Staged hybrid repair of thoracoabdominal aortic aneurysm after chronic type B aortic dissection

The purpose of this study was to evaluate clinical outcomes of combined endovascular and open techniques to eradicate false lumen dilatation in the visceral aortic segment after type B aortic dissection associated with aortic aneurysm. We reviewed eight patients with distal thoracic and abdominal false lumen dilatation treated with a staged procedure. These included arch debranching as needed, proximal thoracic endovascular repair, and open surgical correction with abdominal aortic replacement of the visceral and infrarenal aorta. False lumen eradication was successful in all patients. There were no operative deaths, and paraplegia or paraparesis occurred in two patients. During a mean follow-up of 30 months, no complications or secondary interventions were necessary. The thoracic false lumen remained thrombosed in all patients, with no evidence of aortic dilatation or stent graft complications. Complete thrombosis and eradication of the false lumen can be achieved through a three-stage repair of chronic type B aortic dissection with aneurysmal dilatation. A prospective randomized trial is needed to establish the viability of this approach versus standard open repair of type II thoracoabdominal aortic aneurysms.     

Aneurysmal change at or above the proximal anastomosis after infrarenal aortic grafting.

We conducted a retrospective review of all patients undergoing repair of abdominal aortic aneurysm at or above the proximal anastomosis of a previous infrarenal aortic graft between 1986 and 1991. Infected grafts and patients with suprarenal aneurysms present at the time of the original graft were excluded. Twenty-one patients, 19 men and two women, were included. The original indication for surgery was aneurysm in 14 patients and occlusive disease in seven; the mean interval from initial surgery to presentation was 10 years (range, 3 to 23 years). Twelve lesions were anastomotic false aneurysms, and nine were true aneurysms beginning in the proximal juxta-anastomotic aorta. Fourteen patients had an asymptomatic abdominal mass. Seven patients had symptoms of acute expansion (three), rupture (three), or thrombosis (one). True aneurysm and symptomatic presentation were correlated with aneurysm as the original indication for surgery. Repair was accomplished by an interpositional graft in 13 and graft replacement in eight. Seven patients required suprarenal anastomosis or renal and visceral reconstruction. Five operative deaths (24%) occurred, including two of three patients with rupture (67%) and two of seven patients (28%) in the suprarenal group. The mortality rate for elective repair with an infrarenal anastomosis was 11%. Two additional late deaths occurred during the follow-up period.     

Intraoperative rupture of an abdominal aortic aneurysm during an endovascular stent-graft procedure

PURPOSE: To highlight the risk of intraoperative rupture as a complication of endovascular aortic repair. CLINICAL FEATURES: An 81-yr-old man was admitted for endovascular aortic repair of a 6 cm infrarenal abdominal aortic aneurysm. After establishment of a conduction blockade using a combined spinal-epidural technique, a balloon-activated endovascular stent-graft was advanced to the proximal aneurysmal neck. Approximately four minutes after the stent-graft was deployed, the mean arterial pressure decreased to 30 mmHg and the heart rate increased to 135 bpm. While fluid and vasoactive medications were administered and the airway was secured, repeat aortography confirmed contrast extravasation into the retroperitoneal space at the junction of the proximal aortic neck and the aneurysm sac. The angioplasty deployment balloon was repositioned and inflated proximal to the presumed site of aortic rupture, thus providing aortic control until an open repair of the aorta was undertaken. CONCLUSION: Although endovascular stent-graft placement may be a less invasive method than conventional open aortic reconstruction, it must be recognized that the potential for devastating consequences such as aortic rupture is present.     

