Endovascular treatment of a noninfected anastomotic juxtarenal aortic aneurysm

An 82-year-old man underwent an endovascular procedure with a commercially available endovascular graft for an anastomotic juxtarenal abdominal aortic aneurysm. The anastomotic aneurysm, which showed no sign of infection, developed 4 years after implantation of an aortic end-to-end graft for an infrarenal aortic aneurysm. The aneurysm was diagnosed during routine ultrasonographic follow-up; there was no apparent infection of the graft. Aortography confirmed the diagnosis and also revealed a small pseudoaneurysm at the level of the distal aortic anastomosis. Endovascular surgery was performed in the operating room with the guidance of C-arm fluoroscopy and intravascular ultrasound. Two Vanguard Straight Endovascular Aortic Graft Cuffs (26 x 50 mm and 24 x 50 mm) were implanted, successfully excluding both the anastomotic juxtarenal aortic aneurysm and the distal pseudoaneurysm. The renal arteries were preserved and no early or late endoleaks were observed. The patient was discharged 2 days after the procedure. Sixteen months later, he was alive and well, with no endovascular leakage, no enlargement of the aortic aneurysms, and no sign of infection. In our opinion, this experience shows that commercially available endovascular grafts may be used successfully to treat anastomotic aortic aneurysms and pseudoaneurysms.     

Stent graft treatment for abdominal aortic aneurysm repair: recent developments in therapy

PURPOSE OF REVIEW: Minimally invasive endovascular techniques for the treatment of abdominal aortic aneurysms have significantly reduced the morbidity of these procedures compared with standard surgical repair. In addition, patients with extensive comorbid medical illnesses in whom standard operative repair is contraindicated may be successfully treated using endovascular means. RECENT FINDINGS: Recently, several important developments have significantly advanced this area of treatment. The Food and Drug Administration has approved four endovascular stent grafts for the treatment of abdominal aortic aneurysms: the Medtronic AneuRx, the W.L. Gore Excluder, the Cook Zenith, and the Guidant Ancure. The Zenith received approval for marketing in 2003 and has gained relatively wide use, in part because of its ability to treat aneurysms with relatively large-diameter implantations zones. Also in 2003, Guidant Corporation withdrew the Ancure graft from marketing and distribution. The withdrawal was influenced by difficulties encountered using the graft's delivery system and improper reporting to the Food and Drug Administration. Enrollment has also been recently completed for the phase II Food and Drug Administration trials of the Medtronic Talent graft and the Cordis Fortron graft. These devices have been approved for use in the European Union and are awaiting Food and Drug Administration panel meeting in the United States. Several significant advances have also occurred recently in stent graft research and development. Of particular significance has been the initiation of the phase I trial of the Trivascular Enovus graft. Deployment of the Trivascular graft may be accomplished through a delivery system that is considerably reduced in profile. The potential for percutaneous application of the graft may be available in the future. In selecting the specific stent graft to be used for endovascular abdominal aortic aneurysm repair, the specific graft characteristics must be considered, particularly with regard to the individual patient's anatomic and physiologic characteristics. Comparative analysis of the several of the various stent grafts has been performed. Results have varied with regard to the need for secondary interventions, aneurysm sac size reduction, and the occurrence of continued perfusion of the aneurysm sac. In addition, the indications for use of endovascular grafts compared with standard open surgery have not yet been fully defined. SUMMARY: This article describes the general principles of use for endovascular devices for the repair of abdominal aortic aneurysms. It details the features and results for the devices in current use, and highlights the recent developments in stent graft treatment of abdominal aortic aneurysms.     

Endovascular treatment of aneurysmal disease

Endovascular repair of abdominal aortic aneurysm using stent grafts that are delivered intraluminally by catheters is a less invasive alternative to open surgical repair. Endovascular surgery has been studied for over a decade, and early results are comparable to open repair. With extended follow-up care, however, postoperative complications and graft failures have been reported in some patients, resulting in reintervention, conversion to open repair, and death. The high incidence of secondary interventions causes some researchers to question the durability of endograft repair and emphasizes the need for detailed long-term follow-up care. This article describes the evolution of endovascular treatment of abdominal aortic aneurysm from its origin to its current state and discusses the future direction of endovascular therapy.     

