Acute traumatic rupture of the thoracic aorta treated with endoluminal stent grafts

BACKGROUND: Endovascular technologies provide a new therapeutic option in the treatment for acute traumatic rupture of the thoracic aorta. We report our experience with endoluminal stent graft repair of thoracic aortic ruptures. METHODS: Five patients underwent repair of the thoracic aorta with an endoluminal stent graft for acute traumatic rupture. Data from patient history, the procedure, hospital course, and follow-up were analyzed. RESULTS: All patient were involved in motor vehicle crashes. The mean Injury Severity Score was 51.8 +/- 6.38. All procedures were technically successful. Mean operating room time was 111 minutes and mean estimated blood loss was 200 mL. There were no cases of postprocedural endoleaks or conversions. There were no procedural complications, paraplegia, or deaths. Average follow-up was 20.2 months. CONCLUSION: Five cases of successful endograft repair of thoracic aortic rupture have been demonstrated. This should encourage future studies to determine whether endovascular repair of thoracic aortic ruptures is a safe and feasible alternative to conventional open repair.     

Thoracic aortic stent grafts--early experience from two centres using commercially available devices.

OBJECTIVES: open surgical intervention for aneurysms of the distal arch and descending thoracic aorta is associated with high morbidity and mortality. Stent grafts offer an attractive alternative treatment for these aneurysms. The aim of this study was to assess the morbidity and mortality of endovascular treatment for these aneurysms with stent grafts. DESIGN, PATIENTS AND METHODS: a prospective observational study was performed of 37 consecutive patients treated from July 1997 to October 2000 (30 at Guy's and St. Thomas' and 7 at Sheffield). Indications included degenerative aneurysms (n=18), false aneurysm (5), acute dissection (4), aortic transection (4), aneurysm related to previous surgery for coarctation (3), chronic dissection (2) and traumatic dissection (1). Nineteen were performed as elective and 18 as non-elective procedures. RESULTS: three non-elective patients died in hospital (in-hospital and 30-day mortality 8%) and one suffered a stroke with spontaneous full recovery. No elective patient died. One patient with a persistent proximal endoleak required conversion to open repair at 6 weeks. Two patients with persistent flow into the sac at 24 h spontaneously thrombosed at subsequent 3 month follow-up. Two further patients developed new distal endoleaks at 3 months and required distal extension cuffs. One patient died at 28 months of aortic rupture. Serial CT scans had shown prolapse of the stent graft into the aneurysm sac and the patient died just before planned endovascular repair. No patient suffered paraplegia or renal failure. Intensive care facilities were only required for patients who needed them preoperatively. CONCLUSIONS: thoracic stent grafts can be performed with low morbidity and mortality. They offer a realistic alternative to open surgery. Long term follow up is required to assess their durability.     

Results of Urgent and Emergency Thoracic Procedures treated by Endoluminal Repair

INTRODUCTION: emergency surgery on the thoracic aorta is associated with a high mortality. Endovascular treatment for these patients may offer a realistic alternative to open surgery. METHOD: between 1997 and 2002 data was collected prospectively on all patients who underwent urgent or emergency endoluminal repair for thoracic aortic pathology. All patients had ruptured or were at risk of rupture, and had been assessed as high risk for open surgery. RESULTS: twenty-four patients required urgent/emergency stent grafts. The median age was 74 (range 17-90). Indications included: trauma (transection in 3 and traumatic dissection in 1), acute symptomatic type B dissection (4), symptomatic degenerative aneurysms (7), false aneurysms associated with infection (6), Takayasu's vasculitis causing rupture of the descending thoracic aorta (1), symptomatic aneurysm associated with chronic dissection (1) and a secondary aorto-oesophageal fistula (1). The 30-day survival was 83.3% (20/24) and the survival at 1 year was 70.8% (17/24). The median follow-up was 13.5 months (range 2-57). The complications included: transient paraplegia (1), non-disabling stroke (1), distal endoleak treated with an extension cuff (1) and a proximal endoleak (1) which required removal of the graft at open surgery. CONCLUSION: endoluminal repair of thoracic aortic disease requiring urgent/emergency treatment has encouraging results with low morbidity and mortality rates compared with open surgery. Long-term follow-up is required to assess the durability of the grafts.     

