Iliorenal artery bypass grafting to facilitate endovascular abdominal aortic aneurysm repair

Effective endovascular repair of an infrarenal abdominal aortic aneurysm (AAA) requires adequate proximal and distal landing zones to allow secure endograft attachment. We report a patient with an infrarenal AAA originating 3 mm below the left renal artery with cardiac morbidity that precluded open AAA repair. Left renal artery relocation with retroperitoneal iliorenal bypass grafting was performed to lengthen the proximal landing zone, which facilitated successful endovascular AAA repair. Postoperative surveillance after 3 years showed aneurysm reduction with a patent iliorenal bypass graft. This case underscores the utility of a combined open and endovascular approach in treatment of a challenging aortic aneurysm.     

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.     

Simultaneous endovascular aortic aneurysm repair and coronary artery bypass grafting in a patient with abdominal aortic aneurysm and left main trunk lesion

To patients with severe coronary artery disease (CAD) and expanding large abdominal aortic aneurysm (AAA), simultaneous coronary artery bypass grafting (CABG) and AAA repair has been recommended. A 68-year-old woman had a CAD and an AAA 71 mm in diameter which was enlarging. Coronary angiography showed severe stenoses in the left main trunk (LMT), the left anterior descending artery and the circumflex artery. On-pump beating CABG and AAA repair with endovascular aneurysm repair (EVAR) were performed simultaneously, because intraaortic balloon pumping (IABP) might be needed due to severe stenoses of LMT. Just after EAVR, on-pump beating CABG was performed. The patient was discharged 15 days after the operation. It was suggested that a simultaneous operation of CABG and EVAR might be safe and effective for high risk patients with CAD and AAA.     

Inflammatory abdominal aortic aneurysm treated by endovascular stent grafting: a case report

Despite complications inherent to open surgical repair of inflammatory abdominal aortic aneurysms, there is expected resolution of the retroperitoneal inflammatory process following graft replacement. An endovascular approach could also exclude the aneurysm while potentially avoiding injury to vital structures in the hostile operative field. However, data are limited regarding the role of endovascular stent grafts in the management of inflammatory abdominal aortic aneurysms. Furthermore, postoperative regression of perianeurysmal inflammation is rarely discussed in the few published accounts of endovascular repair of inflammatory aortic aneurysms. The case presented demonstrates successful endovascular treatment of an infrarenal inflammatory aneurysm with resolution of the retroperitoneal inflammation and hydronephrosis.     

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.     

腹主动脉瘤腔内修复术中髂动脉瘤的处理策略

目的:探讨腹主动脉瘤合并髂动脉瘤的腔内修复术(EVAR)方法。方法:回顾性分析2007年8月—2014年3月35例腹主动脉瘤合并髂动脉瘤行EVAR术患者资料,其中9例合并单侧髂内动脉瘤,1例合并双侧髂内动脉瘤,14例合并单侧髂总动脉瘤(直径18 mm),11例合并双侧髂总动脉瘤,所用腔内技术包括栓塞髂内动脉瘤后覆盖,髂内动脉瘤单纯覆盖,"喇叭口"支架,以及"三明治"技术重建一侧髂内动脉等。结果:所有腔内技术均获得成功,手术时间(125±40)min,出血量(173±65)m L。术中发现内漏8例(22.9%),其中I型内漏4例(近端2例,远端2例)均经球囊扩张后内漏消失,III型内漏1例,经扩张及部分加弹簧圈栓塞后内漏消失,II型内漏2例及IV型内漏1例,均未予处理。35例术后随访6~60个月,无动脉瘤破裂,2例术后6个月发现腹主动脉瘤体增大,造影确诊远端I型内漏,经弹簧圈栓塞后内漏消失,其余33例瘤体直径无增大。结论:对于合并髂动脉瘤的腹主动脉瘤患者,有效处理髂内动脉,然后根据髂总动脉直径选择合适的治疗方法可以达到理想的近期效果。     

