Infrarenal Aortic Aneurysm Research Articles

Aortoduodenal fistula after transperitoneal repair of an inflammatory abdominal aortic aneurysm: A case report

Introduction: An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Case Report: A 77-year-old Caucasian male who underwent a conventional repair of an inflammatory infrarenal aortic aneurysm, was readmitted with hematemesis only six weeks after surgery. Gastroscopy and computed tomography angiography indicated an aortoduodenal fistula and urgent aortic reconstruction was performed. An aortoduodenal fistula is a potentially lethal complication after transperitoneal open repair of an abdominal aortic aneurysm. Conclusion: An aortoduodenal fistula seldom occurs as early after conventional transperitoneal open aneurysm repair as in our case. The early occurrence of the aortoduodenal fistula can be explained by the inflammatory character of the aneurysm.

3D Printing of an Aortic Aneurysm to Facilitate Decision Making and Device Selection for Endovascular Aneurysm Repair in Complex Neck Anatomy

To describe rapid prototyping or 3-dimensional (3D) printing of aneurysms with complex neck anatomy to facilitate endovascular aneurysm repair (EVAR). A 75-year-old man had a 6.6-cm infrarenal aortic aneurysm that appeared on computed tomographic angiography to have a sharp neck angulation of ~90°. However, although the computed tomography (CT) data were analyzed using centerline of flow, the true neck length and relations of the ostial origins were difficult to determine. No multidisciplinary consensus could be reached as to which stent-graft to use owing to these borderline features of the neck anatomy. Based on past experience with rapid prototyping technology, a decision was taken to print a model of the aneurysm to aid in visualization of the neck anatomy. The CT data were segmented, processed, and converted into a stereolithographic format representing the lumen as a 3D volume, from which a full-sized replica was printed within 24 hours. The model demonstrated that the neck was adequate for stent-graft repair using the Aorfix device. Rapid prototyping of aortic aneurysms is feasible and can aid decision making and device delivery. Further work is required to test the value of 3D replicas in planning procedures and their impact on procedure time, radiation dose, and procedure cost.

Preventively enteral application of immunoglobulin enriched colostrums milk can modulate postoperative inflammatory response.

Several studies demonstrated acute inflammatory response following traumatic injury. Inflammatory response during surgical interventions was verified by a significant increase of endotoxin plasma levels and a decrease of the endotoxin neutralizing capacity (ENC). However, the incidence of elevated endotoxin levels was significantly higher (89%) than detected bacterial translocation (35%). Thus parts or products of Gram-negative bacteria seem to translocate more easily into the blood circulation than whole bacteria. Along with the bacterial translocation, the inflammatory response correlated directly with the severity of the surgical intervention. In comparison after major and minor surgery Interleukin-6 (IL-6) and C-reactive protein (CRP) was also significantly different. Similar effects in mediator release were shown during endovascular stent graft placement and open surgery in infrarenal aortic aneurysm. Open surgery demonstrated a significant stronger endotoxin translocation and a decrease of ENC. Strategies to prevent translocation seem to be sensible. Colostrum is the first milk produced by the mammary glands within the first days after birth. It contains a complex system of immune factors and has a long history of use in traditional medicine. Placebo-controlled studies verified that prophylactic oral application of immunoglobulin-enriched colostrum milk preparation diminishes perioperative endotoxemia, prevents reduction of ENC and reduces postoperative CRP-levels, suggesting a stabilization of the gut barrier. This effect may be caused by immunoglobulin transportation by the neonatal receptor FcRn of the mucosal epithelium.In conclusion, there is an association of perioperative endotoxemia and the subsequent increase in mediators of the acute phase reaction in surgical patients. A prophylactic oral application of colostrum milk is likely to stabilize the gut barrier i.e. reduces the influx of lipopolysaccharides arising from Gram-negative bacterial pathogens and inhibits enterogenic endotoxemia. This appears to be a major mechanism underlying the therapeutic effect in patients at risk for Gram-negative septic shock.

