Aortic Anastomotic Pseudoaneurysm Research Articles

Solving Intraoperative Complications During Endovascular Repair of Late Contained Ruptured Aortic Pseudoaneurysm After Surgical De-coarctation: Case Report and Systematic Review of Literature.

We present a case of successful endovascular repair of late ruptured aortic anastomotic pseudoaneurysm following previous left subclavian artery-descending thoracic aorta bypass and concomitant emergency thoracic endovascular aortic repair (TEVAR) of complicated endovascular aortic de-coarctation never previously described is also presented. A review of the intraoperative, 30-day, and follow-up morbidity, mortality, and complications of TEVAR as endovascular treatment of late aneurysm/pseudoaneurysms after surgical aortic de-coarctation was also performed. The systematic review was performed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) statement and following PICO model. A literature search was conducted on MEDLINE, PubMed, EMBASE, Cochrane Library, Google Scholar, Science Direct, and Web of Science using the words "tevar of late complication of aortic coarctation surgical repair" and "endovascular repair of anastomotic pseudoaneurysm in coarctation" up to June 17, 2022. Data were extracted from study documents about study design, patient's demographics and comorbidities, details about primary surgical repair, type of late complication, time between open surgery and occurrence of complications, details of the secondary endovascular procedure with technical success, early, and follow-up mortality and morbidity. A total of 18 papers were included with 78 patients (48 men, 69.5%). The most frequent type of primary open surgical repair was patch aortoplasty (46, 58.9%). Focusing on aneurysm and pseudoaneurysm as late complications, most of the patients were asymptomatic (45, 57.7%). All patients underwent TEVAR, 14 of them (17.9%) in urgent/emergent setting. The technical success was 98.7%, with 1 intraoperative death due to rupture of the aorta. In total, 31 patients out of 78 (39.7%) showed different complications in the immediate postoperative time, with type II endoleak being the most observed (8/31, 25.8%). The mean follow-up time was about 2 years (26.5 months, range 3-92). Overall, 30-day mortality was 2.6%. Complications occurred in 30 patients (39.4%), 23 of them resolved during the follow-up period. With the limit of low-quality data, TEVAR can be considered a safe and effective option for the treatment of late complications after open surgery for aortic coarctation, even in urgent settings. Different specialists have to face the technical complexities and risks related to treatment of late complications after surgical de-coartaction, which can be either surgical or endovascular, and depend on patient's ages. Although covered stents appear to have some protection from the development of stent fractures, doesn't provide complete protection from late aneurysm formation. In this setting, TEVAR may represent a valuable option, combining the advantages of the covered stent with those of a device that can cover a wider range of aortic length, especially in adult patients. This study shows thoracic endovascular repair can be considered a safe and effective option in clincal practice for the treatment of late complications after open surgery for AC, even in urgent settings.

Computed Tomography Identifies Clinically Unsuspected Acute Necrotizing Pancreatitis Complicating Abdominal Aortic Repair

Pancreatitis rarely complicates aortic repair. The aim of the study was to examine the role of imaging in identifying this complication and to characterize pancreatitis occuring in this setting. The radiology information system queried reports for terms pancreatitis, fluid collection, peripancreatic fluid, and aortic/aneurysm/endovascular/open repair from January 2010 through May 2018 and yielded 243 unique patients. Aortic repair and pancreatitis did not occur in temporal proximity (within 30days) in 227 patients, and three patients had invalid medical record numbers. The final population was 13 patients. Surgical data included indication for repair and surgical approach. Clinical/imaging data points included method of diagnosis, type of pancreatitis, location, management of collections, and patient outcome. Thirteen patients (n=9 male, age 58-76years) met inclusion criteria. All patients underwent open repair, 9 electively. Acute pancreatitis was first identified by computed tomography in 10 (77%) patients and by serum lipase levels in 3 patients (23%). Necrotizing pancreatitis was present in 10 patients (77%), eight with infected collections (one not sampled). Four patients (31%) had collections fistulizing to the aortic sac, and there was one case of aortic anastomotic pseudoaneurysm. There were 7 deaths (4 septic shock, 1 hemorrhagic pancreatitis, 1 pulmonary embolism, and 1 multiorgan failure) despite 5 of these patients undergoing drainage of collections. In surviving patients, 4 underwent drainage of collections, 1 necrosectomy, and 1 no intervention. Pancreatitis complicating aortic repair occurs after open repair and is often necrotizing. Pancreatitis is more often first detected by imaging rather than serum lipase levels. High mortality is more attributable to complications of pancreatitis rather than failure of the aortic repair.