A SELF-EXPANDING ENDOLUMINAL GRAFT FOR TREATMENT OF ANEURYSMS: RESULTS THROUGH THE DEVELOPMENT PHASE

Background: The results of two and a half years' experience of endoluminal treatment of aneurysmal disease (from March 1993 to December 1995) are reported. Methods: The endoluminal grafts were individually made at Royal Perth Hospital. They are based on Dacron-covered stainless steel self-expanding ‘Z’ stents with Gianturco barbed stents (Cook Pty, Australia) for proximal anchorage for grafts within the aorta, Results: Fourteen straight tube grafts (nine for aortic aneurysm, four for iliac aneurysm and one for subclavian aneurysm) and 24 bifurcate grafts were deployed; all were in patients considered high-risk for conventional repair. Seventy-two per cent of the straight tube grafts successfully excluded the aneurysm. The bifurcate grafts, in use since July 1994, successfully excluded the aneurysm in 88%. There were two delayed deaths from rupture after the grafts failed to exclude the aneurysms; two patients required conversion to open repair and survived; three patients have persistent endoleaks; and three of the bifurcate grafts subsequently occluded a graft limb but did not require further intervention. Ninety per cent of these complications occurred in the first half of the series (prior to January 1995). Conclusions: A learning and development curve was clearly apparent. The results thereafter compare favourably to those for open repair in similar high-risk groups, suggesting that these techniques hold promise for all patients with aneurysms.     

Endovascular repair of para-anastomotic aortic aneurysms

BACKGROUND: Para-anastomotic aneurysms involving the aorta and iliac arteries can occur years after aortic surgery and are at risk for rupture and erosion into surrounding structures. We report on our continued experience with patients who have been treated for these lesions with endovascular management as an alternative to traditional open repair. METHODS: Patients who underwent endovascular repair of para-anastomotic aneurysms involving the distal aortic arch, descending thoracic aorta, abdominal aorta, or iliac arteries were prospectively followed up in a database. Patient comorbidities, initial aortic pathology, initial graft configuration, aneurysm characteristics, evidence of infection, type and configuration of endograft used, and follow-up were analyzed. RESULTS: From 1997 to 2006, 53 patients with 65 para-anastomotic aneurysms were treated with endovascular stent grafts. Patients who were originally treated for aortoiliac occlusive disease presented significantly later than those treated for aneurysmal disease (15.8 vs 8.9 years, P < .01) The initial technical success rate was 98%. Endoleaks were identified in six patients (11%) < or =1 month of surgery, and three required reintervention, including open conversions. Endoleak complications were significantly associated with patients who had symptomatic para-anastomotic aneurysms (P = .01). Perioperative mortality after endovascular repair was 3.8%. Overall mortality within a mean follow-up of 18 months was 49% and was significantly associated with older age at the time of endovascular treatment (P = .03). CONCLUSION: Endovascular repair of para-anastomotic aneurysms involving the aorta and iliac arteries is technically feasible and is associated with a low perioperative morbidity and mortality. Close follow-up is required to identify endoleaks. Long-term survival is limited in older patients. We recommend endovascular stent graft repair for para-anastomotic aneurysms in anatomically suitable patients.     

Endoluminal repair of aneurysms associated with coarctation

BACKGROUND: Late aneurysm formation is a well-recognized complication of surgery for aortic coarctation. Open surgery to repair these aneurysms is associated with significant morbidity and mortality. Endoluminal repair is an attractive alternative to open surgery. METHODS: Data were collected prospectively on consecutive patients who presented with aneurysms associated with coarctation RESULTS: Between June 1999 and October 2001, 5 patients underwent elective endoluminal repair for coarctation aneurysms. All procedures were technically successful and no patients died. Four patients previously had open surgery to repair aortic coarctation, and 1 presented with an aneurysm associated with a previously unrecognized coarctation. The median follow-up was 7 months (range, 3 to 29 months), and to date, all aneurysms remain excluded. CONCLUSIONS: Endoluminal repair is a promising alternative to redo open surgery for thoracic aneurysms associated with previous surgery for aortic coarctation. Long-term follow-up is required to assess the durability of the stent grafts.     