Stent graft treatment for transverse arch and descending thoracic aorta aneurysms

PURPOSE OF REVIEW: The aim of this article is to review the recent relevant literature on endovascular repair of thoracic aortic aneurismal disease. RECENT FINDINGS: The introduction of endovascular stent graft technology has ushered in a new era in therapy for diseases of the aortic arch and descending thoracic aorta. The technical challenges of stent graft deployment in the descending thoracic aorta, such as proximity to the great vessels and arch tortuosity, have been and remain a device engineering focus. More recently, repair of aortic arch aneurysms has been accomplished using both 'hybrid' (open and endovascular) and totally endovascular techniques. SUMMARY: Endovascular stent grafting of aneurismal disease processes of the thoracic aorta is feasible and relatively safe. Exquisite judgment is essential for good results. These results generally rest on a broad knowledge base of thoracic aortic disease processes and experience in both open and endovascular surgery. Careful attention to patient anatomy and device specifications must be maintained. The key to the successful implementation of this technology lies in careful preoperative planning, intraoperative execution with safe device delivery, and prevention of central nervous system injury. Routine follow-up imaging is imperative to better understand the long-term results and indications for these new procedures.     

Angioskopie

In complex thoracic aortic disease endovascular techniques and the use of hybrid stent grafts enables a combination therapy of the aortic arch and the descending aorta through a median sternotomy. This emphasizes the importance of intraoperative visualization of the descending aorta and its pathologies. Intraoperative angioscopy is a new diagnostic method for the assessment of distal aortic disease and assists in therapeutic decision-making and navigation of endovascular techniques in the descending aorta. This study presents the angioscopic results of 62?patients (mean age 60±12?years, 73% male, 54?aortic dissections, eight aortic aneurysms) during surgery of the thoracic aorta. Visualization of the extent of pathology along the downstream aorta was feasible in all patients. The implantation of a hybrid stent graft prosthesis was assisted by angioscopy in 34?patients and endovascular balloon dilatation of the stent graft was navigated by angioscopy in 11?patients. Angioscopy has become an indispensable tool in the intraoperative treatment of complex thoracic aortic disease in our clinic, particularly in the navigation of endovascular interventions in the distal thoracic aorta through the aortic arch.     

Endovascular repair of a tuberculous aortic false aneurysm

INTRODUCTION: Aortic aneurysms are a well known but rare complication of tuberculosis. Their major complication is aneurysmal rupture, unforeseeable and lethal. EXEGESIS: Chest pain and hemoptoic expectoration revealed a false aneurysm of the aortic isthmus in a 48-year-old man. Endovascular repair with a stent graft was urgently undertaken. Tuberculosis was diagnosed 6 weeks thereafter by the growth of gastric juice cultures and medically treated. Most tuberculous aortic aneurysms are false aneurysms, caused by an adjacent tuberculous focus eroding the aortic wall. They present with pain, bleeding or as para-aortic masses. CONCLUSION: Tuberculous false aneurysms of the aorta necessitate an early intervention before they rupture. Surgical treatment remains the preferred option but endovascular repair with a stent graft is a therapeutic alternative, to be considered in high-risk surgical patients.     

Off-pump endovascular treatment of aortic arch aneurysms]