Secondary aortoenteric fistula: Review of a case and literature

The objective of this study was to assess early diagnosis and management of hematemesis in patients who have a history of aortic reconstructive surgery. A 70-year-old male presented with complaints of active hematemesis and melena for 2 days at the emergency room. He gave a history of aortobifemoral bypass for bilateral iliac arterial occlusive disease 9 years ago. Urgent computed tomography (CT) angiography was suggestive of large aortic anastomotic pseudoaneurysm with aortoenteric fistula (AEF). Urgent endovascular repair of pseudoaneurysm with right femoral artery to left femoral artery crossover with ligation of left femoral artery, left common iliac artery, and left graft limb was done. The patient did well after the surgical management. Routine follow-up was done. Repeat CT angiography was done. No any major complication was encountered. Secondary AEF is a life-threatening complication of abdominal aortic reconstruction. The clinical manifestation of the AEF is always hematemesis. Treatment of the disease is urgent hybrid surgical intervention.

Endovascular Treatment of Aorto-Iliac-Femoral Anastomotic Pseudoaneurysms: A Multicentric Study

The purpose of this study was to assess the effectiveness of anastomotic pseudoaneurysms (APAs) endovascular treatment following aorto-iliac-femoral surgical reconstruction. We retrospectively evaluated 54 patients who underwent aorto-iliac-femoral bypass (72 APAs). Follow-up was performed with echo-color-Doppler and/or computed tomography angiography at 1, 3, and 6months after the procedure and then yearly. We compared clinical success in terms of mortality between aortic APAs and nonaortic APAs (iliac-femoral-popliteal). Immediate technical success was 100%. No periprocedural complications occurred. Six patients died during follow-up due to causes not related to APA and 5 due to sepsis at 3months after the procedure. Thirty-day mortality was 9% overall, and we did not register any statistically significant different between aortic APA and nonaortic APA groups. During a mean follow-up of 25.5months (range: 3-72), we registered 3 occlusions of stent-graft leg, respectively, at 3days, 7days, and 24months after the procedure, 2 type I endoleaks and 1 type III endoleak. Primary clinical success rate was 87.2%, and secondary clinical success was 95.7%. Endovascular treatment resulted as a valid alternative to open surgery and could be proposed as the treatment of choice for APAs especially in patients with a high surgical risk.

Transapical Endovascular Aortic Repair to Treat Complex Aortic Pathologies

Clinical condition, hostile anatomy, and previous heart/aortic surgery may preclude standard open surgery and standard endovascular interventions in patients with complex aortic pathologies. We report our initial experience using the transapical endovascular approach to treat a type IA endoleak after transfemoral endovascular graft repair for a contained rupture of a penetrating descending aortic ulcer; an ascending aortic anastomotic pseudoaneurysm after open surgical repair of an ascending aortic dissection; and a type A aortic dissection after minimally invasive mitral valve repair. There were no neurologic or cardiovascular complications, and the 30-day mortality was 0%.

Minimally invasive application of thrombin in the treatment of pseudoaneurysms following open aortic surgery

Anastomotic leaks are uncommon complications following aortic surgery. To avoid the morbidity associated with a second surgical procedure, minimally invasive techniques have become increasingly popular. To evaluate the feasibility and safety of thrombin in interventional treatment of postoperative pseudoaneurysms. CT-guided percutaneous injection was chosen in four cases. Endovascular access using an occlusion balloon catheter placed in the orifice of the pseudoaneurysm was utilized in one case. The average volume of all pseudoaneurysms was 178 ± 190 mL with a volume of the patent lumen of 25 ± 28 mL. All aneurysms thrombosed after injection of 600 ± 237 IU of thrombin. During the follow-up period of an average of 10 months all pseudoaneurysms remained occluded. Our series demonstrates the feasibility of thrombin in the treatment of aortic anastomotic pseudoaneurysms. In combination with occlusion balloon catheters, even wide-necked pseudoaneurysms may be treated successfully. However, further investigations are warranted.