Secondary aortoesophageal fistula after endoluminal exclusion because of thoracic aortic transection

Secondary aortoesophageal fistula (AEF) is a rare but catastrophic complication that occurs after thoracic aortic reconstruction. Recently endoluminal stent grafts have been used in selected patients with a thoracic aortic aneurysm, dissection, or traumatic aortic transection. A 24-year-old woman had massive upper gastrointestinal tract bleeding 15 months after endoluminal stent graft placement because of traumatic descending thoracic aortic transection. Evaluation demonstrated an AEF from the mid-esophagus to the endoluminal stent graft. The endoluminal graft was explanted, with primary repair of the thoracic aortic defect and simultaneous primary repair of the esophageal injury. The patient is well 15 months after open repair of the AEF.     

Endovascular treatment of the descending thoracic aorta.

OBJECTIVES: to report our initial experience with endovascular stent graft repair of a variety of thoracic aortic pathology. DESIGN: retrospective single center study. MATERIAL AND METHODS: between February 2000 and January 2002, endovascular stent graft repair was performed in 26 patients: traumatic aortic isthmus rupture (n=3), Type B dissection (n=11) and descending thoracic aortic aneurysm (n=12). The deployed stent graft systems were AneuRx-Medtronic (n=1), Talent-Medtronic (n=13) and Excluder-Gore (n=12). RESULTS: successful deployment of the stent grafts in the intended position was achieved in all patients. No hospital mortality neither paraplegia were observed. Late, non procedure related, death occurred in four patients (15%). Access artery complications with rupture of the iliac artery occurred in two patients and were managed by iliac-femoral bypass. The left subclavian artery was overstented in seven patients (27%). Only the first patient received a carotido-subclavian bypass. The mean maximal aortic diameter decreased significantly in patients treated for descending thoracic aneurysm. Only one patient had an endoleak type II after 6 months without enlargement of the aneurysm. Complete thrombosis of the thoracic false lumen occurred in all but one patient treated for Type B dissection 6 months postoperatively. Two patients underwent a consecutive stent graft placement, due to a large re-entry tear distal to the first stent graft. CONCLUSIONS: endovascular stent graft repair for Type B dissection, descending thoracic aneurysm and aortic isthmus rupture is a promising less-invasive alternative to surgical repair. Further studies are mandatory to determine its long-term efficacy.     

Surgical correction of failed thoracic endovascular aortic repair

OBJECTIVE: The number of thoracic aortic endovascular procedures is increasing rapidly, and the clinical outcome largely depends on the underlying aortic pathology. When primary stent grafting is unsuccessful, secondary endovascular solutions are most often feasible. However, in recurrent endovascular failure without further minimally invasive options, conservative treatments or conversion to open surgery are the only remaining therapeutic strategies. METHODS: In our experience, 106 patients received thoracic aortic endovascular treatment. Five of these patients and three from other centers underwent conversion to open repair because of 4 type Ia endoleaks (3 thoracic aortic aneurysms, 1 traumatic rupture), 2 retrograde type A dissections, 1 type Ib endoleak with contained rupture, and 1 secondary false aneurysm rupture due to stent graft migration. The latter four were surgical emergencies; the other four were urgent or elective procedures. Three patients underwent supracoronary arch replacement through sternotomy. One patient had arch and proximal descending aortic replacement, three had hemiarch and descending aortic replacement, and one had descending aortic replacement through left thoracotomy. Five stent grafts were totally removed, and three endografts were left in situ. All conversions were performed according to a protocol including total extracorporeal circulation (n = 7) or left heart bypass (n = 1), cerebrospinal fluid drainage and monitoring motor-evoked potentials, transcranial Doppler, and electroencephalography. RESULTS: All patients survived the surgical procedure. Six patients had an uneventful postoperative course, whereas necrotic cholecystitis developed in one patient who required cholecystectomy and prolonged intensive care stay. One polytrauma patient died from secondary rupture due to prosthesis infection 24 days after stent graft explantation. No stroke, paraplegia, renal failure, or other major complication occurred. With a mean follow-up of 14 months (range, 4-71 months), seven patients are alive without any sign of recurrent aortic problems. CONCLUSION: Failure of thoracic endovascular aortic repair comprises a new aortic pathology. Secondary endovascular treatment is feasible in most patients; however, some patients will require open surgery to repair failures of thoracic endovascular aortic treatment. These procedures constitute a large surgical trauma and require an extensive protocol, including extracorporeal circulation, neuromonitoring, and adjunctive modalities to provide organ protection. We recommend that these procedures be performed in centers with experience and the infrastructure to offer these protective measures.     