Endovascular stent-graft repair of pararenal and type IV thoracoabdominal aortic aneurysms with adjunctive visceral reconstruction

OBJECTIVE: Pararenal and type IV thoracoabdominal aortic aneurysms (TAAA) are not currently considered as indications for endovascular repair given unfavorable neck anatomy or aneurysm involvement of the visceral vessels. Open repair of these aneurysms is associated with significant morbidity and mortality, particularly postoperative renal dysfunction. In selective high-risk patients, debranching of the visceral aorta to improve the proximal neck region can be used to facilitate endovascular exclusion of the aneurysm. METHODS: Between October 2000 and July 2003, 10 patients were treated with open visceral revascularization and endovascular repair of pararenal and type IV TAAAs at a single institution. Patient demographics and procedural characteristics were obtained from medical records. RESULTS: Overall 13 visceral bypasses were performed in 10 patients: 6 patients with a single iliorenal bypass, 3 with a hepatorenal bypass, and 1 patient with complete visceral revascularization. Juxtarenal aneurysms occurred in 5 patients (50%), suprarenal aneurysms in 3 patients (30%), and type IV TAAAs in 2 patients (20%). All patients had successful endovascular aneurysm exclusion. Mean follow-up was 8.7 months. There were no perioperative deaths, neurologic deficits coagulopathies, or renal dysfunction. Follow-up spiral computed tomography scans demonstrated patency of all bypass grafts with only one patient requiring a secondary intervention for late type I leak which was sealed with placement of a proximal cuff. CONCLUSION: These initial results suggest that are similar to infrarenal AAA endovascular repair. This combined approach to repair of pararenal and type IV TAAAs reduces the morbidity and mortality of open repair, and represents an attractive option in high-risk patients while endoluminal technology continues to evolve.     

Lessons learned in adopting endovascular techniques for treating abdominal aortic aneurysm

HYPOTHESIS: Endovascular exclusion of abdominal aortic and common iliac aneurysms can be performed safely, and in the short term represents a feasible alternative to traditional, open aneurysm repair. PATIENTS AND METHODS: Forty-one patients were treated with endovascular grafts for 39 abdominal aortic and 2 common iliac artery aneurysms. RESULTS: All devices were successfully deployed. The size of the abdominal aortic aneurysms varied from 4.9 to 11.9 cm (average, 6.13 cm). The median procedure time was 195 minutes. There was one iliac artery rupture, which required celiotomy for repair. The hospital stay varied from 2 to 39 days (average, 6.7 days). The perioperative mortality rate was 2.4%. Sixteen patients (39%) had groin wound complications. Ten patients (24%) had evidence of contrast (endoleak) within the aneurysm sac on completion of the procedure. There were no obvious direct leaks from either the point of proximal or distal fixation. Seven of these endoleaks have resolved spontaneously. Two patients required additional procedures in the postoperative period to treat endoleak. The final patient has evidence of persistent endoleak on 3-month surveillance computed tomography scan. Major late problems occurred in 3 patients. CONCLUSION: Patients with large abdominal aortic aneurysms and considerable cardiac comorbidity can safely undergo endovascular aneurysm repair. Femoral groin wound complications resulting in prolonged hospitalization remain the major cause of perioperative morbidity. In contradistinction to open aneurysm repair, long-term surveillance is essential to detect migration of the device and identify flow within the residual aneurysm sac-complications that could lead to aneurysm rupture following endovascular repair.     

Aortic transection and diverting bypass as treatment of repetitive recurrent abdominal aortic false aneurysm rupture in a patient with Behcet's disease

Abdominal aortic false aneurysms in patients with Behcet's disease have been reported frequently and repaired successfully by various procedures; however, anastomotic false aneurysms have often been reported to occur after the operation. In this article, we report a case of four-time repetitive, recurrent suprarenal abdominal aortic false aneurysm ruptures that lasted for 7 years. The location of this aneurysm was not easy to repair not only by open surgical procedures but by endovascular stent because the aortic defect was too close to the visceral arterial branches. The last operation consisted of primary repair of aortic defect, transection of abdominal aorta at the level of supraceliac aorta with end closure, and a thoracic aorta to abdominal aorta bypass with Dacron graft. An 8-year follow-up revealed no more abdominal aortic aneurysm recurrence.     