Repair of Anastomotic Abdominal Aortic Pseudoaneurysm Utilizing Sequential AneuRx Aortic Cuffs in an Overlapping Configuration

Anastomotic aortic pseudoaneurysm is a known late complication following aortic repair and presents a considerable surgical challenge. We herein evaluate the endovascular alternative of using sequential AneuRx aortic cuffs to bridge the degenerative anastomotic pseudoaneurysms as a definitive treatment. Over a 3-year period, six patients with a mean age of 68.7 years (range 58-75) were identified who had proximal anastomotic aortic pseudoaneurysms secondary to previously implanted bifurcated aortic grafts (mean 15, range 12-20 years) following open surgical correction of aortoiliac occlusive disease. Five patients (83%) presented with concomitant palpable femoral anastomotic pseudoaneurysms and one patient (16%) had a pulsatile abdominal mass. All patients had computed tomographic (CT) scans confirming proximal anastomotic pseudoaneuryms without evidence of infection. The mean diameter of the pseudoaneurysms was 5.3 cm (range 4.0-7.0). Five patients were treated with endovascular methods, while one patient was not suitable for endovascular repair due to the diameter of the native aorta as seen on imaging study at the time of the procedure. AneuRx aortic extender cuffs (3.75 cm length) were deployed sequentially in five patients via a femoral approach. Devices were overlapped approximately 1.5 cm in order to achieve total exclusion of the pseudoaneurysms, and all concomitant femoral aneurysms were repaired surgically at the same time. Successful exclusion of the anastomotic pseudoaneurysm was achieved in four patients (80%) using a combination of two or three overlapping aortic cuffs. One patient had a small residual endoleak that had sealed by 1 month, evidenced by follow-up CT. The renal arteries were preserved in all patients. The average estimated blood loss and operative time were 355 +/- 25 cc and 84 +/- 21 min, respectively. The average length of hospital stay was 2.1 days, and there was no mortality or major morbidity. All patients underwent CT scanning surveillance at 6 and 12 months and yearly afterward. There was no evidence of late endoleak, aneurysmal expansion, or device migration during the mean follow-up of 10 months, ranging 6-27 months. Our study demonstrated that utilizing sequential AneuRx aortic cuffs applied in an overlapping configuration is an effective strategy for degenerative aortic anastomotic pseudoaneurysm from previously placed aortic grafts. Additionally, our study suggests this unique endovascular technique is an ideal alternative for creating a customized tube graft in challenging cases, particularly in high-risk patients.

Treatment of abdominal aortic anastomotic pseudoaneurysm with percutaneous coil embolization

Intraabdominal anastomotic pseudoaneurysms continue to be a late complication of aortic reconstructive procedures. Early surgical repair is critical but is associated with high operative mortality rates. We present a patient who was diagnosed with a distal anastomotic pseudoaneurysm 13 months after transabdominal repair of a symptomatic abdominal aortic aneurysm. Because of the poor operative risk, the patient was considered for a less invasive approach and underwent coil embolization of the abdominal aortic anastomotic pseudoaneurysm. The patient remains without recurrence of pseudoaneurysm 3.5 years later. (J Vasc Surg 2002;35:811-4.)

Tratamiento combinado abierto y endovascular de aneurismas anastomóticos postinjerto bifurcado aortobifemoral

