Infrarenal Aortic Aneurysm Research Articles

Endovascular treatment of the thoracic aorta.

Open surgical repair has been considered the mainstay of therapy for thoracic aortic aneurysms, both elective and emergency procedures alike. Recent advances in endovascular technology have made endovascular stentgraft placement a therapeutic modality that is minimally invasive and potentially a safer treatment for aneurysmal disease of the descending thoracic aorta. Moreover, this technology may be appropriate for other diseases of the thoracic aorta, including traumatic disruptions and dissections. There appears to be an increase in the diagnosis, and therefore incidence, of these various thoracic aortic pathologies, owing both to improvement in imaging capabilities and longer life expectancies. In distinction to endovascular repair of infrarenal aortic aneurysms, the evolution of thoracic stentgrafts has progressed more slowly as there has yet to exist a clinically proven device after 10 years of clinical trials. However, the enthusiasm for this technology persists, for it may indeed hold the potential for the greatest patient benefit as conventional open surgical repair continues to offer serious morbidity and mortality rates. This paper reviews the current status of thoracic aortic stentgrafts, including recent clinical studies, device failures and refinements, and future directions.

Paraplegia after elective repair of an infrarenal aortic aneurysm

Paraplegia is a rare but devastating complication of thoracic/thoraco-abdominal aortic aneurysm repair. The incidence after repair of infrarenal aneurysms is lower, at 1.4-2.0% for emergency cases and 0.1-0.2% for elective cases.1,2

Endovascular repair of aortic rupture

Objectives: to report a single centre experience with endovascular repair of ruptures of the descending thoracic and abdominal aorta. Design: retrospective non-randomised study in a university hospital. Material and Methods: between February 1997 and October 2002, endovascular repair of the aorta was performed on 125 occasions. In 20 cases, this was done as an emergency (nine ruptured infrarenal aortic aneurysms and 11 descending thoracic aortic ruptures). All patients underwent spiral computed tomographic angiography to assess the feasibility of endovascular repair and the size of the endoprosthesis. Results: endovascular repair was successfully completed in all patients. Primary conversion to open repair was not necessary. Postoperative 30-day mortality was 5/20 (25%). There were major complications in 12/20 patients. No ruptures of the aneurysms occurred postoperatively. No primary endoleaks occurred, but in 4/20 (20%) secondary surgical interventions were required after a median follow-up of 12 months (range 1-42 months). Conclusion: our early experience shows the feasibility of this technique with early results that compare favourably to those of emergency open repair. Further studies are required to assess the long-term efficacy.Eur J Vasc Endovasc Surg 26, 311-316 (2003)

Rupture of Infra-renal Aortic Aneurysm after Endovascular Repair: A Series from EUROSTAR Registry

Objectives. Although small, the risk of rupture after EVAR remains a major concern. The aim of this study was to identify mechanisms of late aneurysm rupture after endovascular repair. Methods. Patients who suffered a proven aneurysm rupture after EVAR were identified from the EUROSTAR (European Collaborators on Stent-graft Techniques for Abdominal Aortic Aneurysm Repair) registry. Complications preceding rupture were studied to identify common patterns and possible mechanisms of late rupture. Results. A rupture was documented in 34 patients resulting in death of 21 (62%). Adverse events documented during previous follow-up in these patients included endoleak (30%), migration (18%), limb occlusion (12%) and kinking (12%). The findings at time of rupture were documented in 24 patients and including endoleak: Type III (10), Type I (9), Type II (1); stent-graft disintegration (2) and migration (3). Aneurysm diameter changes could be ascertained in 24 patients and had increased in only seven. Conclusion. The importance of graft-related endoleak, stent-graft disintegration and migration in the causation of aneurysm rupture was confirmed. Poor compliance with follow-up schedule was also identified as a common feature. However, the absence of complications in some patients, who attended regularly for follow-up, highlights the difficulty of predicting rupture after EVAR.