Challenges of endovascular tube graft repair of thoracic aortic aneurysm: midterm follow-up and lessons learned

OBJECTIVES: Endovascular stent-graft repair has great potential in treatment of thoracic aortic aneurysms. This study analyzed a single center's experience with first-generation commercially produced thoracic stent grafts used to treat descending thoracic aortic aneurysms. METHODS: Over 58 months 84 patients underwent endovascular stent-graft repair of descending thoracic aortic aneurysms; 22 patients received the Gore TAG stent graft, and 62 patients received the Talent thoracic endovascular stent-graft system. Each patient was enrolled in one of three distinct US Food and Drug Administration trials at Mount Sinai Medical Center in accordance with strict inclusion and exclusion criteria, including suitability for open surgery, aneurysm anatomy, and presence of comorbid medical illness. Mean age of this cohort was 71 +/- 12 years. There were 54 men and 30 women, and 74 (88%) had three or more comorbid illnesses. Primary technical success was achieved in 76 patients (90%). Mean follow-up was 15 months (range, 0-52 months). RESULTS: Successful aneurysm exclusion was achieved in 69 patients (82%). Major procedure-related or device-related complications occurred in 32 patients (38%). There were six proximal attachment failures (8%), four distal attachment failures (6%), one intergraft failure (1%), two mechanical device failures (3%), five periprocedural deaths (6%), and five late aneurysm ruptures (6%). At 40 months, overall survival was 67% (+/-10%), and freedom from rupture or from type I or type III endoleak was 74% (+/-10%). CONCLUSION: While promising, this midterm experience with commercially available devices highlights the shortcomings of current stent-graft technology. Three significant advancements are required to fulfill the potential of this important treatment method: a stent graft with a durable proximal and distal fixation device, enhanced engineering to accommodate high thoracic aortic fatigue forces, and a mechanism to adapt to aortic arch and visceral segment branches to enable treatment of lesions that extend to or include these vessels.     

Endovascular treatment of arch and proximal thoracic aortic lesions

OBJECTIVE: To analyze at one institution the endovascular treatment for aortic arch and proximal thoracic aortic lesions, categorize open arch reconstruction, and make preliminary recommendations based on pathology (dissection vs aneurysm), and anatomical extent of disease. METHODS: A retrospective review of aortic arch and descending thoracic aortic lesions managed with endovascular treatment between June 2002 and June 2007. RESULTS: Thirty-four patients received endovascular repair for aortic dissection (n = 28) and aneurysm (n = 6). Open supra-aortic transposition or debranching of the great vessels was performed in 14 cases of dissection (50%) and six cases (100%) of aneurysm. In 14 dissections, the entry tear was located in the distal aortic arch, enabling the left subclavian artery to be sealed without reconstruction. The procedures were successful in 33 patients (97.1%); one intraoperative death occurred. Type I endoleaks were found intraoperatively in eight cases. After management with balloon angioplasty and by extending the stent implantation, the endoleaks resolved in four cases and decreased in four cases. One patient with Stanford type A dissection died from an unknown cause 3 months after treatment. The overall survival rate was 94.1% (32/34), and all bypass grafts remained patent during the follow-up period. CONCLUSIONS: Endovascular stent grafting is a safe and effective method for the treatment of aortic arch lesions. Transposition of the supra-aortic great vessels can be effectively combined with endovascular stent grafting to ensure both cerebral blood supply and enough landing area for the stent graft.     

