8 months after endovascular abdominal aortic aneurysm repair (EVAR). A 74-year-old man with a history of EVAR 8 months earlier presented with hypotension, severe back pain, and tenderness on abdominal palpation. A contrast-enhanced computed tomographic scan showed a large retroperitoneal hematoma and confirmed the diagnosis of secondary abdominal aortic rupture. Because the patient had severe comorbidities, the endovascular method was chosen for further management. Two stent grafts were placed appropriately to eliminate a type 1a and a type 3 endoleak owing to modular separation of the left iliac graft limb from the main body stent graft. An additional self-expanding stent was deployed in the solitary right renal artery to open its origin, which was partially overlapped by the proximal cuff. The patient was discharged on the tenth postoperative day and is alive and well 1 year postoperatively. This case indicates that endovascular repair is feasible not only in cases of primarily ruptured AAAs but also in secondarily ruptured AAAs after failure of EVAR.     

Obstructive uropathy associated with endovascular repair of an inflammatory abdominal aortic aneurysm.

A 72-year-old male presented with claudication in the rightleg. Clinical examination suggested an abdominal aortic aneurysm(AAA). Computed tomography (Figure 1) demonstrated an infrarenalAAA with a maximum diameter of 7 cm, and     

Extensive spinal cord ischemia following endovascular repair of an infrarenal abdominal aortic aneurysm: a rare complication

Postoperative paraplegia secondary to spinal cord ischemia (SCI) is an extremely rare and devastating complication of endovascular repair in abdominal aortic aneurysm (AAA) surgery. The reported incidence is only 0.21 % worldwide. This case of postoperative paraplegia occurred in a 60-year-old man immediately following endovascular repair of an infrarenal AAA. Postoperative magnetic resonance imaging showed multiple foci of SCI involvement from C5 to L1. However, neither cerebral spinal fluid drainage nor steroid therapy was effective; he was eventually admitted with no improvement in his neurological status. The mechanism remains multifactorial until now and needs more attention in perioperative management. We report the first case involved in the most significantly extensive SCI after endovascular repair of an infrarenal AAA.     

Aorto-duodenal fistula on an aortic endograft: a rare cause of late conversion after endovascular aneurysm repair

The last few years have seen an increase in popularity of endovascular aneurysm repair because of the improvements made to the endografts design as well as experience gained by physicians, but the long-term results of this procedure are still uncertain. The majority of late complications after an endograft can be treated with an endovascular approach but, in some cases, it may need conversion to open surgery. In this paper, we discuss the case of a male patient who presented with an aorto-duodenal fistula on an endograft requiring explant. After two operations and 20 days in hospital, the patient was discharged and after 1 year he is doing well. In medical literature, there are very few reported cases of aortoenteric fistula complicating endovascular prosthesis, the diagnosis is quite difficult, surgical treatment is fairly complex consisting in endograft removal and we refer to our experience on this difficult and life-threatening operation.     

Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair

In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.     

Aortoduodenal fistula after endovascular stent-graft of an abdominal aortic aneurysm

Despite satisfying short- and middle-term effectiveness and feasibility, endovascular stent-grafting for abdominal aortic aneurysm is still under evaluation. We report a case of an aortoduodenal fistula after the use of this technique. Enlargement of the upper aneurysmal neck was followed by caudal migration of the major portion of the stent-graft, which resulted in kinking of the device in the aneurysmal sac. Ulcerations were found on adjacent portions of both the aneurysmal sac and the adjacent duodenum. Only the textile portion of the prosthetic contralateral limb separated the aortic lumen from the corresponding duodenal lumen. Early detection of complications after stent-grafting is essential to allow successful treatment, either surgical or endoluminal. (J Vasc Surg 2000;31:190-5.)     