Combined emergency abdominal aortic aneurysm repair and valve replacement in a patient with severe aortic stenosis

Simultaneous open surgery has been advocated in the elective management of abdominal aortic aneurysm patients with significant ischemic heart disease, as staged procedures risk worsening myocardial ischemia or aortic rupture, depending on which is the first intervention. The argument for combined aneurysm and valve repair is less established. We describe the case of a 70-year-old female who while awaiting aortic valve replacement suffered rupture of an abdominal aortic aneurysm. The patient was successfully managed with emergency combined open abdominal aortic aneurysm repair and open aortic valve replacement. We would advocate that such a strategy be considered as a salvage technique in similarly difficult management dilemmas.     

A prospective study to assess changes in proximal aortic neck dimensions after endovascular repair of abdominal aortic aneurysms

OBJECTIVE: The purpose of this study was to detect any change in the proximal neck diameter after endovascular repair of abdominal aortic aneurysm. METHODS: The study was performed in a teaching hospital with an endovascular program on 112 patients who had undergone endovascular repair of abdominal aortic aneurysm. The interventions were pre-endovascular and postendovascular repair of abdominal aortic aneurysms with contrast-enhanced, spiral computerized tomography, and the main outcome measures were change in aortic proximal neck diameter, change in maximum aortic diameter, presence of endoleaks, and change in length from lowest renal artery to aortic bifurcation. RESULTS: The median anterior-posterior and transverse diameter decreased from 63.5 mm before surgery to 50.4 and 54.5 mm, respectively, after surgery in a period of 4 years. This trend in reduction in maximum diameter was not seen in the patients with endoleaks. There was no significant change in the proximal neck diameters when measured at 5-mm intervals after endovascular repair. There was also no significant change in the aortic length after endovascular repair. CONCLUSION: We have not demonstrated any evidence for proximal neck dilatation after endovascular repair of abdominal aortic aneurysm.     

Hybrid procedures as a combined endovascular and open approach for pararenal and thoracoabdominal aortic pathologies

OBJECTIVES: to report our experience with hybrid vascular procedures in patients with pararenal and thoracoabdominal aortic pathologies. METHODS: 68 patients were treated for thoracoabdominal aortic pathologies between October 1999 and February 2004; 19 patients (16 men; mean age 68, range 40-79) with high risk for open thoracoabdominal repair were considered to be candidates for combined endovascular and open repair. Aortic pathologies included five thoracoabdominal Crawford I aneurysms, one postdissection expanding aneurysm, three symptomatic plaque ruptures (Crawford IV), five combined thoracic descending and infrarenal aneurysms with a healthy visceral segment, three juxtarenal or para-anastomotic aneurysms, and two patients with simultaneous open aortic arch replacement and a rendezvous maneuver for thoracic endografting. Commercially available endografts were implanted with standardized endovascular techniques after revascularization of visceral and renal arteries. RESULTS: Technical success was 95%. One patient developed a proximal type I endoleak after chronic expanding type B dissection and currently is waiting conversion. Nine patients underwent elective, five emergency and five urgent (within 24 h) repair. 17 operations were performed simultaneously, and 2 as a staged procedure. Postoperative complications include two retroperitoneal hemorrhages, and one patient required long-term ventilation with preexisting subglottic tracheal stenosis. Thirty-day mortality was 17% (one multiple organ failure, one secondary rupture after open aortic arch repair, one myocardial infarction). Paraplegia or acute renal failure were not observed. Total survival rate was to 83% with a mean follow-up of 30 months. CONCLUSIONS: Midterm results of combined endovascular and open procedures in the thoracoabdominal aorta are encouraging in selected high risk patients. Staged interventions may reduce morbidity.     

