Large Infrarenal Abdominal Aortic Aneurysm Research Articles

Trash Feet and Mesenteric Ischemia as a Rare Manifestation of a Complicated Abdominal Aortic Aneurysm: A Case Report.

Abdominal aortic aneurysms and atheromatous plaques are well-established potential culprits in the development of cholesterol embolization. This embolic phenomenon can result in the occlusion of peripheral arteries in the forefoot or toes, commonly referred to as "trash foot". A 61-year old patient exhibited severe symptoms and signs of lower limb and mesenteric ischemia, represented clinically by abdominal pain, hematochezia, and bilateral plantar necrotic lesions, attributed to embolization from a previously unknown large infrarenal abdominal aortic aneurysm. Diagnosis was confirmed by performing angio-CT of the abdomen, an angiologic examination, as well as colonoscopy. The patient underwent open surgical repair of the aortic aneurysm and received intravenous prostanoids, resulting in a successful outcome with resolution of bowel ischemia and complete recovery of bilateral foot lesions with no tissue loss. Cholesterol embolization syndrome seldom manifests with its complete clinical spectrum. Identifying and addressing the underlying cause is crucial, with a focus on potential abdominal aortic aneurysms. A combined approach involving surgical repair and prostanoid therapy may offer a viable option for patients experiencing severe manifestations.

Abstract 12986: Internal Iliac Artery Occlusion With the Amplatzer Vascular Plug During Endovascular Repair of Large Abdominal Aortic Aneurysm

Background: Retrograde blood flow from the internal iliac artery resulting in a type II endoleak is a challenging complication of endovascular aorto-iliac aneurysm repair. Several methods have been developed to address this concern. We present a case where the Amplatzer vascular plug was used to embolize the internal iliac artery in a patient undergoing aorto-iliac stent-grafting with extension of the graft into the external iliac artery. Case: A 67-year-old male presented with abdominal pain. Abdominal contrast computed tomography confirmed a large infrarenal abdominal aortic aneurysm (AAA) measuring 100 mm across, extending into the common iliac artery on the right and the external iliac artery on the left, with perianeurysmal fat stranding indicating impending rupture. The patient was taken emergently to the operating room. Vascular access was obtained through bilateral common femoral arteries. The left internal iliac was occluded with an Amplatzer 16 mm by 12 mm vascular plug, with excellent angiographic apposition. A bifurcated aorto-iliac graft was then sequentially deployed to repair the aneurysm. Final angiography showed patent renal arteries with no endoleak. The patient was discharged home the following day. Discussion: Embolization of the internal iliac artery is indicated in endovascular aorto-iliac aneurysm repair to prevent endoleak formation. Traditionally performed with coils, the Amplatzer vascular plug has emerged as a safe and effective alternative, with the added advantage of recoverability prior to definitive release. Conclusion: Endovascular repair of an AAA must consider the complication of endoleak formation. In this case, the use of an Amplatzer vascular plug was successful in preventing a type II endoleak from the internal iliac artery. Panel A. 3D reconstruction of aneurysm anatomy; Panel B. Angiogram showing final result of endovascular repair with successful occlusion of the left internal iliac artery

Anatomic eligibility for endovascular aneurysm repair preserved over 2 years of surveillance