Type III Thoracoabdominal Aortic Aneurysm Repair: A Combined Surgical and Endovascular Approach

Thoracoabdominal aortic aneurysm (TAAA) repair is a high-risk procedure and thoracic endovascular stenting has encouraging morbidity and mortality. We report a case of Type III TAAA repair in a patient with previous abdominal and thoracic aortic surgery, using a combined surgical and endovascular approach. This innovative method is a particularly attractive option in ‘redo’ operations such as this since it significantly reduces the extent of dissection and avoids thoracotomy.

Aortic stent-grafting: successful introduction into the combined procedure for coronary artery bypass grafting and aortic aneurysm repair.

Coronary artery bypass grafting (CABG) and combined stent-grafting (SG) were evaluated to reduce morbidity and mortality of patients with descending or infrarenal aortic aneurysm. CABG and SG (thoracic n=6, infrarenal n=36) were performed during the same hospitalization in 42 patients (mean age of 73+/-14 years). In 29 patients (mean Euroscore: 9), SG was performed under local anesthesia 9+/-3 days after coronary surgery (simultaneous) and in 13 patients (mean Euroscore: 7) during the same anesthesia (synchronous). In the latter group, 11 out of 13 patients underwent off-pump CABG. All aneurysms were treated by implantation of commercially available self-expanding grafts. CABG was successful in all, but one patient with left internal mammary artery hypoperfusion syndrome, requiring an additional distal saphenous graft to the left anterior descending coronary artery. SG was uneventful in 98% (41/42 patients). Postoperative computerized tomography showed incomplete sealing in seven patients (17%), but only the two attachment endoleaks had to be treated by one proximal and one distal SG extension. Overall hospital stay for the synchronous repair was 12.5+/-6 days and that of the simultaneous group 17.5+/-7 days. Thirty-day mortality was 5% (2/42) as one patient of the simultaneous group experienced a lethal cerebral embolism during SG and one patient of the synchronous group developed an untreatable infection. In the follow-up of 4 years, there were two vascular reinterventions but no additional procedure-related morbidity or mortality. This experience shows that combined CABG and SG of thoracic or infrarenal aortic aneurysm is a safe and less-invasive alternative to the open graft repair, especially in the older patients or patients with severe comorbidities.

Minimal Incision Aortic Surgery (MIAS)

This study evaluates the clinical and economic impact of using less extensive minimal invasive aortic surgery (MIAS) for elective treatment of infrarenal aortic aneurysms (AAA) and aortoiliac occlusive disease (AIOD) in two independent surgical departments. Surgeons from two institutions conducted a prospective consecutive, nonrandomized analysis of MIAS electively performed in 80 patients. MIAS outcomes were compared with 80 consecutive elective standard open aortic procedures (40 from each institution), which were performed during the same time period. Cost analyses for MIAS and standard open repair were performed at each institution. Our results indicated that MIAS is as safe as standard open repair, is more cost-effective, and has significantly shorter hospital stays than with standard open repair.

Changes in TH1/TH2 immunity after endovascular and conventional infrarenal aortic aneurysm repair: Its relevance for clinical practice

Objective: to evaluate local surgical trauma induced by endovascular (TPEG) and conventional infrarenal aortic aneurysm repair (AAA-C), the inflammatory response and changes in cell-mediated and antibody-mediated immunity as illustrated by the type-1/type-2 T-helper (TH1/TH2) cell balance were investigated. Design: prospective study. Patients and Methods: sixteen patients were included, eight patients underwent AAA-C and eight TPEG. Venous peripheral blood samples were collected 24 h preoperatively and 24, 48, 72 h, 5 and 7 days postoperatively. Besides the WBC, intracellular TH1/TH2 cytokines (IFN-γ/IL-4) and the cell surface markers HLA-DR on monocytes and CD23 on B cells were measured by four colour flow cytometry. Results: statistically significant higher values in the AAA-C group were demonstrated for neutrophiles. The TH1/TH2 immunobalance (expressed by forming the ratio of IFN-(γ/IL-4 producing T cells as well as by the ratio of HLA-DRpos monocytes/CD23pos B-cells) showed a significant shift towards TH2 immunity in the AAA-C group whereas TPEG led to a significant lesser shift 24–72 h after surgery (p < 0.05). Conclusions: TPEG leads to a minor distortion of the TH1/TH2 immunobalance. This implies that TPEG is a less stressing procedure, that is especially beneficial in patients whose conditions are considered less suitable for AAA-C due to age and serious comorbidity.Eur J Vasc Endovasc Surg 25, 254–261 (2003)