BACKGROUND: Traditional repair of aortic arch aneurysms requires cardiopulmonary bypass, hypothermia and circulatory arrest. Endovascular repair is an attractive, less invasive alternative that may change our therapeutic approach. The aim of this study was to review our clinical experience with endovascular treatment of aortic arch aneurysms and to address the new problems in this area. METHODS: In the last 5 years, we treated 21 patients for aortic arch pathology with an "off-pump" endovascular repair (18 men, 3 women, mean age 71.4 +/- 7.2 years). We used 26 stent grafts (5 Gore Excluder TAG, 3 Endomed Endofit, 6 Medtronic Talent, 12 Cook Zenith TX1) with a mean of 1.2 graft/patient. Proximal fixation of endograft was achieved by means of aortic "de-branching" in 11 cases. In 10 cases the left subclavian artery was intentionally covered without revascularization. Follow-up included clinical examination, chest X-ray and computed tomography at discharge and at 6-month intervals thereafter. RESULTS: Technical success was 85% (18/21). There was one in-hospital death (4.7%) due to endograft migration. We observed 2 cases of type I endoleak (9.5%). One surgical conversion was performed 2 weeks after the procedure, because of total collapse of the stent graft with rupture of three stents. No complications related to the coverage of the left subclavian artery were observed. At a mean follow-up of 18.7 +/- 12.8 months, no mortality or morbidity including new-onset endoleak, stent-graft migration and thrombosis of supra-aortic grafts were recorded. CONCLUSIONS: Endovascular treatment of aortic arch pathology is feasible even in elderly patients. However, accurate placement in the arch and aneurysm sealing with the currently available devices, may be challenging due to the involvement of supra-aortic vessels, the anatomical curvature of the arch, the high blood flow, and substantial movement of the aorta with each heartbeat.     

Endovascular stent - graft treatment for blunt aortic injury.

BACKGROUND: Thoracic aortic injury resulting from blunt trauma is usually fatal and almost always associated with multiple, complex, nonaortic injuries that can adversely affect standard surgical repair of the aorta. Endovascular stent - graft treatment offers these patients a less invasive operative treatment option. METHODS AND RESULTS: Between January 2002 and October 2003, 6 patients with blunt aortic injury (BAI) were treated with a stent - graft. In all cases endovascular management was selected because of associated polytrauma or comorbidities. All stent - grafts were homemade and deployed through the femoral artery with 18-20 Fr delivery sheaths. There were no cases of perioperative death, renal failure, or neurologic complication. In one patient the postoperative computed tomography scan showed proximal endoleak requiring additional balloon dilatation and stenting. No other endoleaks were observed by CT in the acute phase. None of the follow-up CT scans revealed evidence of endoleak, migration, or alteration of the stent - graft. CONCLUSIONS: Endovascular repair for BAI is technically feasible and is an alternative to open surgery for high-risk patients.     

Changing trends in management of thoracic aortic disease: where do we stand with thoracic endovascular stent grafts?

BACKGROUND: Descending thoracic aortic surgery is linked to a high morbidity and mortality. Thoracic endovascular stent grafts were designed to decrease perioperative risks, especially in patients with severe comorbidities. However, procedure-related complications and clinical outcomes remain ill-defined. PATIENTS AND METHODS: The authors' experience in 24 patients (mean age 63.3+/-25.4 years) from May 2001 to February 2004 is reported. The diagnosis was thoracic aneurysm in 10 patients, complicated penetrating aortic ulcer in six patients, blunt traumatic aortic rupture in four patients, complicated type B dissection in two patients, and aortoesophageal fistula and postoperative pseudoaneurysm in one patient each, respectively. Symptoms were present in 15 of 24 patients (62.5%). The decision to implant a thoracic endovascular stent graft was based on significant coinjuries in three patients, severe comorbidities in 16 patients and patient decision in five patients. RESULTS: The mean operative time was 2.3+/-1.7 h and the mean number of stents per patient was 1.8+/-0.7. Six patients required coverage of the left subclavian artery without complications. A carotid-carotid bypass was required in two patients. In one patient, a thoracic endovascular stent graft was introduced through a 10 mm graft anastomosed to the distal descending aorta accessed through a video-assisted minithoracotomy. Perioperative complications were an arterial access problem in one patient and pneumonia in four patients. The primary success rate was 100%. An 82-year-old patient with a ruptured thoracoabdominal aneurysm died of multi-organ failure (4.1% hospital mortality). All 23 surviving patients were alive at 13.4+/-3.5 months. One patient required an additional procedure for recurrent hematemesis. CONCLUSIONS: Thoracic endovascular stent grafts show excellent early results in well-selected cases. Extra-anatomical bypass or novel vascular access procedures increase the applicability of thoracic endovascular stent grafts. Meticulous follow-up is essential to identify and treat stent graft-related complications. Data on long-term outcomes are required before applying thoracic endovascular stent grafts to patients with a lower operative risk.     