ObjectiveEndovascular aneurysm repair (EVAR) is a widely used option for patients with suitable vascular anatomy who have a large infrarenal abdominal aortic aneurysm (AAA). Patients with small AAAs are managed with careful surveillance and it is a common concern that their anatomy may change with AAA growth, and their option for EVAR may become limited. Device innovation has resulted in expanded ranges of anatomy that may be eligible for EVAR. This study sought to identify changes in anatomic eligibility for repair with contemporary endovascular devices in AAA patients, monitored by computed tomography scan over the course of 2 years. MethodsPatients from the Non-Invasive Treatment of Abdominal Aortic Aneurysm Clinical Trial (N-TA3CT, NCT01756833) were included in this analysis. Females had baseline AAA maximum transverse diameter between 3.5 and 4.5 cm, and males had baseline maximum transverse diameter between 3.5 and 5.0 cm. Patients were included in this analysis if they completed pre-enrollment and 2-year follow-up computed tomography imaging. Pertinent anatomic measurements were performed on a postprocessing workstation in a centralized imaging core laboratory. EVAR candidacy was determined by measuring proximal aortic neck diameter, AAA length, and infrarenal neck angulation. Patients were considered to be eligible for EVAR if they qualified for at least one of the seven studied devicesʼ instructions for use at baseline and at 2 years. A paired t test analysis was used to detect differences in aortic measurements over 2 years, and the McNemar test was used to compare eligibility over 2 years. ResultsWe included 192 patients in this analysis—168 male and 24 female. Of these patients, 85% were eligible for EVAR at baseline and 85% after 2 years of follow-up (P = 1.00; 95% confidence interval –0.034 to 0.034). Of the 164 EVAR candidates at baseline, 160 (98%) remained eligible over 2 years of surveillance. Insufficient neck length was the most common reason for both ineligibility at baseline (18 of 28 patients) as well as loss of candidacy over 2 years (3 of 4 patients). ConclusionsThe majority of patients eligible for EVAR when entering a surveillance program for small AAA remain eligible after 2 years. Substantial changes in AAA neck anatomy resulting in loss of EVAR treatment options are infrequent. Patients with anatomic AAA progression beyond EVAR eligibility remain candidates for complex EVAR and open repair.

3222 A Rare Presentation of a Sizable Asymptomatic Abdominal Aortic Aneurysm

INTRODUCTION: An abdominal aortic aneurysm (AAA) occurs as plaque builds up in vessels due to long-standing atherosclerosis. AAA takes years to develop and has few if any noticeable symptoms during this time. The larger an aneurysm becomes, the more likely symptoms develop including abdominal pain, back pin, dizziness and nausea. Significant risk factors for the development of AAA include smoking, hypertension, old age and family history. Aneurysms are more likely to burst and rupture as its size increases. Symptoms generally develop when an AAA becomes larger than 3 cm and elective repair should be considered for aneurysms measuring greater than 5.5 cm in size. Here, we present a case of an asymptomatic patient presenting to the hospital with an incidental AAA measuring 14 × 11 cm. CASE DESCRIPTION/METHODS: A 100-year-old female with a history of dementia, emphysema secondary to 25 pack year smoking, and anemia presented to the hospital with right leg pain after a recent mechanical fall. She denied any complaints at the time of admission including chest pain, shortness of breath, dizziness, nausea, abdominal pain and back pain. CT of the pelvis revealed acute right subcapital femoral neck fracture as well as a large infrarenal AAA measuring 14 × 11 cm with high risk for rupture. Cardiology was consulted for preoperative risk assessment for hemiarthroplasty versus percutaneous pinning of the right femoral neck. Patient was deemed too high of a risk for hemiarthroplasty and decision was made by medical team to pursue percutaneous pinning although patient remained high risk for surgery due to large AAA. While patient was in the operative room immediately prior to surgery, the patient developed hypotension and hypoxia. After discussion with family and medical team, patient opted for palliative care. DISCUSSION: The case highlights an extreme clinical presentation of a massive AAA that was found incidentally on imaging after a recent mechanical fall. Current guidelines recommend that an AAA should be surgically evaluation when its size exceeds 5.5 cm due to the life threatening risk of rupture. This patient's unusual presentation of a large AAA despite not presenting with any of the classical symptoms is concerning because of the risk associated with spontaneous rupture and death. More research is needed for the evaluation and screening of AAA's to prevent potential catastrophic complications.