Acute aortic dissection into a preexisting abdominal aortic aneurysm

Acute aortic dissection and abdominal aortic aneurysm presenting as coexistent conditions is rare. We report a patient with a history of hypertension and acute severe back pain who had an acute aortic dissection extending into a preexisting 8 cm abdominal aortic aneurysm that was diagnosed by CT scan. There was no evidence of aortic rupture or leakage. The patient was treated with antihypertensive medication for 2 months to allow maturation of the acute dissection prior to elective repair of the abdominal aortic aneurysm. The repair was constructed to allow continued perfusion of both the true and false lumina by fenestration of the aortic septum at the proximal anastomosis. There were no postoperative complications. This case illustrates an unusual combination of aortic diseases. A management plan is described that safely treats both pathologic conditions.Presented at the Fourth Annual Winter Meeting of the Peripheral Vascular Surgical Society, Breckenridge, Colo., January 21– 24, 1994.     

Chronic rupture of abdominal aortic aneurysm

Although the mortality rate after abdominal aortic aneurysm rupture approximates 90% despite the urgent management, a few cases of chronic rupture and delayed repair have been reported in the world literature; anatomic and hemodynamic reasons occasionally allow for the fortunate course of these patients. We report in this article the case of 76-year-old man with a ruptured abdominal aortic aneurysm who was transferred to our facility 4 weeks after his initial hospitalization in a district institution and who finally had a successful open repair.     

Collective experience with hybrid procedures for suprarenal and thoracoabdominal aneurysms

Not every patient is fit for open thoracoabdominal aortic aneurysm (TAAA) repair, nor is every TAAA or juxtarenal abdominal aortic aneurysm suitable for branched or fenestrated endovascular exclusion. The hybrid procedure consists of debranching of the renal and visceral arteries followed by endovascular exclusion of the aneurysm and might be an alternative in these patients. Between May 2004 and March 2006, 16 patients were treated with a hybrid procedure. The indications were recurrent suprarenal or thoracoabdominal aneurysms after previous abdominal and/or thoracic aortic surgery (n = 8), type I to III TAAAs (n = 3), proximal type I endoleak after endovascular repair (n = 2), penetrating ulcer of the juxtarenal aorta (n = 1), visceral patch aneurysm after type IV open repair (n = 1), and primary suprarenal aneurysm (n = 1). Eight (50%) of 16 patients were judged to be unfit for open TAAA repair. The hospital mortality rate was 31% (5 of 16). Four of five deceased patients were unfit for thoracophrenic laparotomy. Two patients died from cardiac complications and three from visceral ischemia. No spinal cord ischemia was detected, and temporary renal failure occurred in four patients (25%). The mean follow-up was 13 months (range 6-28 months). During follow-up, no additional grafts occluded and no patients died. Hybrid procedures are technically feasible but have substantial mortality (31%), especially in patients unfit for open repair (80%). They might be indicated when urgent TAAA surgery is required or when vascular anatomy is unfavorable for fenestrated endografts in patients with extensive previous open aortic surgery.     

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应用跨肾动脉支架人工血管腔内修复术治疗腹主动脉瘤,并探讨其手术适应证,操作要点及并发症的预防。方法对２例病人采用全麻,在动态数字减影血管造影监测下用跨肾动脉支架分叉型人工血管对腹主动脉瘤进行了腔内修复术,结果手术中ＤＳＡ提示动脉瘤消失,无内漏发生。术后１周及分别随访３和９个月,螺旋ＣＴ检查提示腔内人工血管无移位扭曲,血流通畅无内漏发生,结论腹主动脉瘤腔内修复术手术创伤小,病人恢复快,跨肾动支架人工     