Anastomotic aneurysms are subject to the same complications as a true aneurysm and their choice and emergency treatment present very high morbidity and mortality rates. We describe a case in which a combined open and endovascular technique was used to treat the aneurysmatic complication of an aortobifemoral graft. Lesions were identified in a 70-year-old male, 11 years after an aortobifemoral by-pass was performed to treat an aortoiliac ischemic disease. A right femoral pseudoaneurysm was identified by palpation and echo-Doppler. In the pre-operative study, a computerised tomography (CT) scan of the abdom-inopelvic cavity was performed and revealed an aortic anastomotic pseudoaneurysm. The femoral lesion was treated using conventional surgery, a short 8 mm PTFE by-pass from the right-hand branch of the bifurcate to the deep femoral artery. Due to the high surgical risk (ASA IV) and a hostile abdomen, the exclusion of the aortic pseudoaneurysm was performed by implanting a straight stent under intradural anaesthetic. After freeing the stent, a distal leakage of contrast medium was noted and corrected by placing a covered straight stent extension. Immediate arteriographical control did not show any flow of contrast inside the aneurysmatic sac. There were no post-operative complications and the patient remained asymptomatic. The control CT at six months confirmed the complete exclusion of the pseudoaneurysm. In a case in which open surgery represents a high risk, endovascular treatment of uninfected aortic anastomotic pseudoaneurysms is feasible. [ANGIOLOGÍA 2002; 54: 402-8]. El aneurisma anastomótico está sujeto a las mismas complicaciones que un aneurisma verdadero, y su tratamiento, tanto electivo como de urgencia, presenta cifras de morbimortalidad muy elevadas. Describimos un caso en que se utiliza la técnica combinada, cirugía abiertay endovascular, para el tratamiento de la complicación aneurismática de un injerto aortobifemoral. Las lesiones se identifican en un varón de 70 años, 11 años después de la realización de una derivación aortobifemoral por una enfermedad isquémica aortoilíaca. Se identifica un pseudoaneurisma femoral derecho mediante palpación y ecografía Doppler. En el estudio preoperatorio se realiza una tomografía computarizada (TC) abdominopélvica que describe un pseudoaneurisma anastomótico aórtico. Se trata la lesión femoral por cirugía convencional, derivación corta de PTFE de 8 mm desde la rama derecha del bifurcado hasta la arteria femoral profunda. Debido a un alto riesgo quirúrgico (ASA IV) y a un abdomen hostil, bajo anestesia intradural se realiza la exclusión del pseudoaneurisma aórtico por medio de la implantación de una endoprótesis recta. Tras la liberación de la prótesis se verifica una fuga distal de contraste, que se corrige mediante la colocación de una extensión de prótesis recta cubierta. El control arteriográfico inmediato no evidencia ningún flujo de contraste en el interior del saco aneurismático. No hay complicaciones postoperatorias y el enfermo se mantiene asintomático. La TC de control a los seis meses confirma la exclusión completa delpseudoaneurisma. En un caso seleccionado, en que la cirugía abierta represente un riesgo elevado, es factible el tratamiento endovascular de los pseudoaneurismas anastomóticos aórticos no infectados. [ANGIOLOGÍA 2002; 54: 402-8]. O aneurisma anastomótico está sujeito às mesmas complicações que um aneurisma verdadeiro, e o seu tratamento, tanto electivo como de urgencia, apresenta números de morbilidade e mortalidade muito elevados. Descrevemos um caso em que se utiliza a técnica combinada, cirurgia aberta e endovascular, para o tratamento da complicacão aneurismática de um enxerto aortofemoral. As lesões são identificadas num homem de 70 anos de idade, 11 anos após a realizacao de um by-pass aortobifemoral por doenca isquémica aortoilíaca. Um pseudo-aneurisma femoral é identificadoporpalpacao e eco-Doppler. No estudo pré-operatório, realiza-se uma tomografia computorizada (TC) abdominopélvica que descreve um pseudo-aneurisma anastomótico aórtico. A lesao femoral é tratada por cirurgia convencional, by-pass curto de PTFE de 8 mm desde o ramo direito da bifurcação até a artéria femoral profunda. Devido a um alto risco cirúrgico (ASA IV) e a um abdómen hostil, sob anestesia intradural faz-se a exclusão do pseudo-aneurisma aórtico por implantacao de uma endoprótese recta. Após a libertacao da prótese, verifica-se uma fuga distal de contraste, a qual é corrigida com a colocação de uma extensão de prótese recta coberta. O controlo arteriográfico imediato nao evidencia qualquer fluxo de contraste no interior do saco aneurismático. Não existem complicações pós-operatórias e o doente permanece assintomático. A TC de controlo aos seis meses confirma a ausência completa do pseudo-aneurisma. Conclusão. Num caso seleccionado, em que a cirurgia aberta representa um risco elevado, é viável o tratamento endovascular dos pseudo-aneurismas anastomóticos aórticos não infectados. [ANGIOLOGÍA 2002; 54: 402-8].