Symptomatic large infrarenal abdominal aortic aneurysm with concomitant pelvic tumour

Symptomatic large infrarenal abdominal aortic aneurysm with concomitant pelvic tumour

Congenital abdominal aortic aneurysm in a term neonate: a case report

Background: Congenital abdominal aortic aneurysm (AAA) is a rare condition in neonates. To our knowledge, the natural course of the disease in a Thai neonate has not yet been reported. Objectives: To report the characteristics and clinical course of congenital AAA in a Thai neonate. Methods: A female Thai infant was born spontaneously at term (3,990 g) having a large, pulsatile, abdominal mass. Computed tomographic angiography (CTA) of the abdominal aorta showed a large infrarenal AAA, and a fusiform aneurysm at the left common iliac artery. Two small right renal arterial aneurysms were also noted. The large aneurysm was partially resected and a Gore-Tex vascular graft was placed at 15 days old. Histopathology of the aneurysmal wall revealed no specific etiology. Ultrasonography revealed thrombosis of the graft on the 13th day after surgery. Results: Repeated CTA of the abdominal aorta at age 13 mo showed complete thrombosis of the graft with reconstitution of collateral circulation. The infrarenal AAA and left common iliac aneurysm and 2 small right renal artery aneurysms were completely thrombosed. The patient grew and developed normally to the most recent follow up at age 36 mo. Conclusions: Congenital AAA with failure of graft replacement may regress spontaneously. Keywords: Abdominal aortic aneurysm, neonate, aortic aneurysm, idiopathic abdominal aortic aneurysm, neonatal abdominal aortic aneurysm, pulsatile abdominal mass

A Rare Complication of a Retained Wire during Endovascular Abdominal Aortic Aneurysm Repair

We present a case of a high-risk 76-year-old man who was electively admitted for repair of a large infrarenal abdominal aortic aneurysm. After placement of the main body of the bifurcated graft, the contralateral guidewire became entrapped at the level of suprarenal fixation. Multiple endovascular maneuvers were attempted to remove this wire from the femoral approach, but all were unsuccessful. The wire was then transected at the level of the common femoral artery and anchored to the arterial wall with 1 small monofilament suture. A short bare stent was also used to secure this wire to the inner wall of the external iliac artery. However, the proximal end of the wire that extended freely up to the mid-descending aorta was left undisturbed. On postoperative day 2, an attempt at snaring the proximal end of the wire via a brachial approach also failed to displace the trapped wire. At 1-year of follow-up, the patient has been asymptomatic with no obvious sequelae, such as thromboembolism or aortic dissection, and there is no evidence of damage to the aorta or graft on computed tomographic imaging. To our knowledge, this complication has not been previously reported.

Hemolytic Hyperbilirubinemia After Percutaneous Device Closure of Left Ventricular Pseudoaneurysm: A Disregarded Complication

Surgical repair of a left ventricular pseudoaneurysm is challenging. Percutaneous closure with an AMPLATZER Septal Occluder (AGA Medical Corporation, Golden Valley, MN) has evolved to be an effective alternative to conventional surgery with less complication. We report a case of severe hemolytic hyperbilirubinemia and acute renal failure after percutaneous left ventricular pseudoaneurysm endoprothesis repair, which required conventional surgical repair through a left thoracotomy to treat this complication. The rationale and results of such an off-the-label usage of AMPLATZER Septal Occluder were reexamined. Residual leakages were not rare findings in the reviewed literature. The indications for this approach should be individualized.

High output cardiac failure and paradoxical pulmonary emboli secondary to aortocaval fistula

We present images of a rare, potentially fatal but treatable complication of abdominal aortic aneurysms (AAAs). An 81-year-old man was admitted with breathlessness on mild exertion, leg swelling and a...

Cutaneous cholesterol embolization syndrome: A case report

An 81-year-old woman with chronic kidney disease, systemic hypertension, and a large infra-renal abdominal aortic aneurysm, developed bilateral calf muscle pain, altered sensorium, and deterioration of renal function following endovascular aneurysmal repair. On the third post-operative day she developed symmetrical purpuric macules with erythematous margins on the gluteal region and bluish reticulated patches on the soles and tips of toes. This was followed by melena development on the seventh post-operative day. Histology of the skin confirmed the diagnosis of cutaneous cholesterol embolization syndrome (CES). She was treated with hemodialysis and supportive management and she recovered.