Zenith abdominal aortic aneurysm endovascular graft

PURPOSE: The safety and efficacy of the Zenith (Cook Inc, Bloomington, Ind) endovascular graft was assessed based on the United States multicenter trial through 5 years of follow-up. METHODS: Between 2000 and 2003, the pivotal study enrolled patients to open surgery (control) or the Zenith endovascular graft (endovascular). A separate continued access study arm enrolled endovascular patients using the same inclusion/exclusion criteria. Both studies were designed for 2-year follow-up, and the pivotal endovascular patients had the option of extending the study follow-up through 5 years. All endovascular patients were stratified by physiologic risk into high-risk and standard-risk groups to assess overall mortality, rupture, conversion, endoleaks, secondary interventions, and sac enlargement. The entire endovascular cohort was pooled to assess device integrity, limb occlusion, component separation, and migration. The suboptimal endovascular result (SER) was established as an end point to assess late adverse outcomes. Statistical analyses included Kaplan-Meier estimations and Cox regression to assess factors contributing to sac enlargement and SER. RESULTS: The study enrolled 739 endovascular patients (352 pivotal, 387 continued access); 158 patients in the pivotal study reconsented to be followed up for 5 years. For the patients at standard and high risk at 5 years, the respective survival estimate was 83% and 61%, aneurysm-related death was 2% and 4%, and freedom from rupture was 100% and 99.6%, respectively. Cumulative risk of conversion, limb occlusion, migration >10 mm, or component separation was < or =3% at 5 years. Cumulative risk of late endoleak was 12% to 15%, representing the primary indication for secondary interventions which occurred in 20% of standard-risk patients and 25% of high-risk patients through 5 years. Sac enlargement was very rare and associated with advanced age and larger aneurysms. SER was predicted by advanced age and internal iliac artery occlusion. CONCLUSION: These middle- and long-term data support long-term durability of the Zenith endovascular graft. Risk of aneurysm-related death or rupture was exceptionally low, and complications of migration, limb occlusion, and device integrity issues were uncommon. Incidence of late endoleaks and association of endoleaks with sac growth underscore the need for long-term follow-up of patients treated with endovascular grafts, although the sequelae of such events are unknown.     

Midterm results of endovascular aneurysm sealing to treat abdominal aortic aneurysm

Background

Endovascular aneurysm sealing (EVAS) represents a novel approach to the treatment of abdominal aortic aneurysms. It uses polymer technology to achieve an anatomic seal within the sac of the aneurysm. This cohort study reports the early clinical outcomes, technical refinements, and learning curve during the initial EVAS experience at a single institution.

Delayed aortic aneurysm enlargement due to endotension after endovascular abdominal aortic aneurysm repair

Abdominal aortic aneurysm (AAA) enlarges after successful endovascular repair, because of persistent blood flow within the aneurysm sac, or endoleak. In the absence of detectable endoleak, AAA may still expand, in part because of persistent pressurization within the excluded aneurysm, or endotension. We report three patients who underwent successful endovascular AAA repair in whom postoperative surveillance showed aneurysm regression, yet delayed AAA enlargement without demonstrable endoleak developed in all three patients. Endotension was confirmed in all three patients at elective open conversion. Our study underscores the significance of endotension as a mechanism of delayed aneurysm enlargement after successful endovascular AAA repair.     

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.     

Transluminally placed endovascular graft indications: thoracic aortic aneurysm and abdominal aortic aneurysm]

In 1991, Parodi et al described the first clinical use of a new technique for abdominal aortic aneurysm (AAA) repair using transluminally placed endovascular grafts (TPEG). Subsequently, in 1994 Dake et al reported the use of this new technique for the treatment of patients with aneurysms of the descending thoracic aorta. Since then, TPEG for the treatment of aneurysms have been clinically investigated in a number of centers. Initially, TPEG appeared to be an attractive alternative to standard surgical open repair, since they are less invasive and thereby reduce the operative risk in high-risk patients. The effectiveness and safety of TPEG have been reported by many investigators, and indications for this technique are increasing. However, the placement of TPEG within the artery by insertion via a remote site and fixation by attachment systems, such as various types of expandable stents, is completely different from conventional graft replacement. The long-term durability of TPEG is not yet known, and therefore we must remain cautious in patient selection. The cause and morphology of each aortic aneurysm determine whether TPEG are indicated. At present, TPEG is used to treat patients with aneurysms below the distal arch, and infrarenal abdominal aorta. However, indications in patients with aortic dissections are not clearly defined, because though the procedure is technically feasible, the effectiveness is not yet known and further investigation is required.     

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.     