Patología de la aorta torácica y abdominal

Acute aortic syndrome is a lesion of the aortic wall involving the aortic media layer. The term covers aortic dissection, intramural hematoma and penetrating ulcer. Aortic coarctation comprises approximately 7% of all known congenital cardiovascular defects. Aortic aneurysms could be divided into: thoracic, toracoabdominal, infrarenal, yuxtarenal and pararenal aortic aneurysms. Aortic occlusive syndromes encompass a wide variety of aortic and aortoiliac conditions that present with devastating clinical sequale of hypertension coupled with visceral and lower limb ischemia. Common causes of aortic occlusion include: atherosclerotic occlusive disease, acute aortic occlusion (embolic/thrombotic/dissection) and mid aortic syndrome (Takayasu arteritis, congenital aortic hypoplasia, fibromuscular dysplasia, neurofibromatosis). The availability of endovascular treatment has provided new approaches to the management of these conditions and could improve prognosis. The aim of this article is to review recent progress in the diagnosis and therapeutic management of these aortic syndromes.

Visceral stent patency in fenestrated stent grafting for abdominal aortic aneurysm repair

Fenestrated endovascular abdominal aortic aneurysm repair (F-EVAR) has been introduced for treatment of aneurysms in which visceral arteries are incorporated. Patency of target vessels has been reported to be excellent. Results of the use of stent grafts to accommodate visceral arteries in F-EVAR are presented in this study, including an overview of factors that affect outcome. All patients treated with fenestrated stent grafts in a single center between November 2001 and October 2011 were reviewed. Patients treated for suprarenal, juxtarenal, and infrarenal short-necked aortic aneurysms were included. Patients with thoraco-abdominal aneurysms or aneurysms treated with grafts with fixed side branches were excluded. Polytetrafluoroethylene covered stents were used routinely since June 2005. Target vessels and stents were examined using computed tomography angiography reconstructions. Primary end points were primary patency, defined as the absence of occlusion, and loss of renal function. Secondary end points were technical success, stenosis (defined as a ≥50% angiographic diameter reduction), stent fracture, and mortality. A total of 138 patients with a median age of 73 years (range, 50-91 years) met the inclusion criteria. Median computed tomography angiography follow-up was 13 months (range, 1-97 months). In total, 392 target vessels were provided with 140 scallops and 252 fenestrations. Visceral stents (-grafts) were placed in 254 target vessels. Technical success was obtained in 249 arteries (98.0%). Overall stent patency of target vessels was 95.7% at 1 year and 88.6% at 4 years. Renal artery stent patency was 97.4% at 1 year and 91.2% at 4 years (96.8% and 89.1% for uncovered stents; 97.3% and 92.4% for covered stents, respectively). There was no significant difference in patency between covered and uncovered stents in renal arteries (P = .71). Renal artery stenosis occurred in 26 stented arteries (11.3%) and occlusion in seven arteries. Renal artery stent stenosis occurred significantly more in uncovered than in covered stents (P = .04). Stent fractures occurred more in uncovered than in covered stents (P = .01) and was associated with a significantly lower visceral stent patency rate (P < .01). During follow-up, 13 patients developed permanent renal function impairment (9.4%), of which two required permanent dialysis (1.4%). Renal dysfunction was significantly associated with renal stent occlusion or stenosis (P < .01). Patency rates of visceral artery stent (-grafts) in F-EVAR were 95.7% at 1 year and 88.6% at 4 years. Patency rates were affected by stent fractures, which occurred more in uncovered compared with covered stents. Renal artery stent stenosis occurred more in uncovered compared with covered stents. Renal dysfunction was significantly associated with renal stent occlusion or stenosis.

Part One: For the Motion. Young Patients with Good Risk Factors Should be Treated with EVAR

There has been significant improvement in endovascular repair (EVAR) of infrarenal aortic aneurysms over the last 22 years, since Juan Parodi first reported on his historic cases. There are now several commercially available devices approved for EVAR throughout the world. Utilization of this technique for infrarenal abdominal aortic aneurysm (AAA) repair varies worldwide, but has been shown to be up to 80% of all AAA repairs done in the USA. Despite its widespread use in most patients, there are still subgroups in which the benefits of EVAR have not clearly been demonstrated. The subgroup most often debated is the young patient with good risk factors, which serves as the basis for the following debate. While initially thought to be a rare occurrence, this is an important controversy because in the USA more than 5,000 patients a year between the age of 50 and 64 years undergo aneurysm repair. There are substantial reasons why young patients with good anatomic characteristics and low comorbidities are very good candidates for EVAR, and it should be offered to this subgroup.