Oral Antibiotic Prophylaxis Can Influence the Inflammatory Response in Aortic Aneurysm Repair: Results of a Randomized Clinical Study

The purpose of this prospective, randomized study was to evaluate the effect of oral ofloxacin prophylaxis on endotoxin/cytokine release in aortic aneurysm repair, in 25 patients with infrarenal aortic aneurysm at a University hospital. Outcome parameters included complications after operation; endotoxin and endotoxin neutralizing capacity, IL-6, procalciton and neopterin. All patients had the standard perioperative antibiotic prophylaxis (2 g cefotiam). 12 patients randomly received oral ofloxacin prophylaxis (group 1) the day before the operation (200 mg/2x12h); 13 patients were controls (group 2). Data were analyzed by chi-square analysis, Mann-Whitney and Wilcoxon analysis. Ofloxacin had no effect on the occurrence of complications or on the peripheral endotoxin levels. Ofloxacin-treated patients showed increased endotoxin neutralizing capacity (ENC) 30 min after clamping compared to controls (15.8±15 vs 262.8±709 p=0.005) and increased IL-6 levels preoperatively and 30 min after clamping. Patients with complications had significantly higher IL-6 levels early during the operation and postoperatively (30 min after clamping: 36.4±15.1 vs 18.8±11.9 pg/ml p=0.01; 2nd postoperative day: 768±688 vs 225±322 pg/ml p=0.005). Ofloxacin prophylaxis had no effect on procalcitonin, or neopterin plasma levels. Neither procalcitonin nor neopterin could detect patients with complications IL-6 plasma levels predicted the occurrence of complications in aortic aneurysm repair. Oral ofloxacin prophylaxis may influence the ENC and IL-6 plasma levels but had no effect on complications, endotoxin and other inflammatory mediators.

Endovascular stent grafting vs. open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis

Endovascular stent grafting vs. open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis

Endovascular Treatment of Ruptured Infrarenal Aortic and Iliac Aneurysms

Standard surgical treatment for ruptured abdominal aortoiliac aneurysms (AAAs) has achieved some dramatic individual results but is generally associated with substantial morbidity and an in-hospital mortality which ranges from 35-70% (1-8). Recent efforts to improve these poor results have not changed this bleak outlook significantly. Since 1994, we have evaluated the possibility that endovascular grafts coupled with other interventional techniques might help to improve the treatment outcomes of ruptured AAAs (9). Although we first used these grafts and techniques in a selected group of high-risk patients in whom pretreatment computerized tomographic (CT) scans could be obtained, we presently believe that they should be applied more widely to treat most patients with ruptured AAAs. The present chapter describes our experience to date with the use of endovascular grafts and other catheter-based techniques to treat ruptured AAAs. Obstacles to use of endovascular grafts in the ruptured aneurysm setting

Endovascular Repair of Ruptured Abdominal Aortic Aneurysm under Local Anaesthesia

We presenta case of ruptured AAA treated successfully byendovascular repair, entirely under local anaesthesia(LA).ReportA 79-year-old gentleman presented to the Accidentand Emergency department with sudden onset of left-sided abdominal pain and collapse. Despite severehypotension, he remained conscious and so a com-puted tomography (CT) scan was performed. Thisshowed a ruptured infrarenal aortic aneurysm, whichappeared to be suitable for endovascular repair (Figs. 1and 2).The patient was immediately transferred to theoperating theatre. Bilateral small groin incisions weremade. An 18 French sheath was inserted into the leftcommon femoral artery (CFA) and a 30 mm balloonpassed through this sheath, to gain control of the neckof the aneurysm, should this be necessary. A similarsheath was inserted into the right CFA and thebifurcated Zenith device (Cook UK Ltd) was insertedand deployed. The whole procedure was performedunder LA (Bupivacaine 0.5%, total volume 25–30 ml)in just under 3 h.A completion angiogram revealed the left renalartery to have been occluded by the graft. Unsuccess-ful attempts were made to withdraw the device, priorto accepting this position. The patient’s creatininepeaked at 175mmol/l on the third postoperative day,but had returned to within normal range bydischarge.A total offour units of blood were given intraopera-tively and the patient did not require further transfu-sion. He was observed on the intensive treatment unitfor 48 h and was fit for discharge on the sixthpostoperative day.

