Conventional Open Surgical Repair Research Articles

Iliac Pseudoaneurysm Stenting after Conventional Abdominal Aneurysm Repair

Anastomotic iliac aneurysms after surgical repair of abdominal aortic aneurysms are associated with a significant morbidity and mortality. Conventional open surgical repair of such aneurysms involves general anæsthesia and may necessitate complex redo vascular reconstruction. We report a case of endoluminal treatment of a 35 mm aneurysm of the right common and external iliac arteries with a superadded external iliac artery stenosis in a 60-year-old female following surgical implantation of an aorto-biiliac prosthesis 25 years previously.After occlusion of the internal iliac artery with metal coils, the stenosis of the external iliac artery was treated by means of percutaneous transluminal angioplasty (PTA) via a transcutaneous right femoral artery approach. The aneurysm was then successfully excluded by the implantation of a stent-graft into the common and external iliac artery. Interventional stent graft placement under local anesthæsia provides a useful therapeutic approach for anastomotic aneurysms of the iliac arteries.

Endovascular treatment in diseases of the descending thoracic aorta: 6-year results of a single center.

The purpose of this study was to evaluate endovascular treatment in diseases of the descending thoracic aorta. This study was designed as a single center's (university hospital) experience. Over a 6-year period (1995 to 2001), thoracic endografts were placed in 74 patients with a diseased descending thoracic aorta who were at high risk for conventional open surgical repair: 34 had atherosclerotic aneurysms, six had posttraumatic aneurysms, 14 had type B dissection with aneurysmal dilatation of the false lumen, 12 had isthmic transections from blunt trauma, five had thoracoabdominal aneurysms (treated with a combined procedure), two had aortic coarctation, and one had an aortobronchial fistula. Twenty-six procedures (35.1%) were conducted as emergencies, and 48 (64.9%) were elective. The feasibility of endovascular treatment and sizing of stent grafts were determined with preoperative spiral computed tomography and intraoperative angiography. Endovascular operations were completed successfully in all 74 patients; postprocedural conversion to open repair was necessary in three cases. The overall 30-day mortality rate was 9.5% (seven deaths). Temporary neurologic deficits developed in two patients; not one patient had permanent paraplegia. The primary endoleak rate was 20.3% (15 patients). The mean follow-up period was 22 months (range, 3 to 72 months). Five deaths occurred in the follow-up period, and three patients needed secondary conversion to open repair 2, 3, and 14 months after initial endografting. Endoluminal treatment in diseases of the thoracic descending aorta is feasible and may offer results as good as the open method.

Interventional Stent Graft Placement for Aneurysm of the Coeliac Trunk

Aneurysms of the coeliac trunk are rare. Conventional open surgical repair of such aneurysms involves general anesthesia and may necessitate complex vascular reconstruction. We report on a case of a 5 cm aneurysm of the coeliac trunk in a 67-year-old male on warfarin therapy, which was treated endoluminally. Through a transcutaneous approach via the right femoral artery, the common hepatic artery as well as the left gastric artery were occluded with metal coils and a proximal stenosis of the celiac trunk was dilated by percutaneous transluminal angioplasty (PTA). Subsequently a stent graft was placed into the coeliac trunk in order to exclude the aneurysm from circulation. Interventional stent graft placement provides a suitable therapeutic approach for aneurysms of the coeliac trunk.

Interventional Stent Graft Placement for Aneurysm of the Coeliac Trunk

Aneurysms of the coeliac trunk are rare. Conventional open surgical repair of such aneurysms involves general anesthesia and may necessitate complex vascular reconstruction. We report on a case of a 5cm aneurysm of the coeliac trunk in a 67-year-old male on warfarin therapy, which was treated endoluminally. Through a transcutaneous approach via the right femoral artery, the common hepatic artery as well as the left gastric artery were occluded with metal coils and a proximal stenosis of the celiac trunk was dilated by percutaneous transluminal angioplasty (PTA). Subsequently a stent graft was placed into the coeliac trunk in order to exclude the aneurysm from circulation. Interventional stent graft placement provides a suitable therapeutic approach for aneurysms of the coeliac trunk.