Endovascular treatment of abdominal aortic aneurysms

BACKGROUND: Endovascular treatment of abdominal aortic aneurysms is a rapidly evolving technique that has gained broad acceptance in the treatment of patients with abdominal aortic aneurysms. METHODS: A review of the English literature was done to determine the short- and long-term outcomes of endovascular repair of abdominal aortic aneurysms. Reports of complications such as endoleak, graft migration, graft limb occlusion, aneurysm rupture, and aneurysm enlargement were evaluated. RESULTS: Short-term results of endovascular repair of abdominal aortic aneurysms are excellent. The necessity for open conversions is less than 5%. The cumulative risk of aneurysm rupture is approximately 1% per year. The coverall incidence of graft limb occlusion was 2.8% in the follow-up period. The cumulative risk for a secondary procedure was 12% at 1 year, 24% at 2 years, and 35% at 3 years. Moderate and severe neck angulation was associated with an increased incidence of adverse events in the follow-up period. Endografts have the potential to become infected and develop aortoduodenal fistula. The treatment of ruptured aneurysms with endovascular grafts has been successful and a technique that is increasingly used. CONCLUSION: Endovascular treatment of abdominal aortic aneurysm is an effective technique with excellent short-term results. The long-term results remain to be determined. Ongoing surveillance is necessary to avoid late complications of aneurysm rupture.     

Fate of the excluded abdominal aortic aneurysm sac: Long-term follow-up of 831 patients

Purpose: Nonresective treatment of the infrarenal abdominal aortic aneurysm by proximal and distal ligation of the aneurysm sac (exclusion) combined with aortic bypass has been previously reported. A 10-year experience with 831 patients undergoing this procedure was reviewed.Methods: From 1984 to 1994, 831 (761 elective, 70 urgent) of 1103 patients being treated for abdominal aortic aneurysm underwent repair with the retroperitoneal exclusion technique. Perioperative morbidity and mortality, estimated blood loss, transfusion requirements, natural history of the excluded aneurysm sac, and long-term survival were all assessed.Results: The operative mortality rate for patients undergoing exclusion and bypass was 3.4%. The incidence of nonfatal perioperative complications was 5.2%. Colon ischemia requiring resection occurred in 2 (0.2%) of the 831 patients. Estimated blood loss was 638 ± 557 cc (50 to 330 cc). On follow-up 17 (2%) patients were found to have patent aneurysm sacs as detected by duplex examination. Fourteen patients required surgical intervention. No cases of graft infection or aortoenteric fistula have been noted.Conclusion: Retroperitoneal exclusion and bypass is a viable alternative to traditional open endoaneurysmorraphy in surgery for abdominal aortic aneurysm. Most excluded aneurysm sacs have thrombosis without any long- or short-term complications; however, in a small number of patients delayed rupture of patent aneurysm occurs, thus emphasizing the need for diligent follow-up and appropriate intervention. (J Vasc Surg 1996;24:851-5.)     

Surgical treatment of thoracoabdominal aortic aneurysm after repairs of descending thoracic or infrarenal abdominal aortic aneurysm.

OBJECTIVE: The outcome of thoracoabdominal aortic aneurysm repair after operations for descending thoracic or infrarenal abdominal aortic aneurysm was investigated. METHODS: Between May 1982 and July 2000, 102 patients underwent thoracoabdominal aortic aneurysm repair. Of these patients, 36 had previously undergone operations for descending thoracic or abdominal aortic aneurysm. To evaluate the influence of previous descending thoracic or infrarenal abdominal aortic aneurysm repair on the results of TAAA replacement, patients were divided into two groups: one group of patients who had previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group I, n=36) and one group of patients who had not previously undergone descending thoracic or infrarenal abdominal aortic aneurysm repair (group II, n=66). RESULTS: Patients with previous descending thoracic or infrarenal abdominal aortic aneurysm repair had more chronic dissection and extensive thoracoabdominal aortic aneurysm. The distal aortic perfusion time and total aortic clamp time were both longer in group I. The total selective visceral and renal perfusion time and operation time did not differ significantly between the two groups. In 30-day mortality rates were 5.5% in group I and 13% in group II. Major postoperative complications included paraplegia in 14% of patients in group I and 3.1% in group II, renal failure requiring hemodialysis in 22% of patients in group I and 19% of patients in group II, respiratory failure in 36% of patients in group I and 30% of patients in group II, postoperative hemorrhage in 11% of patients in group I and 16% of patients in group II. CONCLUSION: The presence of a previous descending thoracic or infrarenal abdominal aortic aneurysm did not adversely affect the outcome of thoracoabdominal aortic aneurysm repair.     