Infectious Aortitis in a Liver Transplant Recipient

The development of an abdominal aortic aneurysm secondary to infectious aortitis following solid organ transplantation is a rare event that in the absence of surgical intervention, can lead to uncontrolled sepsis, catastrophic hemorrhage and death. Arterial allografts have been a viable surgical option for the past 30 years, although operative modalities have undergone a paradigm shift in recent years. We describe the first case in the literature of a liver transplant recipient who developed an infrarenal aortic aneurysm secondary to Salmonella bacteraemia, which was treated successfully with aortic allograft transplantation.

A Spinal Osteophyte as Indication for Treatment of an Infra-renal Aortic Aneurysm

A Spinal Osteophyte as Indication for Treatment of an Infra-renal Aortic Aneurysm

A Spinal Osteophyte as Indication for Treatment of an Infra-renal Aortic Aneurysm

Infra-renal aortic aneurysm rupture is a feared condition, therefore is it important to preview potential factors that could lead to it. A 59-year-old male with ankylosing spondylitis presented with a 4.6 cm diameter infra-renal aortic aneurysm. He had an osteophyte like a harpoon of the third and fourth lumbar vertebra, contacting directly with the aneurysm wall. The patient was submitted to an endovascular procedure. Surgical treatment was mandatory because of the potential high risk of rupture produced by the continuous trauma of the aorta against the osteophyte. The authors believe that this case reveals a possible new indication for treatment.

The fate of untreated concomitant suprarenal aortic aneurysms after endovascular aneurysm repair of infrarenal aortic aneurysms

Many patients treated with endovascular aortic repair (EVAR) have a concomitant suprarenal abdominal aortic aneurysm (sAAA). The natural history of these sAAAs and whether they require intervention after EVAR is unknown. We identified 470 patients from the M2S database (M2S Inc, West Lebanon, NH) as having an infrarenal AAA (iAAA) with a concomitant sAAA (diameter, 2.9-4.7 cm). The analysis included 217 patients with preoperative computed tomography angiography and follow-up imaging of ≥12 months. Patients who did not undergo EVAR (n = 65) served as a control. Patients with EVAR were subdivided into 90 with suprarenal fixation (SR) and 62 with infrarenal fixation (IR). Standard measurements from the M2S images were extracted, and growth rates were calculated for different abdominal aortic segments. The average follow-up was 33.0 ± 18.8 months. The average sAAA initial size and growth rate were 34.6 ± 3.0 and 0.6 ± 1.1 mm/y for SR, 34.0 ± 3.3 and 0.6 ± 1.3 mm/y for IR, and 36.6 ± 3.4 and 1.2 ± 1.5 mm/y for controls (SR vs IR, P > .05; SR or IR vs control, P < .05). After EVAR, two of 152 (1.3%) sAAAs grew to ≥ 50 mm, which was not statistically different from four of 65 (6.2%) in the control group (P = .07). At 48 months, the Kaplan-Meier freedom from sAAA growth to ≥ 50 mm was 99.3% for patients undergoing EVAR and 95.2% for controls (P = .061). Patients with starting sAAAs sized ≥ 40 mm had a higher growth rate (1.4 ± 2.1 mm/y) and frequency of growth to ≥50 mm (14.3%) than patients with starting sAAAs sized <40 mm (0.7 ± 1.2 mm/y and 1.5%; P < .05). Isolated treatment of iAAAs via EVAR with a concomitant sAAA is acceptable because endografts with or without SR do not affect sAAA growth rates. Routine EVAR follow-up is sufficient for sAAAs of <40 mm, and more intensive follow-up should be considered for sAAAs of 40 to 50 mm. For sAAAs approaching 50 mm, an endograft with IR should be considered in case sAAA repair is required in the future.