Complications]

Transluminal endovascular stent grafts placement has recently been introduced as a promising alternative to surgical treatment of aortic aneurysms, but complications can occur. Mortality, aneurysm rupture, massive microembolization, paraplegia, endoleaks, and graft migration are significant problems associated with endovascular aneurysm repair. An endoleak, defined as persistence of blood flow within the aneurysm sac outside the lumen of the stent graft, is among the most common complications and is a major problem because it may permit aneurysm expansion and rupture. Endoleaks are caused by inadequate hemostatic sealing at the proximal or distal attachment site or by retrograde sac perfusion through patent aortic branch vessels; the reported incidence varies from 10-40%. In the treatment of thoracic aortic aneurysms, the occurrence of paraplegia is considered to be the Achilles heel of this technique, because reconstruction of intercostal arteries is impossible. Coverage of the intercostal artery, which is thought to be important for distal spinal cord blood supply, with stent grafts should be avoided. Although we consider this exciting new technique holds great promise for aortic aneurysm repair, further advances in device technology are necessary to minimize the risk of complications with this procedure.     

Stent-graft repair for acute traumatic thoracic aortic rupture

Traumatic rupture of the thoracic aorta is potentially life-threatening and leads to death in 75 to 90 per cent of cases at the time of injury. In high-risk patients, as traumatic injuries of the aorta combine with multiple associated injuries, endoluminal repair is now reported as a promising therapeutic strategy with encouraging results. This study determined the outcome of patients with traumatic thoracic aortic injury treated endovascularly during the past 7 years at our institution. Thirteen patients, 11 males and 2 females (mean age, 39 years; range, 19-82), with traumatic rupture of the otherwise unremarkable descending aorta (10 acute, 3 chronic), out of a series of 64 endovascular thoracic stent-graft procedures, were treated by implantation of Talent (n = 8), Vanguard (n = 5), and Excluder (n = 2) self-expanding devices between January 1996 and August 2003. The immediate technical success rate was 92 per cent (12/13). One patient showed a proximal endoleak type I, which was treated successfully by an additional stent-graft procedure. Secondary success rate was 100 per cent. The mortality rate was 0 per cent. Two additional stent-graft procedures were performed due to type I endoleaks after 18 and 28 months. There was no other intervention-related morbidity or mortality during the mean follow-up time of 26.4 months' (range, 6-86). Endovascular stent-graft repair of traumatic thoracic aortic injuries is a safe, effective, and low-morbidity alternative to open thoracic surgery and has promising midterm results.     

Endovascular stent-grafting for descending thoracic aortic aneurysms.

OBJECTIVE: Endoluminal placement of covered stent-grafts emerges as a less-invasive alternative to open surgical repair of thoracic aortic aneurysms (TAA). The present report describes our experience with endovascular stent-grafting in the treatment of descending TAA. METHODS: From 1997 to 2001, 28 descending TAA's were treated in 27 patients (17 male, mean age 70 years) by endovascular stent-grafting. The aneurysms (mean diameter, 6.6 cm) had diverse causes, but the majority were due to atherosclerosis (71%). They were predominantly localized in the proximal (32%), central (39%), and distal part (22%) of the descending thoracic aorta. In two patients (7%), the entire thoracic aorta was treated. Preliminary subclavian-carotid artery transposition was performed in five patients. AneurX (n=6), Talent (n=9), and Excluder (n=13) stent-grafts were used. In 13 cases (46%), multiple stents were necessary for complete aneurysm exclusion. RESULTS: In 27 of 28 cases (96%), the endovascular stent-grafts were successfully deployed. In one patient, stent dislocation into the aneurysm required open surgical repair in a subsequent procedure. There was no operative mortality. None of the patients developed paraplegia or paraparesis. No distal embolization occurred. After a median follow-up of 21 months (range, 1-49 months), there was one non-related late death. There was no aneurysm rupture. Maximal aneurysm diameter either remained stable or decreased slightly over time in all but one patient with evidence of an endoleak. Endoleaks occurred in eight patients (29%) during follow-up. In five of them the endoleaks sealed spontaneously, whereas in two patients a distal extension was inserted. CONCLUSIONS: Endovascular repair of descending TAA's is a promising less-invasive alternative to open repair. Extended follow-up is necessary to determine its definite efficacy in the longer term.     