Cost-effectiveness of endovascular abdominal aortic aneurysm repair

BACKGROUND: The rapid introduction of endovascular abdominal aortic aneurysm repair (EVAR) has considerable implications for the management of abdominal aortic aneurysm (AAA). This study was undertaken to determine an optimal strategy for the use of EVAR based on the best currently available evidence. METHODS: Economic modelling and probabilistic sensitivity analysis considered reference cases representing a fit 70-year-old with a 5.5-cm diameter AAA (RC1) and an 80-year-old with a 6.5-cm AAA unfit for open surgery (RC2). Results were assessed as incremental cost-effectiveness ratio (ICER) compared with open repair (RC1) or conservative management (RC2). RESULTS: In RC1 EVAR produced a gain of 0.10 quality-adjusted life years (QALYs) for an estimated cost of 11,449 pound, giving an ICER of 110,000 pound per QALY. EVAR consistently had an ICER above 30,000 pound per QALY over a range of sensitivity analyses and alternative scenarios. In RC2 EVAR produced an estimated benefit of 1.64 QALYs for an incremental cost of 14,077 pound giving an incremental cost per QALY of 8579 pound. CONCLUSION:: It is unlikely that EVAR for fit patients suitable for open repair is within the commonly accepted range of cost-effectiveness for a new technology. For those unfit for conventional open repair it is likely to be a cost-effective alternative to non-operative management. Sensitivity analysis suggests that research efforts should concentrate on determining accurate rates for late complications and reintervention, particularly in patients with high operative risks.     

Ruptured abdominal aortic aneurysm after endovascular repair

OBJECTIVE: The purpose of this study was to present the experience with aneurysm rupture after deployment of Guidant/EVT (Guidant) endografts and review previously reported cases with other devices. METHODS: Records from Guidant/EVT clinical trials and postmarket approval databases from February 1993 to August 2000 were analyzed to identify patients with rupture and to extract pertinent data. Previously reported cases were obtained with a Medline search. RESULTS: Seven ruptures were found with Guidant/EVT devices. Five of these occurred among the 686 patients in US Food and Drug Administration protocols (group I) who were followed for a mean of 41.8 +/- 21.9 months and limited to the subgroup of 93 first generation tube endografts. Two ruptures occurred in group II (3260 patients after market approval with limited follow-up), specifically in the subgroup of 166 patients who underwent treatment with second generation tube grafts. No ruptures were found in patients with bifurcation or unilateral iliac implants followed for a mean of 37.5 months. All ruptures were caused by distal aortic type I endoleaks on the basis of attachment system fractures (first generation devices only), aortic neck dilatations, persistent primary endoleaks, migration, overlooked imaging abnormalities, refused reintervention, and poor patient selection. The mortality rate was 57% (4/7) overall and was 50% for surgical repair (3/6). A literature search identified 40 additional ruptures related to other devices, for a total of 47. All 44 that were documented with adequate data were caused by endoleaks (26 type I, 2 type II, 11 type III, and 5 source not reported). Other contributing factors were graft module separation and graft wall deterioration. The overall mortality rate for the combined series was 50%, with an operative mortality rate of 41%. CONCLUSION: Postendograft AAA rupture is infrequent, although the true incidence rate is unclear because of inadequate follow-up of individual device designs. Tube endografts should be limited to the rare patient with ideal anatomy, no other alternatives, and at high risk for standard open repair. Prevention of aneurysm rupture requires long-term surveillance with attention to subtle imaging abnormalities and the establishment of reliable follow-up protocols for specific devices. The outcome of postendograft aneurysm rupture is similar to that of rupture without prior endograft therapy.     

完全穿刺技术在腹主动脉瘤腔内修复术中的应用

目的 探讨应用Perclose ProGlide缝合器完全穿刺技术行腹主动脉瘤腔内修复术的安全性和有效性.方法 2008年5月至2010年4月,36例腹主动脉瘤患者完全穿刺下行腔内修复术治疗.其中男性30例,女性6例;平均年龄68岁.所应用的支架型血管包括:3例Endurant,13例Talent,20例Zenith.18～24 F的鞘管预置两把ProGlide,14～16 F的鞘管预置单把ProGlide.缝合动脉切口时取出鞘管并将线结下滑收紧.统计技术成功率、相关并发症及手术操作时间.术后3、6、9、12个月及其后每年进行CT血管造影随访.结果 20例局部麻醉,16例全身麻醉.68条股动脉共应用128把ProGlide,其中38条股动脉各应用2把,8条各应用3把,2条各应用4把,20条各应用1把.63条股动脉(63/68,92.6%)技术操作成功,2条中转切开缝合,3条出现血肿,无需手术处理.平均随访时间(12±3)个月.1例于术后3个月出现无症状的动脉夹层.结论 完全穿刺技术在腹主动脉瘤腔内修复术中的应用是安全和有效的.由于可能需要切开缝合,建议在杂交手术室中操作.     