Spinal Cord Ischaemia Following Fenestrated Endovascular Aortic Repair for Infrarenal Aortic Aneurysm: Report of a Rare Complication and Its Successful Treatment

Introduction: Spinal cord ischaemia (SCI) is a rare complication of infrarenal aortic aneurysm repair. Report: We present a case of a 68-year-old man with an infrarenal aortic aneurysm treated by fenestrated endovascular aneurysm repair (FEVAR). He developed paraplegia alleviated by cerebrospinal fluid (CSF) drainage and resolved by revascularization of the inadvertently occluded internal iliac artery (IIA). Discussion: The incidence and aetiology of SCI following aortic repair are discussed with an emphasis on collateral flow. SCI is rare in FEVAR and does not require routine CSF monitoring but awareness. Prompt restoration of adequate spinal perfusion is curative. Spinal Cord Ischaemia Following Fenestrated Endovascular Aortic Repair for Infrarenal Aortic Aneurysm: Report of a Rare Complication and Its Successful TreatmentEJVES ExtraVol. 26Issue 2PreviewSpinal cord ischaemia (SCI) is a rare complication of infrarenal aortic aneurysm repair. Full-Text PDF Open Access

Spinal Cord Ischaemia Following Fenestrated Endovascular Aortic Repair for Infrarenal Aortic Aneurysm: Report of a Rare Complication and Its Successful Treatment

Introduction Spinal cord ischaemia (SCI) is a rare complication of infrarenal aortic aneurysm repair. Report We present a case of a 68-year-old man with an infrarenal aortic aneurysm treated by fenestrated endovascular aneurysm repair (FEVAR). He developed paraplegia alleviated by cerebrospinal fluid (CSF) drainage and resolved by revascularization of the inadvertently occluded internal iliac artery (IIA). Discussion The incidence and aetiology of SCI following aortic repair are discussed with an emphasis on collateral flow. SCI is rare in FEVAR and does not require routine CSF monitoring but awareness. Prompt restoration of adequate spinal perfusion is curative.

Early Detection of Gut Ischemia-Reperfusion Injury During Aortic Abdominal Aneurysmectomy: A Pilot, Observational Study

D-lactate is the enantiomer of L-lactate, which is measured routinely in clinical practice to assess cell hypoxia. D-lactate has been proposed as a specific marker of gut ischemia-reperfusion (IR), particularly during surgery for ruptured abdominal aortic aneurysms. The aim of this study was to compare the use of D-lactate measurement and colonic tonometry (taken as a reference method) for gut IR detection during elective infrarenal aortic aneurysm (IrAA) surgery. Prospective, monocenter, observational study. Vascular surgery unit, university hospital. Candidates for elective IrAA surgery. Patients without (controls) and with gut IR (defined as ΔCO2>2.6 kPa) were compared retrospectively. D-lactate levels were compared with colonic perfusion levels (ΔCO2), as assessed by colonic tonometry, at 7 time points during surgery and until 24 hours after surgery. D-lactate also was measured in mesenteric vein blood before and after gut reperfusion. Plasma TNF-α level was measured at the same time points to assess systemic inflammatory response. Eighteen patients requiring elective IrAA surgery were included. The ΔCO2 and TNF-α level varied significantly over time. There was a significant ΔCO2 peak at the end of clamping (2.6±1.8 kPa, p = 0.006) and a significant peak in TNF-α level after 1 hour of reperfusion (183±53 ng/L, p = 0.05). D-lactate levels were undetectable in systemic and mesenteric blood in all the patients throughout the study period. Gut IR patients (n = 6) experienced a longer overall duration of intraoperative hypotensive episodes and received more catecholamines than the controls (n = 12). Compared with colonic tonometry, D-lactate was not a reliable biomarker of gut IR during elective IrAA surgery.