The fate of patients referred to a specialistvascular unit with large infra-renal abdominalaortic aneurysms over a two-year period

The fate of patients referred to a specialistvascular unit with large infra-renal abdominalaortic aneurysms over a two-year period

The Fate of Patients Referred to a Specialist Vascular Unit with Large Infra-renal Abdominal Aortic Aneurysms over a Two-year Period

Introduction: The basic premise in managing patients with abdominal aortic aneurysms (AAA) must be to reduce overall mortality from the disease. Operative mortality is widely reported, but data on patients deemed unsuitable for repair are scarce. The purpose of the present study was to report the fate of patients referred with AAA, to define the proportion deemed unsuitable for surgery and to investigate the reasons for conservative treatment. Methods: All patients who were referred to a regional vascular centre with large (>5.5 cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classified into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplan–Meier analysis. Multivariate analysis investigated factors leading to non-operative management. Results: 251 patients with a mean (s.d.) age of 75(8) years were assessed. Thirty-two (13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251 (87%) patients underwent repair (25/251 (10%) open repair 194/251 (77%) EVAR) with 1/219 (0.5%) 30-day mortality. AAA repair was associated with significantly greater survival (p < 0.001, log-rank test) at 2 years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were significant predictors of the decision to treat patients conservatively (p < 0.001). Conclusion: Most patients were suitable for surgical intervention with low perioperative mortality. Data on “turndown” rates should be routinely reported to quantify the denominator for operative success.

The Fate of Patients Referred to a Specialist Vascular Unit with Large Infra-renal Abdominal Aortic Aneurysms over a Two-year Period

Introduction The basic premise in managing patients with abdominal aortic aneurysms (AAA) must be to reduce overall mortality from the disease. Operative mortality is widely reported, but data on patients deemed unsuitable for repair are scarce. The purpose of the present study was to report the fate of patients referred with AAA, to define the proportion deemed unsuitable for surgery and to investigate the reasons for conservative treatment. Methods All patients who were referred to a regional vascular centre with large (>5.5 cm) infra-renal AAA between 1st January 2008 and 31st December 2009 were included. Patients were classified into two groups; those managed non-operatively, or those offered elective repair. Survival was reported by Kaplan–Meier analysis. Multivariate analysis investigated factors leading to non-operative management. Results 251 patients with a mean (s.d.) age of 75(8) years were assessed. Thirty-two (13%) patients were deemed unsuitable for repair, mostly because of medical co-morbidity (16/32). 219/251 (87%) patients underwent repair (25/251 (10%) open repair 194/251 (77%) EVAR) with 1/219 (0.5%) 30-day mortality. AAA repair was associated with significantly greater survival ( p < 0.001, log-rank test) at 2 years. In multivariate analysis Glasgow Aneurysm Score, female gender and respiratory disease were significant predictors of the decision to treat patients conservatively ( p < 0.001). Conclusion Most patients were suitable for surgical intervention with low perioperative mortality. Data on “turndown” rates should be routinely reported to quantify the denominator for operative success.

Obstructive uropathy due to inflammatory abdominal aortic aneurysm occurring 18 years after surgical repair of an atherosclerotic aneurysm.

