Aortic aneurysm surgery: problems and innovations

Ralf Kolvenbach,Winston Bonetti Yoshida

doi:10.1590/s1677-54492009000400008

Ralf Kolvenbach, Winston Bonetti Yoshida

Open Access

https://doi.org/10.1590/s1677-54492009000400008

Copy DOI

Abstract

A long way was traveled since the first surgery was performed for the treatment of abdominal aortic aneurysm. Throughout this time, several innovations have been created in order to reduce the invasiveness of the surgical procedures and to improve their safety and durability. This review discusses the major and recent advances on aortic aneurysm interventions, including, the endovascular aortic repair, the laparoscopic aortic surgery, the conventional hybrid and endovascular techniques, combined laparoscopic and endovascular techniques, as well as future prospects for both thoracic and abdominal aorta. Faced with so many changes and developments, modern vascular surgeons must keep their minds open to innovations and should develop comprehensive training with different techniques, to provide the best therapeutic option for their patients.

Highlights

Over the past 50 years, enormous progress has been made in aortic reconstructions.Major operations have been reduced to routine procedures via groin punctures or cut downs
Paraplegia can still occur in up to 4% of those patients stented for descending thoracic aortic aneurysms (TAA)
Laparoscopic adjuncts after Endovascular Aortic Repair (EVAR) include several options: 1) clipping of the inferior mesenteric artery (IMA) and lumbar arteries to treat type II endoleaks; 2) thrombus removal and tight closure of the sac of the aneurysm to reduce the sac diameter; 3) fixation of the endograft to the aortic neck to prevent device migration; 4) banding of the aorta to prevent neck dilatation and; 5) laparoscopic conversion after EVAR failure (Figure 7)

Summary

Introduction

Over the past 50 years, enormous progress has been made in aortic reconstructions. Major operations have been reduced to routine procedures via groin punctures or cut downs. Patients with thoracoabdominal aneurysms can be treated with an endovascular graft in combination with multiple bypasses to the visceral and renal arteries (Figures 4 and 5) With this hybrid technique there is no need for a thoracotomy with a subsequent smoother postoperative course and reduced ischemia time. The EVAR-2 trial found no advantage of stent grafts over observation in high risk patients who underwent endovascular aneurysm repair, and the smaller Dutch DREAM trial failed to find survival difference at 3 years between those who underwent endovascular treatment and those who had open surgical repair.[3,4] In addition, it will be another 4 years when the PIVOTAL study is completed, until we find out whether endovascular repair is justified in patients with small aortic aneurysms. Even enthusiastic proponents of endovascular therapy admit that 6 years there will still be plenty of open vascular surgery

Laparoscopic aortic surgery

Combining laparoscopy and EVAR

Complicated aortic neck

Findings

Conclusion