Ruptured Cryptogenic Mycotic Abdominal Aortic Aneurysm by Salmonella enteritidis

The aim of this study is to describe a case of ruptured cryptogenic mycotic abdominal aortic aneurysm by Salmonella enteritidis (SE) and present a comprehensive review of the literature. A 66-year-old man with a past medical history of coronary artery bypass graft (CABG) and polymylagia rheumatica (PMR) presented with a 2-day history of right-flank-to-groin pain and fever. He was found to have tenderness on the right of the umbilical region and laboratory data showed leukocytosis, raised C-reactive protein, and a significant drop in hemoglobin level as compared with his first visit 17 days earlier, with no hemodynamic instability. An immediate computed tomography angiogram (CTA) was performed, which showed a 4-cm, fusiform, ruptured infrarenal aortic aneurysm. Exploratory laparatomy was performed and the aorta was isolated and excised from the infrarenal level to the common iliac bificuration. A straight silver Dacron graft soaked in rifampicin was placed with an end-to-end anastomosis. The excised aorta and the lymph nodes were sent for histologic and microbiologic assessment. Blood culture and specimen microbiology grew Salmonella enteritidis (SE). The histology exhibited atherosclerosis at the rupture point with decreasing neutrophil deposition from the intima to the adventitia layer, respectively. Infrarenal abdominal mycotic aneurysm (MA) by SE was observed and showed vague, nonspecific signs and symptoms. We recommend a high index of suspicion and low threshold for use of CT imaging in any infected patient of age >60 years with fever and abdominal pain on a background of diabetes and connective tissue disease. A comprehensive review of the literature was performed due to a lack of consensus on the best surgical treatment and limited information on the path of SE-induced aortitis or MA from presentation to final outcome.

A case of mycotic aneurysm due to Burkholderia pseudomallei

Burkholderia pseudomallei is an free-living gram-negative bacterium causing melioidosis and is endemic in Southeast Asia. A 56-year-old diabetic construction worker with a 1-month history of abdominal pain and 1-day history of high-grade fever was found to have a left non-dissecting infrarenal mycotic aortic aneurysm by abdominal computerized tomography scan. Bacteriological examination of his blood yielded Burkholderia pseudomallei. The patient was treated with right axillo-bifemoral bypass with excision of aneurysm and high-dose intravenous ceftazidime for two weeks, followed by oral trimethoprim/sulfamethoxazole and oral doxycycline for a minimum of five months.

Type II endoleaks after endovascular repair of abdominal aortic aneurysm are not always a benign condition

The aim of the study was to determine whether type II endoleak (T2E) after endovascular repair of abdominal aorta (EVAR) is a benign condition (ie, not associated with growth, reintervention, rupture, or death). Data from patients who underwent EVAR for atherosclerotic infrarenal aortic aneurysms between June 1995 and May 2010 in the Vascular Surgery Department of Henri Mondor Hospital were prospectively collected. Data from patients presenting with at least one T2E on computed tomography scan during their follow-up were compared with those with no T2E. Three subcategories of T2E were studied according to time of occurrence (early or late), persistence (persistent or transient), and recurrence (recurrent or not recurrent). Seven hundred patients were included with follow-up ranging from 1 month to 15 years (median, 31.3 months; range, 12.4-61.4); 201 (28.9%) had at least one T2E. Patients with T2Es were significantly older (P < .001), female (P = .015), had larger aneurysms (P = .019), and patent lumbar arteries (P = .003). Patients without T2Es had a higher incidence of current smoking (P < .001) and chronic obstructive pulmonary disease (P < .005). Multivariate analysis showed risk of T2E was increased in older patients (odds ratio [OR], 1.04; confidence interval [CI], 95% 1.02-1.06; P < .001) and in those with patent lumbar arteries (OR, 1.70; CI, 95% 1.16-2.50; P = .007), and was reduced in active smokers (OR, 0.16 CI, 95% 0.04-0.71; P = .015) or patients with coronary artery disease (OR, 0.65; CI, 95% 0.45-0.92; P = .016). Patients with T2Es had more complications (death, rupture, reintervention, or conversion) (P < .001) and greater aneurysm sac enlargement (>5 mm upon follow-up) (P < .001). Multivariate analysis showed T2E was a risk factor for aneurysm diameter growth >5 mm; this risk was increased if T2E persisted more than 6 months (hazard ratio [HR], 3.16; CI, 95% 2.55-6.03; P < .001), was recurrent (HR, 1.88; CI, 95% 1.18-3.01; P = .008), or associated with a type I or III endoleak (HR, 1.96; CI, 95% 1.41-2.73; P < .001). Recurrent T2E was associated with a higher rate of reintervention (P = .04) and conversion to open surgery (P = .028). Not all T2Es are benign. Recurrent as well as persistent T2Es are prone to life-threatening complications.