“三文治技术”在腹主动脉瘤腔内修复中保留髂内动脉血流的应用

目的探讨“三文治技术”在合并髂总动脉瘤的腹主动脉瘤患者腔内修复中保留髂内动脉血流的可行性及安全性。方法我们对1例合并双侧髂总动脉瘤的肾下性腹主动脉瘤患者行腔内修复术。该患者由于腹主动脉瘤合并双侧髂总动脉严重扩张,覆膜支架覆盖腹主动脉及髂总动脉瘤的时需覆盖双侧髂内动脉开口,可能造成髂内动脉血流受阻而引起盆腔缺血。我们在进行左髂总动脉腔内修复时应用了“三文治技术”,以覆盖病变血管同时保留一侧髂内动脉血供。结果手术成功地对腹主动脉瘤及双侧髂总动脉瘤进行了覆膜支架的腔内修复,同时保留了髂内动脉血供。结论在复杂腹主动脉瘤髂内修复时,使用“三文治技术”可能是一种有效的保留分支血管血供的方法。     

Endovascular therapies for vascular disease

Endovascular techniques including angioplasty, stenting, and endoluminal stent grafts represent important therapeutic options for the treatment of vascular disease. Technologic advances have allowed for the treatment of aneurysmal disease as well as extra-cranial carotid disease that previously required surgical methods. The success of various endovascular therapies varies based on anatomic location and extent of disease. The clinical results in different arterial segments are increasingly recognized in the published literature. The aortoiliac arterial bed appears to respond most favorably, with less favorable results observed in the infra-inguinal and infrapopliteal locations. There is increasing evidence that stent-supported carotid angioplasty using cerebral protection will play an important future role in the treatment of carotid artery stenosis. Less invasive techniques to treat abdominal aortic aneurysms with endoluminal stent grafts have dramatically changed the available therapeutic options. Improved devices and delivery systems will likely increase the number of patients who can be successfully treated in this manner. The evolution of endovascular therapies will continue to change the way we treat vascular disease.     

Endovascular approaches for complex forms of recurrent aortic coarctation.

PURPOSE: To review a single-center experience with endovascular treatment of recurrent aortic coarctation in adults. METHODS: Since 1998, 11 patients (9 men; mean age 48+/-15 years, range 16-63) with recurrent aortic coarctation following previous coarctation repair were referred to our institution for treatment. Clinical presentations included pseudoaneurysm (n=2), restenosis (n=3), pseudoaneurysm accompanied by restenosis (n=4), and rupture of a post-coarctation pseudoaneurysm (n=2). All patients were treated using an endovascular approach as part of a single-center investigational device exemption protocol. RESULTS: Endovascular interventions included Palmaz stent implantation (n=3), implantation of an endoluminal graft (n=2), or a combination of both treatments in 6 patients. Three patients underwent balloon angioplasty before stenting or endografting, and 2 patients had a carotid-subclavian bypass done before the endovascular repair. All repairs were technically and clinically successful. The median length of stay after repair was 2.0+/-2.3 days. In follow-up, 2 patients underwent a carotid-subclavian bypass for left upper extremity claudication. Two patients required reintervention owing to migration of the stent in 1 and an endoleak 2 years after the initial procedure in the other. CONCLUSION: Endovascular approaches to adult coarctation appear to be safe and effective. With the emergence of endoluminal grafts and the widespread availability of the Palmaz stent, endovascular repair offers an excellent alternative to open surgery for complex cases of recurrent coarctation. Additional studies are indicated to assess the long-term outcomes of these patients.     

Non-Surgical Repair of Abdominal Aortic Aneurysm

The conventional treatment of abdominal aortic aneurysm is surgical replacement with a synthetic graft. Attempts have been made to treat these aneurysms using stent mounted grafts with reasonable success, thus obviating the need for surgery. However, certain problems like thromboembolism and the large profile are yet to be overcome. We report a case of a 75-year-old man where an attempt to repair a symptomatic abdominal aortic aneurysm was made using an endovascular uncovered òwalló stent combined with endosaccular coil implantation.     