Outcome after celiac artery coverage during endovascular thoracic aortic aneurysm repair: preliminary results

BACKGROUND: Endovascular repair of descending thoracic aortic aneurysms has emerged as an alternative to open repair. Coverage of the left subclavian origin has been reported to expand the proximal sealing zone. We report the planned coverage of the celiac artery origin with a thoracic stent graft to achieve an adequate distal sealing zone. METHODS: All patients undergoing endovascular aneurysm repair are prospectively entered into a computerized database. All patients who underwent thoracic endovascular aneurysm repair with coverage of the celiac artery origin were identified and retrospectively analyzed. End points for evaluation included indications for covering the celiac artery, anatomic features of the distal landing zone, demonstration of collateral circulation between the celiac artery and the superior mesenteric artery, technical success of the procedure, and presence of clinical ischemic symptoms after the procedure. RESULTS: Between March 2005 and May 2006, 46 patients underwent endovascular repair of descending thoracic aortic aneurysms. Seven patients had planned celiac artery coverage with a thoracic stent graft to secure an adequate distal sealing zone. Six patients demonstrated collateral circulation through the gastroduodenal artery between the celiac and superior mesenteric arteries before deployment of the stent graft. One patient had a distal type I endoleak at the conclusion of the procedure related to inadequate sealing at the superior mesenteric artery origin. No type II endoleaks were evident at the final intraoperative angiogram or 30-day computed tomography scan. There were no postoperative deaths, no ischemic abdominal complications, and no clinical spinal cord ischemia. Short-term follow-up (1 to 10 months) has demonstrated no additional endoleaks (type I not fully assessed), no aneurysm growth, and no aneurysm ruptures. CONCLUSION: This limited series supports the suitability, in selected patients, of covering the celiac artery origin for a distal landing zone when the distal sealing zone proximal to the celiac artery is inadequate. We recommend the angiographic evaluation of the collateral circulation between the celiac and superior mesenteric arteries when covering the celiac artery origin is being considered.     

降主动脉瘤的腔内移植物治疗

目的 探讨腔内移植物治疗降主动脉瘤的可行性。方法 12例降主动脉瘤接受了血管腔内技术治疗,包括5例真性动脉瘤、6例Stanford B型夹层动脉瘤及1例假性动脉瘤。13枚支架型血管在局部（n=2)或全身麻醉（n=10)下经一侧股动脉切开安装在病变部位。结果 腔内技术成功率100％。无瘤体破裂、截瘫、脏器及肢体缺血等并发症。早期并发症：3例早期内漏血。CT及MRA随访1－30个月：5例真性动脉瘤4例被完全旷置,1例内漏转化为持续性。6例Stanford B型夹层入口4例一期封堵满意,2例少量内漏血自愈,4例假腔内完全血栓形成2,例部分形成。1例假性动脉瘤效果满意。结论 腔内移植物治疗降主动脉瘤是一种安全、可靠、实用的新方法。但其远期治疗效果有待继续观察,尤其是夹层动脉瘤的腔内治疗具有更多的不确定性。     

Novel way to confirm successful endovascular repair of a thoracic aortic aneurysm using a remote wireless pressure sensor

Due to the continuous risk of rupture from endoleaks after endoluminal graft repair of thoracic aneurysms, the need for lifelong postoperative surveillance has become necessary. Patients are put at a lifetime risk of radiation exposure and may be at an increased risk of contrast induced nephropathy from routine contrast use during follow-up computed tomography for postoperative surveillance of endoluminal grafts. Measuring aneurysm sac pressures using remote wireless pressure sensor may provide a noninvasive method to detect endoleak, procedural success, and long-term stent graft stability.     