Endovascular Repair With Fenestrated-Branched Stent Grafts Improves 30-Day Outcomes for Complex Aortic Aneurysms Compared With Open Repair

Endovascular repair is associated with better 30-day outcomes than open surgical repair for patients with infrarenal aortic aneurysms. In patients with complex aortic aneurysms (CAAs) requiring suprarenal or supravisceral aortic cross-clamping during open repair, few data exist directly comparing the real-world outcomes of open repair versus endovascular repair with fenestrated-branched stent grafts (FEVAR). Outcomes for patients who underwent elective CAA repair using open repair and FEVAR between 2005 and 2010 were analyzed using the American College of Surgeons National Surgical Quality Improvement Program database. CAA was defined as aneurysm of the aorta involving the visceral and/or renal arteries. This study compared 1091 patients who underwent open repair (group A: male, 71.5%; age, 71 ± 9 years) with 264 patients treated with FEVAR (group B: male, 82.2%; age, 74 ± 9 years). The 2 groups did not significantly differ with respect to American Society of Anesthesiologists (ASA) classification (ASA III/IV: A, 93%; B, 95%, P = 0.6), severe chronic obstructive pulmonary disease (A: 21%; B: 22%; P = 0.7), prior cardiac surgery (A: 24%; B: 20%; P = 0.19), or preoperative renal function (glomerular filtration rate: A: 69 ± 2; B: 70 ± 27; P = 0.535). Group A had significantly higher risk of any complication (A: 42%; B: 19%; P < 0.001), nonsurgical complications (A: 30%; B: 8%; P < 0.001), pulmonary complications (A: 21%; B: 2%; P < 0.001), renal complications (A: 10%; B: 1.5%; P = 0.001), and any cardiovascular complication (A: 8%; B: 2%; P < 0.001). The composite end point of surgical site infections/graft failure/bleeding transfusions were also higher in group A (A: 22%; B: 15%; P = 0.014). Thirty-day mortality was significantly lower for FEVAR (A: 5.4%; B: 0.8%; P = 0.001), as was total length of hospital stay (A: 11 ± 10 days; B: 4 ± 5 days; P < 0.001). This nationwide real-world database suggests that in similar patient populations, repair of CAAs with FEVAR is associated with reduced 30-day morbidity and mortality compared with open repair. Although long-term comparative studies are needed, FEVAR may represent a preferred treatment alternative to open repair for patients with CAAs.

Repair of infrarenal aortic aneurysm—the debate is OVER

Randomized trials of open versus endovascular repair (EVR) of abdominal aortic aneurysm have demonstrated the short-term superiority of EVR, but have raised questions about the long-term durability of this approach. The final report from the OVER trial now demonstrates that EVR is the treatment of choice for morphologically suitable aortic aneurysms.

Retrograde ascending Stanford B aortic dissection complicating a routine infrarenal endovascular aortic reconstruction

Retrograde ascending aortic dissections usually complicate endovascular reconstructions of Stanford B dissections. Although rare, with an incidence of 1.3% to 6.8%, they are catastrophic, with a high mortality rate of up to 42%. The exact mechanism is not known, but all indications point to a mechanical interaction between the tips of the proximal bare stent and a fragile aortic wall. Practically all reported cases involve dissections of the thoracic aorta. We report a patient with an asymptomatic retrograde ascending aortic dissection that originated at the level of a damaged suprarenal stent during capture tip retrieval during a routine endovascular aneurysm repair to treat an infrarenal aortic aneurysm.

Paraplegia following Elective Endovascular Aortic Repair of an Infrarenal Aortic Aneurysm

Paraplegia following Elective Endovascular Aortic Repair of an Infrarenal Aortic Aneurysm