Engineering Goals for Future Thoracic Endografts—How Can We Make Them More Effective?

Endovascular treatments for catastrophic aortic conditions have gained increasing popularity over the past 20 years. Originally developed for abdominal aortic aneurysms (EVAR), treatment has been modified for use in thoracic aortic repair (TEVAR). As expanding numbers of patients with increasingly intractable conditions and more hostile anatomies are treated, endovascular stent designs are maturing to be suitable for these more demanding situations. This article discusses the engineering considerations that apply to changing stent graft designs for current and evolving thoracic applications. The biological parameters that differentiate thoracic from abdominal aortic environments are outlined. Factors concerning materials, sealing mechanisms, deployment, stent frame architecture, and migration resistance are described, and eagerly awaited potential future developments are summarized.     

开窗支架型血管治疗近肾腹主动脉瘤的初步临床结果

目的回顾性分析开窗支架型血管治疗近肾腹主动脉瘤（AAA）的初步结果。方法4例合并严重疾病无法行开放手术的近肾AAA患者,根据术前CT数据定制个体化开窗支架型血管。于全身麻醉下置人此支架型血管并置入肾动脉支架。结果术后即时造影示各分支血管血流通畅,支架形态良好,两例有少量近端I型内漏。术后3个月复查4例患者支架形态正常,两例I型内漏均消失,但另一名患者出现Ⅱ型内漏。结论应用个体化开窗支架型血管治疗近肾AAA近期效果良好。     

腔内隔绝术治疗Stanford B型主动脉夹层210例分析

目的评价腔内隔绝术治疗Stanford B型主动脉夹层的疗效和安全性。方法收集2002年4月至2010年10月于沈阳军区总医院行主动脉腔内隔绝术治疗Stanford B型主动脉夹层210例资料,年龄(53.4±11.1)岁。经股动脉切开置入覆膜支架封堵胸主动脉破裂口,置入后造影检查证实疗效;合并严重冠状动脉狭窄者于腔内隔绝术后3～7 d完成经皮冠状动脉介入治疗(PCI)。观察介入治疗的疗效。结果腔内隔绝术成功率100%,共置入208枚主体覆膜支架及13枚cuff支架。20例患者完全封闭左锁骨下动脉开口,无左上肢及脑供血不足症状。26例患者行PCI成功率100%,对32支靶血管共置入36枚冠状动脉支架,无出血、心肌梗死等并发症。患者术后平均随访(60±35)个月,随访率96.6%(201/208)。33例出现腔内隔绝术后综合征,13例术后有残余内漏,其中8例残余内漏于术后3个月自行封闭。术后半年,3例再发升主动脉夹层,1例发生截瘫。术后1年,1例发生迟发性内漏。行PCI患者无主要心脏不良事件发生。本组共死亡6例,其中与腔内隔绝术有关死亡4例,分别发生在术后1 h、术后5 d、出院后2 d、15 d,与腔内隔绝术无关死亡2例,分别问胃癌晚期和肺心病。结论腔内隔绝术治疗Stanford B型主动脉夹层近期及长期疗效好、并发症低。合并冠心病患者择期二次行PCI安全可行。     

When not to operate for abdominal aortic aneurysms.

Refinement in anaesthetic and surgical techniques for repair of abdominal aortic aneurysms has significantly reduced the mortality associated with treating this condition. Endovascular techniques have further pushed back the frontiers for the treatment of aortic aneurysms, and higher risk patients are now being treated under local or regional anaesthesia. The question of when not to offer intervention is becoming more and more difficult. Age is not a bar to aneurysm surgery in a patient who is physically fit; but the risk and benefit of intervention must be carefully evaluated for each patient on an individual basis, and risk calculation must be evidence based. Contraindications to aneurysm surgery are relative and few and include: small aneurysms (<5.5 cm), a co-morbidity that increases surgical risk by >10% and a life expectancy of <1 year. Endovascular graft technology is rapidly advancing, but until the long term results of endovascular repair of aortic aneurysms are proven, the indications for intervention should be the same as for open repair.     

Midterm experience with the endovascular treatment of isolated iliac aneurysms.