Thoracic stent grafts

Abstract Background The Endovascular Aneurysm Repair trial of infrarenal aortic aneurysm repair requires 20 operations to be performed at each centre to eliminate learning curve errors. An analysis was undertaken of the authors' learning curve experience of commercially made thoracic stent grafts. Methods Stent grafting was attempted in 26 patients. Aortic pathology included 13 atheromatous aneurysms, six dissections, one coarctation, three false aneurysms and three transections. Successful deployment was performed in 24 patients (92 per cent), but failed in two women due to small iliac arteries. Stent grafts used were Gore Excluder (16 patients), AneuRx (six), Vanguard (one) and Stenford (one). Four patients required two stents, two needed three stents, and 18 had a single stent. Results Thirteen elective procedures were uneventful. Two deaths occurred in 11 urgent procedures, from pulmonary embolism and aortic rupture of an unsuspected false aneurysm. The overall in-hospital mortality rate was 8 per cent (two of 24 patients). One graft with a persistent endoleak was removed at open repair at 6 weeks. The subclavian artery origin was covered in three elderly patients, resulting in minor distal ischaemia. No spinal cord problems were seen. One patient died from pneumonia at 8 weeks, and another died from rupture at 28 months as a result of prolapse of the stent into the aneurysm sac. Conclusion Assessment of the diameter of the iliac arteries is important, especially in women, to ensure that they accommodate the size of the sheath. Patients with false aneurysms have a poor outcome, and treatment by stent grafting may not be durable. Covering the origin of the left subclavian artery can be undertaken in elderly patients with transient minor symptoms. The use of stent grafts in acute type B dissection should be the subject of a randomized trial. Continued surveillance is essential.

Endovascular repair of a recurrent infrarenal aortic aneurysm

Endovascular repair of a recurrent infrarenal aortic aneurysm

Endotension in an experimental aneurysm model

The purpose of this study was to design an experimental model of endotension and to investigate whether attachment site failure without endoleak results in higher aneurysm sac pressure (ASP). Infrarenal aortic aneurysms were created in canines with an elliptical knitted polyester patch. Pressure transducers were inserted into the aneurysm. Group I (n = 4) underwent endovascular stent graft exclusion of the aneurysm. An attachment site failure was formed in group II (n = 5) before aneurysm exclusion. ASP measurements were obtained for 3 weeks, and the ratio of mean ASP to mean systemic blood pressure (ASP/BP) was calculated. Before explant, norepinephrine was administered and ASPs were recorded at varying systemic pressures. Stent graft cuff exclusion of the attachment site failure was performed in group II. Intraoperative arteriography and duplex ultrasonagraphy did not reveal an endoleak in either group. ASP/BP in group I was 0.39 +/- 0.02 compared with 1.01 +/- 0.02 in group II (P <.001). Mean systemic pressure varied from 55 to 177 mm Hg after norepinephrine administration. Within this interval, ASP/BP was 0.51 +/- 0.10 in group I compared with 0.91 +/- 0.10 in group II (P <.001). ASP/BP before cuff deployment in group II was 0.98 +/- 0.08 compared with 0.46 +/- 0.04 after cuff deployment (P <.001). Systemic pressure is transmitted to the aneurysm sac through an attachment site failure, despite no endoleak, resulting in endotension. Cuff exclusion of the attachment site failure decreases ASP. ASP may help determine the need for future intervention after endovascular aneurysm repair.

Spinal cord infarction: MR imaging and clinical features in 16 cases.

