Endovascular abdominal aortic aneurysm repair: 5-year follow-up results

Endovascular aneurysm repair (EVAR) offers a minimally invasive alternative to open repair and has the benefits of reduced perioperative morbidity and mortality. There are potential complications specific to EVAR, including device failure, graft migration, and endoleak, which necessitate long-term follow-up. This remains a relatively novel technique, and therefore, little long-term data exist. This study reports 5-year EVAR outcome data from a single center. Five-year follow-up data for 58 patients at a single center who underwent EVAR using a variety of different commercial devices was reviewed. All patients were followed up with 6-monthly duplex ultrasound scanning and clinical assessment in a nurse-led clinic, in addition to yearly computed tomographic (CT) scans for those participating in the EVAR trial. All patients in this series were male, with a median age of 72 years (range 58-81). Mean preoperative aortic diameter was 5.95 cm, and this reduced following EVAR to 5.2 cm (mean diameter) at 5 years. Mean hospital stay was 7 days, and there were no perioperative deaths. There were 20 (34%) early and 15 (26%) late complications. There were 13 endoleaks confirmed on CT; four (31%) were type I and nine (69%) were type II. All-cause mortality was 26%. There were no late aneurysm-related deaths. EVAR has the advantages of shorter hospital stay and reduced perioperative morbidity and mortality. Long-term follow-up remains a priority following aortic stenting in order to detect late complications such as endoleak.     

高外科风险腹主动脉瘤腔内修复术的近远期结果

目的 探讨高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果.方法 1997年7月至2011年7月,120例因肾下腹主动脉瘤行腔内修复术治疗的高外科风险患者纳入本研究.本组患者男性96例,女性24例;年龄52～95岁,平均74岁.平均动脉瘤直径(57±8)mm.术后1、3、6、12个月及此后每年进行CT血管造影或B超随访.主要研究内容是手术病死率及远期生存率,次要研究内容是二次手术率、动脉瘤体术后的变化以及支架的通畅率.结果 全身麻醉83例,局部麻醉37例.术后Ⅰ型内漏5例,Ⅱ型内漏25例,Ⅲ型内漏1例,技术成功率95％.手术病死率2.5％.随访6～144个月,平均(36±3)个月.术后1年生存率为92％,3年生存率为75％,5年生存率为43％.术后3年支架的一、二期通畅率分别为97％和100％.5年二次手术率为10％ (12/120),手术原因为:7例内漏,2例支架断裂,2例支架移位,1例支架内血栓形成.结论 高外科风险腹主动脉瘤患者接受腔内修复术治疗的近远期结果满意,证实该技术适用于这类人群.     

Endovascular aneurysm repair: a perioperative perspective

Endovascular aneurysm repair (EVAR), has surpassed open repair as the technique of choice in many centres in response to several large studies which showed significantly improved 30-day mortality. While several multicentre EVAR trials looked at surgical outcomes, very few have specifically investigated the effect of anaesthetic techniques or perioperative care of these patients. The purpose of this review to is to present some of the current evidence for the different aspects of perioperative management of patients undergoing EVAR. This includes surgical considerations, pre-operative assessment, and choice of anaesthetic technique as well as pharmacological protective strategies.     

Endovascular popliteal aneurysm repair: are the results comparable to open surgery?

INTRODUCTION: The aim of this study was to review our experience of popliteal aneurysms using endovascular techniques. METHODS: Thirty popliteal aneurysms in 25 patients were treated over an 11-year period. Median aneurysm diameter was 26 (16-48) mm. Five were symptomatic and 25 asymptomatic. Patients were treated with the Haemobahn/Viabahn stent-graft (26), Passager (two), Aneurx (one), and PTFE homemade device (one). Data were assessed using life table analysis, and expressed as cumulative patency rates and standard error (SE). RESULTS: Median follow-up was 24 (range 1-95) months. Primary patency was 92.9% (SE 4.5%), 84.7% (SE 6.8%), 80% (SE 8.2%), 74.5% (SE 9.4%) and 74.5% (11.3%) at 1, 6, 12, 24 and 36 months, respectively. Cumulative secondary patency was 96.5% (SE 3.3%), 88.7% (SE 6.0%), 88.7% (SE 8.6%), 83.2% (SE 8.0%) and 83.2% (SE 9.8%) at 1, 6, 12, 24 and 36 months, respectively. CONCLUSION: Endovascular treatment of popliteal aneurysms in this series achieved patency rates similar to open surgery. Aneurysm repair was performed without peroperative deaths and the risks associated with open surgery.     