AIM: The aim of this retrospective, single institution study was to describe our 4-year experience with the endovascular repair of isolated iliac artery aneurysms. METHODS: Between May 1997 and June 2001, 16 patients (15 males; mean age 64+/-9 years), were treated with covered stent grafts. Twelve of the endovascular procedures were performed under epidural and 4 under local anaesthesia. The percutaneous approach was employed in 13 cases and the femoral artery had to be exposed in 3 cases that demanded simultaneous revascularization of the peripheral circulation (n=2) or required a 16 F sheath to employ a Baxter Lifepath stent graft (n=1). The mean size of the iliac aneurysms was 4.5 cm (range 3.5 to 5.2 cm). Four aneurysms involved the hypogastric ostium in absence of any distal neck. RESULTS: All the patients underwent initially successful endovascular treatment of isolated iliac aneurysms and were followed from 3 to 52 months (mean 18 months). No procedural deaths and no acute or late graft thrombosis occurred. The perioperative complications included 1 dissection of the external iliac artery that required a further endovacular procedure and 1 case of endovascular leak fed to the hypogastric artery. A CT scan 4 months later showed spontaneous thrombosis of aneurysm and no further leakage. Two patients had undergone combinated femoro-popliteal arterial bypass. CONCLUSION: In our early clinical experience the use of self-expandable covered stent graft successful treated isolated iliac artery aneurysms. Endovascular repair is a safe and effective technique with good midterm results in patients at standard and high risk.     

Endovascular treatment of aortic aneurysms of the abdominal aorta with covered stents

Abdominal aortic aneurysms are common in the aging population; their surgical treatment is well established and allows good results in specialized centers. Endovascular exclusion of abdominal aortic aneurysms has been shown to be feasible since 1991 and nowadays commercially available bifurcated endografts allow safe exclusion in selected cases. In the last year 22 patients with an aorto-iliac aneurysm received endovascular treatment at our Institution. We included patients with favorable anatomic characteristics (i.e. neck > 15 mm length, and < 28 mm diameter, iliac neck < 12 mm diameter, absence of > 90 degrees iliac or aortic angulation) and, in particular, those with increased surgical risk for systemic pathology (12 patients), or hostile abdomen (9 patients). We employed Vanguard II (Boston Scientific) endovascular grafts introduced through a surgically exposed common femoral artery; the contralateral limb of bifurcated grafts was inserted percutaneously. The endograft was successfully implanted in all cases, requiring additional iliac cuffs for complete aneurysm exclusion in 3 cases. Periprocedural morbidity included one case of thrombosis and one case of pseudoaneurysm of the punctured femoral artery, which required surgical treatment. In one case surgical exposure of the iliac artery was required in order to advance the device into the aorta. In one patient who previously underwent hemicolectomy, postoperative colonic ischemia was observed, and pharmacological treatment was required. Moreover we also observed one case of groin infection that was treated successfully with local wound care and systemic antibiotics, and one late contralateral limb thrombosis that was successfully treated with loco-regional thrombolysis. The mean follow-up was 6.1 months: one patient died because of congestive heart failure. No further morbidity was recorded. A type-II endoleak was observed in one patient, originating from the inferior mesenteric artery with no sac enlargement; this patient is still under observation. In conclusion, with proper clinical selection, commercially available endovascular devices allow safe exclusion of abdominal aortic aneurysms. Long-term follow-up is needed to ascertain the durability of the procedure.     

B型主动脉壁间血肿治疗策略的选择

目的:探讨Standford B型主动脉壁间血肿的治疗策略的选择。方法: 总结我院2年期间通过内科药物和腔内修复手术治疗的Standford B型主动脉壁间血肿患者16例,根据患者治疗结果进行评价主动脉壁间血肿治疗策略的选择。结果: 16例患者中,药物治疗的患者6例,腔内修复治疗的患者10例（其中4例是由于药物治疗后症状持续加重转为腔内修复手术治疗的）。腔内治疗患者均存活,药物治疗组中死亡2例,均为出现急性主动脉夹层引起死亡。结论: 腔内修复治疗对于Standford B主动脉壁间血肿是安全可行治疗选择。