Abdominal Aortic Aneurysm

Most abdominal aortic aneurysms (AAAs) are asymptomatic, not detectable on physical examination, and silent until discovered during radiologic testing for other reasons. Tobacco use, hypertension, a family history of AAA, and male sex are clinical risk factors for the development of an aneurysm. Ultrasound, the preferred method of screening, is cost-effective in high-risk patients. Repair is indicated when the aneurysm becomes greater than 5.5 cm in diameter or grows more than 0.6 to 0.8 cm per year. Asymptomatic patients with an AAA should be medically optimized before repair, including institution of beta blockade. Symptomatic aneurysms present with back, abdominal, buttock, groin, testicular, or leg pain and require urgent surgical attention. Rupture of an AAA involves complete loss of aortic wall integrity and is a surgical emergency requiring immediate repair. The mortality rate approaches 90 percent if rupture occurs outside the hospital. Although open surgical repair has been performed safely, an endovascular approach is used in select patients if the aortic and iliac anatomy are amenable. Two large randomized controlled trials did not find any improvement in mortality rate or morbidity with this approach compared with conventional open surgical repair.

Aortic Stent Grafting: A New Approach to a Deadly Diagnosis

Ruptured abdominal aortic aneurysm (AAA) is the 13th leading cause of death in the United States. Diagnosis is the key to prevention of death from AAA. Millions of Americans harbor this silent, potentially lethal aneurysm. For over 50 years, conventional open surgical repair has been performed for ruptured aortic abdominal aneurysm. It is a major operation with an extended hospital stay and recovery period. An alternative approach to AAA repair has evolved over the past 10 years that combines advances in catheter and stent technologies. With the AAA aortic stent graft, patients usually do not require intensive care and are discharged home within 48 hours of the procedure. This article describes the AAA aortic stent graft procedure, in the formation of a case management team to develop a clinical pathway and standing orders for these patients and defines the outcomes of care.

Results of an aortic endograft trial: Impact of device failure beyond 12 months

Purpose: Analysis endpoints of patient survival and aortic rupture at a reporting interval of 12 months are regularly used to compare endograft aortic aneurysm (EAG) repair to conventional open surgical (COS) repair. This study reports a multicenter EAG repair versus COS repair parallel cohort trial at 12 months and additional observations of specific device failure types and their impact on an aortic endograft design beyond that follow-up period. Methods: From August 1997 to September 1998, 240 patients who were treated with bifurcation EAG repairs and 28 patients who were treated with straight EAG repairs were compared with 98 patients who were treated with COS repair for elective infrarenal aortic aneurysm repair. Allocation to treatment was based on aneurysm anatomy. All cohorts underwent infrarenal procedures. Data from concurrent, nonrandomized patient accrual from 17 United States institutions were prospectively gathered and independently adjudicated for safety and efficacy. An independent core laboratory evaluated all imaging data. Results: There were 308 men and 58 women (mean age, 72 years; range, 42-94 years) treated for infrarenal aortic aneurysm (mean diameter, 55 mm; range, 40-115 mm). Mean preoperative aneurysm diameters were clinically similar (EAG repair, 54 mm vs COS repair, 57 mm). The two cohorts were not significantly different in terms of gender (P = .30) or age (P = .32). EAG repair technical success (aneurysm exclusion, graft patency, patient survival) at 30 days was 89.2%. Five patients required immediate conversion to COS repair, four caused by access complications and one caused by operator-induced EAG repair malposition. The 30-day mortality rate was 1.5% for EAG repair and 3.1% for COS repair (P = .59). The 12-month survival rate was 94.3% for EAG repair and 95.9% for COS repair. The intermediate-term cumulative survival rate at 24 months was 84.9% for EAG repair and 80.3% for COS repair (P = .48). EAG repair device failure occurred from fabric erosion in six patients, with two deaths from ruptured aneurysm at 18 and 28 months after endografting and four device failures resolved by secondary procedures. Five endograft limb dislocations were all resolved by secondary endovascular procedures. Major or minor endograft migration required secondary procedures in five patients, including conversion in two patients. Conclusion: The clinical outcome at 12 months demonstrated effective aneurysm treatment and comparable safety between EAG repair and COS repair by conventional endpoints. Ongoing follow-up beyond 12 months revealed device-related adverse events that required endograft design changes. Diligent surveillance of outcomes beyond 12 months is necessary to adequately evaluate EAG repair devices. (J Vasc Surg 2001;33:S55-63.)