Endovascular abdominal aortic aneurysm repair

Around two-thirds of abdominal aortic aneurysms (AAA) are incidentaldiscoveries during the investigation of backache, hip pain orurinary tract complaints. They are much more common in men thanwomen (5:1) and account for 2% of all deaths in men aged >60yr. Open surgical repair of the aneurysm is considered as thestandard, traditional method of treatment. Surgery is recommendedwhen the AAA exceeds 55 mm in anteroposterior diameter as measuredby ultrasound scan. The risk of spontaneous rupture dependson aneurysm size, ranging from <1% per annum for AAA <55mm diameter to >17% per annum for aneurysms >60 mm diameter.Ninety per cent of AAAs are located distal to the renal arteries. Endovascular repair of an aortic aneurysm using an in-situ prostheticgraft was suggested as a technique in 1969 by Dotter, but wasonly first performed successfully by Parodi and colleagues in1990. Over the last 10 yr, the availability of endovascularstent grafts has provided an alternative treatment for patientswith AAA, especially the elderly with significant co-existingmedical conditions. Endovascular repair is much less invasive.However, it is challenging technically and requires a multidisciplinaryapproach. During endovascular surgery, an aortic stent graft is passedvia the femoral arteries through the aortic lumen to fit tightlyabove and below the AAA. The aim is to exclude the aneurysmsac from the systemic circulation, thereby decreasing or eliminatingthe risk of future rupture. The procedure is performed throughincisions in one or both groins; no laparotomy is required.However, certain anatomical considerations apply.     

腹主动脉瘤腔内治疗现状

1991年,Parodi等发明人工血管内支架（stent graft,SG）并用于临床成功治愈腹主动脉瘤（abdominal aortic aneurvsm,AAA）,此后腹主动脉瘤腔内治疗（endovascular abdominal aortic aneurysm repair,EVAR）取得迅速发展。由于EVAR避免了传统开腹手术创伤大和出血多的缺点,使高龄或伴有心、肺、肝、肾功能不全的患者获得积极治疗的机会。一般来讲,腔内治疗主要是指肾下型腹主动脉瘤。     

Endovascular repair of abdominal aortic aneurysm: one-year results of the French AneuRx trial

The purpose of this prospective study was to evaluate the results of abdominal aortic aneurysm (AAA) repair using the Medtronic AneuRx endovascular stent graft. Forty-seven patients presenting with asymptomatic AAA were recruited in 17 French vascular centers. The mean age of these patients was 72.2 ± 7.8 years (range, 54 to 85.2 years). Indications were validated by an independent committee and all procedures were supervised by a trained medicotechnical assistant. Clinical data and follow-up imaging were also reviewed by an independent committee. The primary end point was successful implantation, defined as exclusion of the aneurysm without mortality, morbidity, or reintervention. The secondary end point was durable exclusion at 1 year, assessed by serial computed tomography (CT scan). Implantation of the AneuRx endovascular stent graft in this series of highly selected patients was associated with no mortality and low morbidity. One-year follow-up findings showed reduction in aneurysm diameter in 45% of patients. This finding indicates that endovascular treatment is effective. However, observation of stable aneurysm diameter in 50% and increased aneurysm diameter in 5% suggests that careful, indefinite follow-up surveillance is necessary.     