Spinal cord infarctions are rare and due to heterogeneous etiologies. The aim of the study was to analyze the MR imaging findings and evaluate their correlations with clinical symptoms in ischemic spinal cord lesions. MR images and clinical features of 16 patients (11 male, 5 female) with typical sudden onset of neurological deficits caused by spinal cord ischemia were evaluated. MR imaging was performed within 2 h to 14 days after the initial neurological symptoms. Eight patients had follow-up examinations including contrast-enhanced MR imaging. MR abnormalities were best demonstrated on sagittal T2-weighted images, with "pencil-like" hyperintensities (16/16) and cord enlargement (9/16). Axial T2-weighted images showed bilateral (13/16) and unilateral (3/16) hyperintensities according, in 15 patients, to anterior spinal artery (ASA) territory, with three of them located particularly in the spinal sulcal artery territory. In one patient only the posterior spinal artery (PSA) territory was involved. Spinal cord was affected at the cervical level (especially C2-C3) in seven patients, at the upper thoracic level (T3-T5) in two patients and at the thoracolumbar region including the conus medullaris (T10-L1) in seven patients. Presumed etiologies were vascular surgery (3 patients), infrarenal aortic aneurysm (1 patient), bilateral vertebral artery dissection (1 patient), hypotension (1 patient), spine operation (1 patient), excessive cocaine misuse (1 patient) and cardioembolic vertebral artery occlusion (1 patient); six of seven patients with unclear etiologies had vascular risk factors such as hypertension, diabetes and cigarette smoking. MR imaging is therefore useful in detecting spinal cord infarction, with axial T2-weighted images showing hyperintensities in the ASA territory in 15 of 16 patients. Contrary to the presumed spinal cord watershed at the lower cervical and upper thoracic level, and despite numerous central arteries in the cervical cord, our data suggest a high ischemic vulnerability of the cervical spinal cord at level C2-C3.

Mechanism of failure in the treatment of type II endoleak with percutaneous coil embolization

Purpose: Type II endoleak after endovascular abdominal aortic aneurysm repair is a failure of aneurysm sac exclusion with unknown long-term consequences. Elevated aneurysm sac pressures documented in these patients have led us to aggressively treat type II endoleaks with percutaneous transluminal coil embolization (PTCE). The purpose of this study was to evaluate the results and the mechanisms of failure of PTCE for type II endoleak. Methods: One hundred ninety-one patients underwent endograft repair of infrarenal aortic aneurysms. Twenty-three of 28 patients with persistent primary (>3 months) or secondary (new-onset) endoleak underwent angiography; 14 of these patients had type II endoleaks. We reviewed our endovascular registry data, hospital charts, and radiologic studies of patients with type II endoleaks and analyzed the results in those treated with PTCE of the inflow vessel. Results: All 14 patients with type II endoleaks were men, with a mean age of 76.7 years and a mean preoperative maximal aneurysm diameter of 5.7 ± 1.0 cm. The type II endoleak was primary in 12 patients (86%) and secondary in two patients (14%) and iliolumbar in 11 patients (78%) and mesenteric in three patients (21%). Although a dominant affluent collateral channel (inosculation) was apparent in eight patients (57%), six patients (43%) showed a network of collateral vessels (retiform anastomosis). In six patients (43%), angiography revealed a second or “outflow” vessel indicative of a complex endoleak. In four patients with retiform iliolumbar type II endoleaks, PTCE was not attempted because of the retiform nature of the endoleak. The remaining 10 patients underwent PTCE, with coil deployment in all 10 and apparent initial technical success in nine patients. Follow-up computed tomographic scans revealed persistent endoleaks in six patients (60%). Mechanisms of failure included persistent flow through the coils in the treated vessel in two patients, development of a retiform anastomosis around the coiled vessel in three patients, and development of a new mesenteric endoleak after successful occlusion of an iliolumbar endoleak in one patient. Two patients underwent repeat PTCE with successful aneurysm sac exclusion in one. Internal iliac artery injury complicated one of the 12 PTCEs, and the resulting pseudoaneurysm was successfully treated with PTCE. Angiographic visualization of an outflow vessel (complex endoleak) was associated with PTCE failure ( P = .008). Conclusion: PTCE of type II endoleaks has a high failure rate because of multiple anatomic mechanisms. (J Vasc Surg 2002;36:485-91.)