腹主动脉瘤血管腔内治疗的体会

目的 观察腹主动脉瘤血管腔内治疗的近期疗效.方法 对12例肾下型腹主动脉瘤进行分析.结果 术中出血平均245 mL,住院时间平均8.6 d,术后禁食时间平均1.5 d.白细胞、血红蛋白和血小板以及肾功能、肝功能均在正常范围;PT和APTT术后延长,1周内恢复正常.并发症包括:肺部感染1例、腹胀2例,经保守治疗好转;内漏1例,3个月后自然消失.结论 腹主动脉瘤血管腔内治疗具有安全、微创及对人体内环境干扰小的优点.     

Local anesthesia for endovascular abdominal aortic aneurysm repair

OBJECTIVES: This study reports the results of a prospective continuous cohort of patients treated for endovascular aneurysm repair (EVAR) with a unified anesthetic strategy based on the use of local anesthesia (LA) in all patients, while reserving regional (RA) or general anesthesia (GA) only for those with predefined individually or surgically specific indications. METHODS: All patients treated by EVAR for an elective aortic abdominal aneurysm (AAA) between April 1998 and December 2003 were included. The strategy of treatment generated three cohorts of patients (LA, RA, or GA). Primary outcome included all-cause mortality, nonfatal cardiac morbidity, respiratory complications, and renal failure. Secondary outcome measures included conversion to general anesthesia, use of analgesics, and time-related outcomes (operating time, length of stay in intensive care unit and hospital, time required to resume oral intake, and time to ambulation). RESULTS: A total of 239 patients underwent EVAR: 170 LA, 31 RA, and 38 GA. Overall mortality was one patient (0.4%). LA was associated with a lower incidence of complications compared with GA (P < .001). In the LA group, two patients had to be converted to GA, one because of a dissection and one because of anxiety. In 13% of the patients in the LA group, additional intravenous sedation or analgesia was required. Operating time and length of stay in intensive care was shorter in the LA and RA groups than in the GA group (P < .001). Length of stay in hospital and time to ambulation and regular diet was shorter in the LA group compared with the RA and GA groups (P < .001). CONCLUSIONS: A strategy based on the preferential use of LA for EVAR restricting RA or GA only to those with predefined contraindications is feasible and appears to be well tolerated.     

An operative method for surgical revision of a late failure after endovascular repair of an abdominal aortic aneurysm

Endoleak is a well-recognized complication of endovascular aortic exclusion stent-grafts. The Vanguard device is anchored into the proximal aorta by an expandable stent surmounted by a circular array of metal hooks. Attempted removal of the whole prosthesis may therefore be technically difficult and result in damage of the aortic wall. Surgery for endoleak may be complicated and carry a mortality rate of 20% to 40%. We describe a simple surgical technique for repair of endoleaks associated with a Vanguard stent-graft, which would be applicable to other such devices. This method involves minimal disruption of the proximal stent and avoids problems that may arise from an attempt to completely remove the endovascular device.     

Endovascular repair and pharmacotherapy of an inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula

An inflammatory abdominal aortic aneurysm complicated by primary aortoduodenal fistula was successfully treated by stent grafting. Pharmacotherapy with octreotide after endovascular aneurysm repair was also performed with the expectation of spontaneous and rapid closure of the fistula. Gastrointestinal endoscopy performed 10 days after endovascular aneurysm repair showed closure of the large aortoduodenal fistula, and oral intake was started on the operative day 16. To date, 16 months after the initial operation, the patient is doing well without any symptoms or signs of infection and without any antibiotic therapy.     

Aortocaval fistula after endovascular stent-grafting of abdominal aortic aneurysm

The authors present a case report of a 79-year-old man with insufficient cardiac contractile function who underwent endovascular stent-grafting for an abdominal aortic aneurysm. Thirty months later, the aneurysm ruptured into the inferior vena cava and subsequently formed an aortocaval fistula caused by migration of the stent-graft. Urgent secondary endovascular stent-grafting successfully excluded the blood flow into the vena cava. Endovascular stent-grafting is deemed suitable for treating this serious disorder, especially in severely debilitated or compromised patients who might not withstand a standard surgical intervention. Furthermore, in patients with previous stent-grafting, since the primary stent-graft makes repair by open surgery more difficult, a secondary endovascular intervention is recommended if feasible.