Endovascular treatment of proximal arsastomotic aneurysms after aortic prosthetic reconstruction

To describe the efficacy and value of endovascular stent-grafts for the treatment of aortic anastomotic pseudoaneurysms. Three patients with proximal aortic anastomotic pseudoaneurysms 8--15 years after prosthetic reconstruction were treated by transfemoral stent-graft implantation. In two patients the pseudoaneurysms were excluded by Talent prostheses [tube graft (n = 1), bifurcated graft (n = 1)]. In one patient an uniiliac Zenith stent-graft was implanted and an extra-anatomic crossover bypass for revascularization of the contralateral lower extremity was performed. All procedures were successful with primary exclusion of the pseudoaneurysms. During the follow-up (mean 16 months) one endoleak occurred due to migration of the tube stent-graft. The endoleak was sealed successfully by implanting an additional bifurcated stent-graft. Stent-graft exclusion of aortic pseudoaneurysms offers a minimally invasive and safe alternative to open surgical reconstruction.

ENDOSCOPIC IMAGE OF SECONDARY AORTOENTERIC FISTULA

Surgical treatment of abdominal aortic aneurysms by resection of the aneurysm and graft replacement is now an accepted procedure, but this has led to various postoperative complications. One example of this is secondary aortoenteric fistula. The diagnosis of aortoenteric fistula is often difficult to establish. We report a case of aortoenteric fistula that occurred 1 year after resection of the aneurysm and graft replacement. A 69‐year‐old man was admitted to our hospital following a sudden episode of melena. He had undergone aorto‐bifemoral bypass surgery with a prosthetic graft 1 year previously for abdominal aortic aneurysm. Upper gastrointestinal endoscopy and computed tomography scan were performed and aortoenteric fistula as a result of aortic anastomotic pseudoaneurysm, was diagnosed. In the first stage operation, an extra‐anatomic bypass was implanted from the right axillary artery to both femoral arteries. Removal of the graft and aortic stump closure were carried out in the second stage. The patient recovered uneventfully. This case shows the use of endoscopy for early diagnosis of secondary aortoenteric fistula.

In Vivo Crushing of an Aortic Stent Enables Endovascular Repair of a Large Infrarenal Aortic Pseudoaneurysm

Purpose: To report an unusual approach to endovascular exclusion of a large aortic pseudoaneurysm. Methods and Results: A 63-year-old male had an unsuccessful endovascular repair of an aortic anastomotic pseudoaneurysm that left an expanded, uncovered Palmaz stent lying obliquely within the aorta. After nearly 3 years, the pseudoaneurysm enlarged to 7 cm, and the patient became symptomatic. Repair of the pseudoaneurysm was accomplished by crushing the indwelling stent to allow placement of a stent-graft. Conclusions: Malpositioned stents that are hindering an endoluminal procedure may be crushed against the arterial wall in vivo to facilitate passage of endovascular instruments or devices.

Aortic Anastomotic Pseudoaneurysms

Correlation of imaging and anatomic findings in seven men with abdominal aortic graft prostheses (four "end-to-end" anastomoses and three "end-to-side" anastomoses) was done to compare the value of different imaging modalities in detecting postoperative complications, especially aortic anastomotic pseudoaneurysms (AAPs). In all cases, angiographic and CT studies were carried out. In six patients ultrasound and MR examinations were also performed. Anatomic verification was obtained by surgery in six patients and autopsy in one case. Five patients had an AAP (four at surgery and one at autopsy), one had a true abdominal aortic aneurysm above the anastomosis, and one a nondetectable abnormality of the aortic suture line. Digital subtraction angiography diagnosed one of five AAPs, missed the true aneurysm in the sixth patient, and was normal in the patient without any aneurysm. Computed tomography correctly diagnosed the five AAPs and the true aneurysm and was normal in the last patient. Ultrasound correctly diagnosed the AAPs in three of four patients, incorrectly diagnosed an AAP in the patient who had the true aneurysm, and was normal in the patient without any aneurysm. Magnetic resonance diagnosed four of four AAPs and the true aneurysm and was normal in the last patient. Computed tomography seems to be the best imaging modality with which to diagnose and evaluate an aortic AAP in patients with aortoiliofemoral graft prosthesis.