Primary Aorto-enteric Fistula in a 90-year-old Male

M. Goonewardene, S. Rai and N. LagattollaThe Treves Department of Surgery, West Dorset County Hospital, Williams Avenue,Dorchester, Dorset DT1 2JY, U.K.IntroductionPrimary aorto-enteric fistula is a rare life-threateningcause of gastrointestinal bleeding. Patients rarelydisplay the expected clinical triad of abdominal painwith gastrointestinal bleeding and a pulsatile abdom-inal mass. The presentation can thus be misleading,leading to a delay in diagnosis. We present the case ofa 90-year-old man with rectal bleeding caused by anaorto-ileal fistula which was successfully repaired.Case ReportA 90-year-old man presented with a 4-day history ofrectal bleeding associated with lower abdominal colicrelieved by passing stools. He described passing vari-ously fresh blood with clots, or dark bloody stools onfour occasions. He lived alone and was previouslyvery fit and well with no medical or surgical history.On admission he was pale, but haemodynamicallystable with a blood pressure of 155/92 and a regularpulse of 80. The rest of the initial examination wasunremarkable except for a digital rectal examinationwhich revealed dark blood. Blood tests showed:HB 10.1 WBC 10.2 HCT 0.302 PLT 321 Neut 9.1 Na134 K 4.8 Urea 10 Creat 108. A clotting screen wasnormal. Rigid sigmoidoscopy demonstrated darkblood up to 20cm, with no source evident. An uppergastrointestinal source of blood loss was suspected,and an urgent gastroscopy was arranged. Thisshowed no abnormality.On the 5th day of his admission, his abdominal painworsened. Re-examination of his abdomen revealed apulsatile abdominal mass, which had been missedinitially. He was referred to the vascular team. As thepatient was still haemodynamically stable, and with apresumptive diagnosis of ischaemic colitis with anincidental abdominal aortic aneurysm, an urgentabdominal CT scan was requested (Fig. 1). Thisdemonstrated an 8-cm maximal diameter infrarenalaortic aneurysm, irregular in outline, with a consider-ably eccentric lumen. The reporting radiologist madenote of the proximity of small bowel loops to theaneurysm. There was no other potential source ofgastrointestinal haemorrhage.He was taken to theatre. Through a long midlineexcision, an inflammatory infrarenal aortic aneurysm

Aneurysm-related death: Primary endpoint analysis for comparison of open and endovascular repair