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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     

腔内修复术治疗胸主动脉夹层动脉瘤

目的 探讨应用支架人工血管行腔内修复术治疗胸主动脉夹层动脉瘤的临床效果.方法 回顾性分析采用腔内修复术治疗胸主动脉夹层动脉瘤32例患者的临床资料.男26例,女6例;平均年龄61岁.术前根据CTA结果 确诊,并对病变部位及解剖条件进行评估.手术在DSA监控下进行,全麻或局麻,应用Telent 8例(美敦力公司),国产支架24例(2例上海微创,22例北京裕恒佳).结果 7例破口距左锁骨下动脉开口＜1.0 cm,3例将覆膜支架跨过左锁骨下动脉开口将其封闭后,夹层动脉瘤消失,无上肢及脑缺血症状.治愈31例,死亡1例.31例夹层动脉瘤患者随访3～56个月均健在,其中5例CTA复查有内漏存在.结论 EVAR手术为夹层动脉瘤的治疗开辟了一个新的方法 ,具有比传统手术并发症少、病死率低等优点.在Stanford B型夹层动脉瘤的治疗中,EVAR可代替传统的开胸手术.     

Endovascular aneurysm repair (EVAR)

Endovascular repair of an abdominal aortic aneurysm (AAA) is an evolving technology which continues to be practiced in more and more centres worldwide in an effort to avoid major abdominal surgery and its associated morbidity and mortality. As with conventional open surgery, the objective of endovascular management is to provide a durable repair maintaining antegrade flow in the graft whilst simultaneously excluding flow in the aneurysm. Endovascular treatment offers a less invasive alternative to standard surgical repair with the potential of reduced hospitalisation, morbidity and mortality.     

Endovascular aneurysm repair in high-risk patients

Purpose: The purpose of this study was to evaluate the role of endovascular aneurysm repair in high-risk patients. Methods: The elective endovascular repair of infrarenal aortic aneurysm was performed in 116 high-risk patients with either custom-made or commercial stent grafts. The routine follow-up examination included contrast-enhanced computed tomography (CT) before discharge, at 3, 6, and 12 months, and annually thereafter. Patients with endoleak on the initial CT underwent re-evaluation at 2 weeks. Those patients with positive CT results at 2 weeks underwent endovascular treatment. Results: Endovascular repair was considered feasible in 67% of the patients. The mean age was 75 years, and the mean aneurysm diameter was 6.3 cm. The American Society of Anesthesiologists grade was II in 3.4%, III in 65.5%, IV in 30.1%, and V in 0.9%. There were no conversions to open repair. Custom-made aortomonoiliac stent grafts were implanted in 77.6% of the cases, custom-made aortoaotic stent grafts in 11.2%, and commercial bifurcated stent grafts in 11.2%. The 30-day rates of mortality, major morbidity, and minor morbidity were 3.4%, 20.7%, and 12%, respectively, in the first 58 patients and 0%, 3.4%, and 3.4%, respectively, in the last 58. The late complications included five cases of stent graft kinking, two cases of femorofemoral graft occlusion, and three cases of proximal stent migration, one of which led to aneurysm rupture. At 2 weeks after repair, endoleak was present in 10.3% of the cases. All the type I (direct perigraft) endoleaks underwent successful endovascular treatment, whereas only one type II (collateral) endoleak responded to treatment. The technical success rate at 2 weeks was 86.2%, and the clinical success rate was 96.6%. The continuing success rate was 87.9%. Seventeen patients died late, unrelated deaths. Conclusion: Endovascular aneurysm repair is safe and effective in patients at high risk, for whom it may be the preferred method of treatment. (J Vasc Surg 2000;31:122-33.)     

Endovascular, transperitoneal, and retroperitoneal abdominal aortic aneurysm repair: results and costs.