The role of endovascular grafting technique in the treatment of infrarenal abdominal aortic aneurysm

The objective of this report is to review the author's initial clinical experience with screening a population of patients with abdominal aortic aneurysm, to describe the selection criteria for endovascular repair and to report results from a single institution. The technique of transfemoral repair of abdominal aortic aneurysm uses the endovascular graft system that is currently in a Food and Drugs Administration approved protocol for investigation in the United States. Some 69 patients with abdominal aortic aneurysm were screened in order to find ten suitable candidates. Ten implantations were carried out, of which eight were successful and two required conversion to conventional open aneurysm repair without complication. There were no deaths or complications. It is concluded that tube graft repair by the transfemoral route is feasible and applicable to approximately one patient in seven. The availability of a bifurcated graft will enhance the percentage of aneurysm patients treatable by this technique. Long-term results, at this time, are unknown.     

Hypogastric artery bypass to preserve pelvic circulation: improved outcome after endovascular abdominal aortic aneurysm repair

OBJECTIVE: This study was carried out to compare the functional outcomes after hypogastric artery bypass and coil embolization for management of common iliac artery aneurysms in the endovascular repair of aortoiliac aneurysms (EVAR). METHODS: Between 1996 and 2002, 265 patients underwent elective or emergent EVAR. Data were retrospectively reviewed for 21 (8%) patients with iliac artery aneurysms 25 mm or larger that involved the iliac bifurcation. Patients underwent hypogastric artery bypass (n = 9) or coil embolization (n = 12). Interviews about past and current levels of activity were conducted. A disability score (DS) was quantitatively graded on a discrete scale ranging from 0 to 10, corresponding to "virtually bed-bound" to exercise tolerance "greater than a mile." Worsening or improvement of symptoms was expressed as a difference in DS between two time points (-, worsening; +, improvement). RESULTS: There was no difference in age (72.6 +/- 7.3 years vs 73.1 +/- 6.4 years), sex (male-female ratio, 8:1 vs 11:1), abdominal aortic aneurysm size (60.1 +/- 5.9 mm vs 59.3 +/- 7.0 mm), or number of preoperative comorbid conditions (1.9 +/- 0.8 vs 2.1 +/- 0.8) between hypogastric bypass and coil embolization groups, respectively. Mean follow-up was shorter after hypogastric bypass (14.8 vs 20.5 months; P <.05). There was no difference in the mean overall baseline DS between the bypass and the embolization groups (8.0 vs 7.8). Six (50%) of the 12 patients with coil embolization reported symptoms of buttock claudication ipsilateral to the occluded hypogastric artery. No symptoms of buttock claudication were reported after hypogastric bypass (P <.05). There was a decrease in the DS after both procedures; however, coil embolization was associated with a significantly worse DS compared with hypogastric artery bypass (4.5 vs 7.3; P <.001). In 4 (67%) of 6 patients with claudication after coil embolization symptoms improved, with a DS of 5.4 at last follow-up. This was significantly worse than in patients undergoing hypogastric artery bypass, with a DS of 7.8 at last follow-up (P <.001). There was no difference between the groups in duration of procedure, blood loss, length of hospital stay, morbidity, or mortality (0%). CONCLUSIONS: Hypogastric artery bypass to preserve pelvic circulation is safe, and significantly decreases the risk for buttock claudication. Preservation of pelvic circulation results in significant improvement in the ambulatory status of patients with common iliac artery aneurysms, compared with coil embolization.     

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.     

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.     

Ruptured abdominal aortic aneurysm: endovascular program development and results

Improvements in endovascular technology and techniques have allowed us to treat patients in ways we never thought possible. Today endovascular treatment of ruptured abdominal aortic aneurysms is associated with markedly decreased morbidity and mortality when compared to the open surgical approach, yet there are several fundamental obstacles in our ability to offer these endovascular techniques to most patients with ruptured aneurysms. This article will focus on the technical aspects of endovascular aneurysm repair for rupture, with particular attention to developing a standardized multidisciplinary approach that will help ones ability to deal with not just the technical aspects of these procedures, but also address some of the challenges including: the availability of preoperative CT, the choice of anesthesia, percutaneous vs. femoral cut-down approach, use of aortic occlusion balloons, need for bifurcated vs. aorto-uniiliac stentgrafts, need for adjunctive procedures, diagnosis and treatment of abdominal compartment syndrome, and conversion to open surgical repair.