Blunt traumatic aortic transection: endoluminal repair with commercially available aortic cuffs

Blunt traumatic aortic transection remains a lethal condition. Treatment requires a high index of suspicion, prompt diagnosis, and expedient operative repair. Even in the best of circumstances, morbidity and mortality associated with open surgical repair are high, particularly because of frequent occurrence of other severe associated injuries. Endoluminal aortic stent-graft repair is an accepted treatment option in patients with aneurysm degeneration, and may be an alternative means of managing contained aortic transection. We describe three cases of blunt traumatic thoracic aortic transection treated with commercially available aortic endoluminal stent grafts.     

Feasibility of the Inoue single-branched stent-graft implantation for thoracic aortic aneurysm or dissection involving the left subclavian artery: short- to medium-term results in 17 patients

OBJECTIVE: This study assessed the short- to medium-term clinical results of the Inoue single-branched stent graft for repair of thoracic aortic aneurysms or dissections involving the left subclavian artery. METHODS: A retrospective review of experiences at two institutions was performed. We analyzed the data of consecutive 17 patients with thoracic aortic aneurysms or dissections who underwent endovascular repairs with the Inoue single-branched stent graft between July 1999 and April 2004. Complete baseline and follow-up data were available on all patients. The mean age was 71 +/- 9 years, and 13 of the patients (76%) were men. Eight patients (47%) were considered unfit for open surgery because of advanced age or the presence of comorbid diseases. RESULTS: The stent grafts were successfully delivered and deployed in all 17 patients. Periprocedural major complications, defined as those that caused any persistent disorder, occurred in one patient who developed spinal ischemia. A postoperative computed tomographic scan revealed three attachment site endoleaks; two endoleaks were from the proximal attachment sites and one endoleak was from the distal attachment site. The mean follow-up period was 26 months (range, 7 to 65 months). Two deaths occurred in the follow-up period from cerebral bleeding and pneumonia, both considered unrelated to the stent grafting. Two patients with attachment site endoleaks needed secondary stent-grafting; one patient required the implantation of a straight stent-graft in the distal attachment site and the other, the implantation of a double-branched stent-graft. Another patient with attachment site endoleak was considered very high-risk for open surgery or secondary stent grafting and did not undergo secondary intervention. The aneurysmal sac size of the patient has been stable for 28 months. The branched section of the stent graft was patent in all patients in the follow-up period. CONCLUSION: The results demonstrate the feasibility of the Inoue single-branched stent graft for thoracic aortic aneurysms or dissections involving the left subclavian artery.     

Intra-aneurysm sac pressure--the holy grail of endoluminal grafting of AAA.

OBJECTIVES: To relate intra-aneurysm sac pressure during endoluminal AAA repair to early and late endoleak, as well as to the aneurysm size upon follow-up. DESIGN: Prospective clinical investigation. METHODS AND PATIENTS: In 46 patients who had their AAAs treated by a stent graft (group I), intra-operative pressure measurement was performed (aorta uni-iliac stent grafts: 25 cases, bifurcated stent grafts: 21 cases). In 18 patients with open repair (group II) flow in the inferior mesenteric artery, and the pressure in the aneurysm sac was measured, before and after aortic and iliac cross clamping. Values are given in median with range. RESULTS: In group I, complete exclusion of AAA (no endoleak on intra-operative control angiogram) resulted in a statistically significant decrease in mean sac pressure from 74 (55-101) to 47 (4-104) mmHg. Pulse pressure reduced from 67 (34-103) to 8 (0-74) mmHg. In 11 patients a proximal type I endoleak was sealed by balloon modeling, after which the mean sac pressure reduced from 63 (14-91) to 52 (4-74) mmHg (n.s. versus patients with primary seal). Intra-operative pressure did not correlate with change in AAA diameter during twelve months follow-up. In group II, cross clamping of the proximal aorta significantly reduced mean sac pressure to 32 (21-55) mmHg, and the pulse pressure to 0 (0-13) mmHg (p < 0.05). Subsequent cross clamping of the iliac arteries did not significantly change the pressures. CONCLUSIONS: Measurement of intra-aneurysm sac pressure can help to detect and treat endoleaks during endoluminal grafting. However, the intra-operative sac pressure did not predict the fate of aneurysm during follow up. Compared to open repair of AAA, the sac pressure after endoluminal grafting remains significantly higher, in relation to pulse pressure.