Spontaneous aortic dissection in the presence of coexistent or previously repaired atherosclerotic aortic aneurysm.

Acute aortic dissection occurred in 18 patients who had previously diagnosed atherosclerotic aneurysms of the thoracic and/or abdominal aorta. These patients were reviewed to assess the clinical course when these two forms of aortic pathology coexist. Patients were grouped according to status of their atherosclerotic aneurysm (previously repaired vs. untreated) and the segments of the aorta effected by the acute spontaneous dissection. Group 1 patients (n = 5) had previously undergone-abdominal aortic aneurysmectomy (AAA) repair, and the abdominal aortic suture line effectively terminated the dissection process. In Group 2 patients (n = 5), the acute dissection and the atherosclerotic aneurysm involved different segments of the aorta. Group 3 patients (n = 8) experienced spontaneous aortic dissection involving atherosclerotic aneurysms (five infrarenal, three thoracoabdominal), with threatened or actual rupture occurring in six patients, resulting in three deaths. In Group 3 patients, rupture occurred both at the atherosclerotic aneurysm (four patients) and at the site of the aortic intimal tear of the dissection (two patients) after AAA repair. The use of Magnetic Resonance Imaging (MRI) has proven to be highly accurate in delineating the nature and extent of pathology in recently encountered patients with complicated aortic disease. Coexistence of atherosclerotic aneurysm and acute dissection appears to increase the risk of aortic rupture, in both proximal and distal aortic segments.     

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.     

The management of aortoduodenal fistula by in situ replacement of the infected abdominal aortic graft.

Conventional surgical wisdom dictates the complete removal of infected abdominal aortic graft, oversewing of the aorta, and restoration of lower limb bloodflow by extra-anatomic bypass grafting. Dissatisfied with this approach because of the high incidence of local complications, mortality, and loss of limb, 20 patients with secondary aortoduodenal fistula had duodenal repair, excision of the old graft, and placement of a new graft in the same location. A similar technique was used in three patients with erosion of an aortic graft into the jejunum. Length of follow-up averaged 5.2 years, and was more than 1 year in each instance. Of the eighteen patients who survived the repair, three have had early recurrent rupture or false aneurysm of the proximal aortic anastomosis, with consequent death in two, but fifteen patients (83%) have had no further related problem. There was no loss of limb. Use of greater omentum as a protective barrier seemed helpful. Optimal antibiotic usage, and the idea that varying degrees of graft infection require different approaches, require further definition. In conclusion, in situ graft replacement is the correct operative strategy in this challenging group of patients.     

Should endovascular repair be used for small abdominal aortic aneurysms?

The outcomes of endovascular repair for small abdominal aortic aneurysm (4.0-4.9 cm) is reported. All patients undergoing endovascular abdominal aortic aneurysm repair between 2000 and 2006 with maximal diameter 4.0 to 4.9 cm form the small aneurysm study cohort. Data were analyzed retrospectively and life-table methods were used. Of 743 endovascular repairs, 132 (17.8%) were performed for small abdominal aortic aneurysm. Perioperative complication rate was 9.1%. Freedom from aneurysm expansion was 96% at 1 year, 86% at 3 years, and 77% at 5 years. Overall survival was 98%, 93%, and 84% at 1, 3, and 5 years, respectively. Perioperative 30-day mortality was 0.8% with an aneurysm-related mortality of 1.5% at 5 years. There were no deaths from delayed aneurysm rupture. Endovascular repair of small abdominal aortic aneurysm is associated with low perioperative morbidity and mortality compared with published results for open repair, and treatment threshold can be reduced to 4 cm in selected patients.