Purpose: The purpose of this study was to utilize an objective endpoint analysis of aneurysm treatment, which is based on the primary objective of aneurysm repair, and to apply it to a consecutive series of patients undergoing open and endovascular repair. Method: Aneurysm-related death was defined as any death that occurred within 30 days of primary aneurysm treatment (open or endovascular), within 30 days of a secondary aneurysm or graft-related treatment, or any death related to the aneurysm or graft at any time following treatment. We reviewed 417 consecutive patients undergoing elective infrarenal aortic aneurysm repair: 243 patients with open repair and 174 patients with endovascular repair. Results: There was no difference between the groups (open vs endovascular) with regard to mean age ± standard deviation (73 ± 8 years vs 74 ± 8 years) or aneurysm size (64 ± 2 mm vs 58 ± 10 mm) ( P = not significant [NS]). The 30-day mortality for the primary procedure after open repair was 3.7% (9/243) and after endovascular repair was 0.6% (1/174, P < .05). The 30-day mortality for secondary procedures after open repair was 14% (6/41) compared to 0% after endovascular repair ( P < .05). The aneurysm-related death rate was 4.1% (10/243) after open surgery and 0.6% (1/174) after endovascular repair ( P < .05). Mean follow-up was 5 months longer following open repair ( P < .05). Secondary procedures were performed in 41 patients following open surgery and 27 patients following endovascular repair ( P = NS). Secondary procedures following open repair were performed for anastomotic aneurysms (n = 18), graft infection (n = 6), aortoenteric fistula (n = 5), anastomotic hemorrhage (n = 4), lower extremity amputation (n = 4), graft thrombosis (n = 3), and distal revascularization (n = 1). Secondary procedures following endovascular repair consisted of proximal extender cuffs (n = 11), distal extender cuffs (n = 11), limb thrombosis (n = 3), and surgical conversion (n = 2). The magnitude of secondary procedures following open repair was greater with longer operative time 292 ± 89 minutes vs 129 ± 33 minutes ( P < .0001), longer length of stay 13 ± 10 days vs 2 ± 2 days ( P < .0001) and greater blood loss 3382 ± 4278 mL vs 851 ± 114 mL ( P < .0001). Conclusions: The aneurysm-related death rate combines early and late deaths and should be used as the primary outcome measure to objectively compare the results of open and endovascular repair in the treatment of infrarenal abdominal aortic aneurysms. In our experience, endovascular aneurysm repair reduced the overall aneurysm-related death rate when compared to open repair. Secondary procedures are required after both open and endovascular repair. However, the magnitude, morbidity, and mortality of secondary procedures are reduced significantly with endovascular repair. (J Vasc Surg 2002;36:297-304.)

Capturing an accurate measure of success—Outcomes and endpoints in endovascular aneurysm repair

Purpose: The purpose of this study was to utilize an objective endpoint analysis of aneurysm treatment, which is based on the primary objective of aneurysm repair, and to apply it to a consecutive series of patients undergoing open and endovascular repair. Method: Aneurysm-related death was defined as any death that occurred within 30 days of primary aneurysm treatment (open or endovascular), within 30 days of a secondary aneurysm or graft-related treatment, or any death related to the aneurysm or graft at any time following treatment. We reviewed 417 consecutive patients undergoing elective infrarenal aortic aneurysm repair: 243 patients with open repair and 174 patients with endovascular repair. Results: There was no difference between the groups (open vs endovascular) with regard to mean age ± standard deviation (73 ± 8 years vs 74 ± 8 years) or aneurysm size (64 ± 2 mm vs 58 ± 10 mm) (P = not significant [NS]). The 30-day mortality for the primary procedure after open repair was 3.7% (9/243) and after endovascular repair was 0.6% (1/174, P <.05). The 30-day mortality for secondary procedures after open repair was 14% (6/41) compared to 0% after endovascular repair (P <.05). The aneurysm-related death rate was 4.1% (10/243) after open surgery and 0.6% (1/174) after endovascular repair (P <.05). Mean follow-up was 5 months longer following open repair (P <.05). Secondary procedures were performed in 41 patients following open surgery and 27 patients following endovascular repair (P = NS). Secondary procedures following open repair were performed for anastomotic aneurysms (n = 18), graft infection (n = 6), aortoenteric fistula (n = 5), anastomotic hemorrhage (n = 4), lower extremity amputation (n = 4), graft thrombosis (n = 3), and distal revascularization (n = 1). Secondary procedures following endovascular repair consisted of proximal extender cuffs (n = 11), distal extender cuffs (n = 11), limb thrombosis (n = 3), and surgical conversion (n = 2). The magnitude of secondary procedures following open repair was greater with longer operative time 292 ± 89 minutes vs 129 ± 33 minutes (P <.0001), longer length of stay 13 ± 10 days vs 2 ± 2 days (P <.0001) and greater blood loss 3382 ± 4278 mL vs 851 ± 114 mL (P <.0001). Conclusions: The aneurysm-related death rate combines early and late deaths and should be used as the primary outcome measure to objectively compare the results of open and endovascular repair in the treatment of infrarenal abdominal aortic aneurysms. In our experience, endovascular aneurysm repair reduced the overall aneurysm-related death rate when compared to open repair. Secondary procedures are required after both open and endovascular repair. However, the magnitude, morbidity, and mortality of secondary procedures are reduced significantly with endovascular repair.