PURPOSE: Contemporary treatment of abdominal aortic aneurysms (AAA) includes transabdominal (TA), retroperitoneal (RP), and endovascular (EV) repair. This study compares the cost and early (30-day) results of a consecutive series of AAA repair by means of these three methods in a single institution. METHODS: A total of 125 consecutive AAA repairs between February 1993 and August 1997 were reviewed. Risk factors, 30-day morbidity and mortality rates, and hospital stay and cost were analyzed according to method of repair (TA, RP, EV). Cost was normalized by means of a conversion factor to maintain confidentiality. Cost analysis includes conversion to TA repair (intent to treat) in the EV group. RESULTS: One hundred twenty-five AAA repairs were performed with the TA (n = 40), RP (n = 24), or EV (n = 61) approach. Risk factors among the groups (age, coronary artery disease, hypertension, diabetes, chronic obstructive pulmonary disease, and cigarette smoking) were not statistically different, and thus the groups were comparable. The average estimated blood loss was significantly lower for EV (300 mL) than for RP (700 mL) and TA (786 mL; P>.05). Statistically significant higher cost for TA and RP for pharmacy and clinical laboratories (likely related to increased length of stay [LOS]) and significantly higher cost for EV in supplies and radiology (significantly reducing cost savings in LOS) were revealed by means of an itemized cost analysis. Operating room cost was similar for EV, TA, and RP. There were six perigraft leaks (9.6%) and six conversions to TA (9.6%) in the EV group. CONCLUSION: There were no statistically significant differences in mortality rates among TA, RP, and EV. Respiratory failure was significantly more common after TA repair, compared with RP or EV, whereas wound complications were more common after RP. Overall cost was significantly higher for TA repair, with no significant difference in cost between EV and RP. EV repair significantly shortened hospital stay and intensive care unit (ICU) use and had a lower morbidity rate. Cost savings in LOS were significantly reduced in the EV group by the increased cost of supplies and radiology, accounting for a similar cost between EV and RP. Considering the increased resource use preoperatively and during follow-up for EV patients, the difference in cost between TA and EV may be insignificant. EV repair is unlikely to save money for the health care system; its use is likely to be driven by patient and physician preference, in view of a significant decrease in the morbidity rate and length of hospital stay.     

Endovascular repair of abdominal aortic aneurysm: current status

INTRODUCTION: Endovascular aneurysm surgery (EVAR) was introduced a decade ago. Early results are promising, however, there remain concerns regarding the longer-term durability of this technique. Consequently, the national multi-centre EVAR trial has been commenced to define the role of endovascular surgery in the management of abdominal aortic aneurysm. DISCUSSION: Successful EVAR requires accurate pre-operative assessment of aneurysm morphology. Current stent-grafts allow 60% of all infra-renal AAA to be treated. Reduced physiological stress and low peri-operative morbidity and mortality rates have been demonstrated with this technique when compared to open repair. Endoleak is an Achilles heel of EVAR, although in itself does not accurately predict outcome. First and second generation devices are estimated to have a 1% per year risk of rupture. CONCLUSIONS: Increased understanding of the issues surrounding aneurysm morphology and successful stent-grafting have allowed a major reduction of early type I endoleak. Late endoleak and graft migration remain problematic. Type I and III endoleaks are risk factors for subsequent rupture although the significance of type II endoleak remains uncertain. More robust indicators of outcome success/failure are required so that follow-up may be rationalised.     

Endovascular repair of symptomatic sciatic artery aneurysm

Persistent sciatic artery (PSA) is a rare embrionary anomaly in which the internal iliac artery and the embryonic axial artery continue to provide the major blood supply to the lower limb after birth. Aneurysm formation occurs in as many as 46% of cases. We describe a percutaneous treatment of a complete PSA aneurysm in a high operative risk patient.     

Endovascular abdominal aortic aneurysm repair in women

The objective of this review is to establish the role of endovascular aortic aneurysm repair (EVAR) in women. A step by step approach is taken looking at sex and gender differences in epidemiology, pathogenesis and natural history. We then proceed to discuss the results from the three randomized controlled trials comparing EVAR to open repair. Finally, sex-specific secondary prevention, risk factor management and medication, is discussed. Women seem to have higher mortality and more complications after EVAR. Risk factors such as diabetes and hypertension are associated with worse outcome in women compared to men. The role of EVAR in women is poorly investigated and its definite role remains to be determined. Aggressive treatment of risk factors and the optimisation of medication in women are indicated and deserve more attention in clinical practice and future research.