Sir, Chronic periaortitis has a wide range of causes [1]. Obstructive uropathy associated with chronic periaortitis complicating abdominal aortic aneurysm (AAA) repair is well recognized and tends to occur early within 12 months of AAA repair. It is unusual for this to occur many years after surgery. A 71-year-old male was referred to the renal team after an emergency hospital admission by the medical team with acute kidney injury. Serum creatinine was 774 µmol/L (eGFR 7 mL/min/L), having been 140 µmol/L (eGFR 47 mL/min/L) 4 months previously. There was history of an atherosclerotic AAA open repair with an aortic graft in 1990. In 1994, the patient had a surgical exploration and evacuation for retroperitoneal haematoma. In 1995, the patient underwent surgical repair for leaking AAA. The proximal half of the graft was resected and replaced with a second Gelsoft graft (rifampicin soaked). In September 2008, the patient was admitted to our hospital with malaise, anorexia and oliguria. On examination, there was a pulsatile abdominal mass just lateral (left) to his midline laparotomy scar. An abdominal CT scan showed a large infrarenal AAA measuring 9.2 cm. The right kidney was of normal size but severely hydronephrotic with a hydroureter extending down to the level of the aortic bifurcation. The left kidney was small and also hydronephrotic (Figure 1). There was extensive fibrosis noted at the level of the aortic bifurcation associated with obstructive uropathy (Figure 2). Fig. 1 Bilateral hydronephrotic kidneys. Fig. 2 A large infrarenal abdominal aortic aneurysm with extensive fibrosis. The patient remained hypotensive with a poor urine output. He subsequently deteriorated and died 4 days after admission. Early hydronephrosis developing within the first year occurs in 10–20% of patients following surgical graft repair of AAA. The most probable cause for this is mechanical due to the compression of the ureter against the native iliac artery from the anteriorly placed graft [2]. In a prospective study of 101 patients who underwent aortofemoral and aortoiliac reconstructive surgery, 12% of patients developed mild to moderate hydronephrosis. All patients were asymptomatic, and the obstruction resolved spontaneously in 10 of 11 patients within 3 months of onset. The incidence of delayed hydronephrosis occurring 1 year or more post surgical repair is unknown. This complication may be relatively common after reconstructive vascular surgery as in our patient, especially in association with infected grafts [3]. The mechanism for the development is not fully understood. The most widely held view is that this complication develops secondary to an inflammatory process causing fibrosis [4]. The long time interval is unusual and suggests perhaps a different mode of inflammatory pathways compared to what is commonly seen in early obstructive uropathy associated with surgical graft repair of AAA. More research is needed to elucidate the mechanisms underlying chronic periaortitis [5]. Conflict of interest statement. None declared.

Testicular infarction: A rare complication of endovascular aneurysm repair treatment for aortoiliac aneurysm

Endovascular aneurysm repair (EVAR) is an established therapy to prevent rupture in large infrarenal abdominal aortic aneurysms (AAA). As experience with this therapy has grown, treatment of more challenging anatomy has led to the identification of several new procedurally related complications. We report the case of a 67-year-old man with an asymptomatic, large infrarenal AAA with an associated left common iliac artery aneurysm. Endovascular therapy for an aortoiliac aneurysm involved prior coil embolization of his left internal iliac artery to allow conventional EVAR with extension to the external iliac artery of the left graft limb, thus excluding the left iliac aneurysm. He presented 6 weeks postoperatively with onset of left-sided scrotal pain and underwent emergency orchidectomy for ischemic infarction of his left testis. The histology report confirmed that the left testis was necrotic secondary to a thrombus in the testicular artery. To our knowledge, this is the first report of testicular infarction after EVAR.

Transient Ischemic Attack in an Elderly Patient: What to Expect?

A 77-year-old man presented with an episode of facial droop, confusion, and profuse sweating that resolved en route to the emergency department. A computed tomography scan of the abdomen was ordered when on physical examination a palpable, pulsatile abdominal mass was noted. Computed tomography scan revealed a large infrarenal abdominal aortic aneurysm (AAA) with peripheral thrombus and a small, contained leak (Figure 1).

Abdominal aortic aneurysm: A Surgical Cause For Isolated Thrombocytopenia And Easy Bruising

Most causes of thrombocytopenia are non-surgical and are managed medically. However, surgical causes should not be overlooked. We report an eighty-year-old male patient who presented with easy bruising because of thrombocytopenia. Evaluation showed a large infra-renal abdominal aortic aneurysm with associated iliac aneurysm. Surgical repair of the aneurysms resolved the thrombocytopenia. Abdominal aortic aneurysm should be considered in evaluating elderly patients with easy bruising and/or thrombocytopenia.

Large infra-renal abdominal aortic aneurysms: endovascular vs. open repair - single centre experience

Endovascular aneurysm repair (EVAR) has become an established alternative to open repair (OR). We present a consecutive series of 486 elective patients with large infra-renal aortic abdominal aneurysm, comparing OR with EVAR. Prospective data collected during an 8-year period from January 1997 to October 2005 was reviewed. Statistical analysis performed using SPSS data editor with chi(2) tests and Mann-Whitney U-tests. There were 486 patients with 329 OR (293 males, 36 females) with median age of 72 years with median diameter 6.3 cm and 157 EVAR (148 males, 9 females) with median age 75 years with median diameter 6.1 cm. Mortality was 13 (4%) for OR and 5 (3.2%) for EVAR (three of whom were in the UK EVAR 2 trial). Blood loss was significantly less for EVAR 500 ml vs. 1500 ml for OR. Sixty-five (19.8%) patients with OR had significantly more peri-operative complications compared with 14 (8.9%) with EVAR. The length of stay in hospital was significantly less for EVAR. This non-randomised study shows that although EVAR does not have a statistically significantly lower mortality, it does have statistically significantly lower complication rates compared with OR. EVAR can be achieved with good primary success, but long-term follow-up is essential to assess durability.

Endovascular abdominal aortic aneurysm repair: Long-term outcome measures in patients at high-risk for open surgery

The study was conducted to determine the outcome in the United States after endovascular repair (EVAR) of infrarenal abdominal aortic aneurysms (AAAs) in patients at high-risk for open surgery by using independently audited, high-compliance, chart-verified data sets, and to compare those results with open surgery. High-risk was defined to match a recent European trial (EVAR2) and included age of > or =60 years with aneurysm size of > or =5.5 cm, plus at least one cardiac, pulmonary, or renal comorbidity. Data from five multicenter investigational device exemption clinical trials leading to Food and Drug Administration (FDA) approval were analyzed. Of 2216 EVAR patients, 565 met the high-risk criteria. Of 342 surgical controls (OPEN), 61 met high-risk criteria. Primary outcome comparisons included AAA-related death, all-cause death, and aneurysm rupture. Secondary measures were endoleak, AAA sac enlargement, and migration. Average age of the high-risk EVAR subset was 76 +/- 7 years vs 74 +/- 6 years OPEN (P = 0.07), mean EVAR AAA size was 6.4 +/- 0.8 cm vs 6.6 +/- 1.0 cm OPEN (P = .33), and average EVAR follow-up was 2.7 years vs 2.5 years OPEN. The 30-day operative mortality was 2.9% in EVAR vs 5.1% in OPEN (P = .32). The AAA-related death rate after EVAR was 3.0% at 1 year and 4.2% at 4 years compared with 5.1% at both time points after OPEN (P = .58). Overall survival at 4 years after EVAR was 56% vs 66% in OPEN (P = .23). After treatment, EVAR successfully prevented rupture in 99.5% at 1 year and in 97.2% at 4 years. Endovascular repair of large infrarenal AAAs in anatomically suited high-surgical-risk patients using FDA-approved devices in the United States is safe and provides lasting protection from AAA-related mortality. EVAR mortality remained comparable with OPEN up to 4 years. The decision to treat AAAs in patients with advanced age and significant comorbidities must be individualized and carefully considered, but repair provides excellent protection from AAA-related death.

Diagnosis and management of type 2 endoleaks after endovascular aneurysm repair

Endovascular repair is a major treatment advance in patients with large infrarenal abdominal aortic aneurysms. Since the FDA approved two commercial devices 2.5 years ago, over 40,000 patients have undergone this procedure in the United States. Although we have learned a great deal, more than a few mysteries relating to the long-term performance of these devices remain. This results in never-ending surveillance protocols searching for graft failure and aneurysm expansion. One of the especially contentious issues is the management of type 2 endoleaks. Unlike other endoleaks that are related to problems with the graft and/or fixation, this type of leak occurs in patients with properly functioning devices. This is why so much controversy exists about whether or not these patients must be treated. Some advocate “watchful-waiting” intervention only when there is aneurysm expansion.1 Others routinely treat patients with type 2 endoleaks in an attempt to prevent expansion.2–4 As with most controversial topics, if you look carefully, there is more agreement than disagreement between the two groups. In this review, we will first describe the methods used for endoleak diagnosis and treatment. We will then review our current endoleak treatment algorithm and explain its rationale for use.