Standard Open Repair Research Articles

Anesthésie et réanimation pour chirurgie réglée de l'anévrisme de l'aorte abdominale

Objectives. – Patient scheduled for infrarenal abdominal aortic aneurysm surgery carries a high risk of cardiac or respiratory comorbidity. To outline the perioperative management for these patients. Methods. – Review of the literature using MesH Terms “abdominal aortic aneurysm”, “anesthesia”, “analgesia” “critical care” and/or “surgery” in Medline database. Results. – Cardiac preoperative evaluation and management have recently been reviewed. Intermediate and high-risk patients should undergo non-invasive cardiac testing to decide between a preoperative medical strategy (using betablocker ± statin and aspirin) and an interventional strategy (coronary angioplasty or cardiac surgery). Perioperative myocardial ischaemia should also be investigated by clinical, electrocardiographic and biologic monitoring such as plasmatic troponin Ic dosage. Specific score could also assess the respiratory failure risk preoperatively. Epidural analgesia decreases this risk. There is no evidence that a pharmacological treatment decreases the incidence of acute renal failure after aortic surgery. Endovascular repair is actually recommended for older, higher-risk patients or patients with a hostile abdomen or other technical factors that may complicate standard open repair.

Multi-institutional Pivotal Trial of the Zenith TX2 Thoracic Aortic Stent-Graft for Treatment of Descending Thoracic Aortic Aneurysms: Clinical Study Design

Despite significant improvements in surgical techniques and perioperative management, the repair of descending thoracic aortic aneurysms remains a challenge with the potential for substantial morbidity and mortality. Over the past several years, buoyed by the technical success of endovascular repair of infrarenal abdominal aortic aneurysms, several case series reports of endovascular stent-graft placement for descending thoracic aortic aneurysms have demonstrated the potential safety and efficacy of this treatment modality. Several single-institution studies have documented promising results with these devices, but without controlled clinical trials, the data are insufficient to determine if thoracic aortic endografts provide equivalent or improved outcomes compared with standard open repair. We describe a study design of an ongoing prospective, nonrandomized, multi-institutional, investigational device exemption phase II pivotal clinical trial investigating the safety and effectiveness of the Zenith TX2 thoracic aortic endovascular graft in the elective treatment of patients with descending thoracic aortic aneurysms.

Outcomes of Hemodialysis-Dependent Patients Following Elective Abdominal Aortic Aneurysm Repair

As hemodialysis-dependent patients have a shorter life expectancy it has been recently questioned whether they benefit from procedures such as abdominal aortic aneurysm (AAA) repair. The purpose of this study was to review our results with elective AAA repair in hemodialysis-dependent patients. During a recent 6-year period (1998-2003), 7 such patients underwent elective repair of their infrarenal aortic aneurysms. Mean age and aneurysm diameter were 71 years and 69 mm, respectively. Mean length of stay was 28.6 days including routine intensive care unit admission. Three patients underwent standard open repair, and 3 underwent endovascular repair. In the seventh patient iliac calcification precluded endograft delivery and resulted in conversion to open repair. Another endovascular patient suffered from perforation of her sigmoid colon. One- and 3-year survival rates in the entire cohort were 100% and 75%, respectively. The authors conclude that aneurysm repair in hemodialysis patients is warranted and life prolonging in appropriate risk patients, despite lengthy hospital stays. However, successful endovascular repair may be prevented by the severe arterial calcification in these patients.

Tissue Adhesives for Repairing Inguinal Hernia: A Preliminary Study

To investigate the efficacy of tissue adhesives for closing the orifice of the inguinal hernia sac (IHS) as an alternative method for treating inguinal hernia. Five-week-old male Lewis rats (n=4) were used, because Lewis rats have a large patent IHS. The rats were divided into 9 groups (n=6 in each) according to the type of tissue adhesive used: G1, fibrin glue (Beriplast); G1b, Beriplast plus blood; G2, microfibrillar collagen hemostat (Avitene); G2b, Avitene plus blood; G3, fibrinogen-based sealant (TachoComb); G3b, TachoComb plus blood; G4, synthetic absorbable sealant (Advaseal); G5, bilateral single port laparoscopic injection of octylcyanoacrylate (Dermabond); and G6, sham operation (control group). In G1-G4, surgery was performed through a midline lower abdominal incision. In G5, a 5-mm laparoscope was inserted in the epigastrium, a fine catheter was passed through the side port of the laparoscope into the right HIS, and 0.2 mL Dermabond was injected. The left IHS was treated in the same way. All rats were sacrificed 3 months after treatment, and IHS patency was examined macroscopically. All rats in G5 and G6 were mated 50 days after treatment to check fertility. All rats survived until sacrifice. At sacrifice, all IHS were patent in G6. All IHS were also patent in G1-G4, but all IHS were closed at the internal ring in G5. In G5 there were no adhesions between the orifice of the closed sac and the small bowel in 5/6, and only minor adhesions in 1/6. G5 fertility (5/6: 83%) was the same as for the control group (G6). Our results suggest that laparoscopic injection of Db into the IHS is simple, safe, reliable, virtually scarless, and may be a reasonable alternative to standard open surgical inguinal hernia repair.

Subcutaneous endoscopically assisted ligation (SEAL) of the internal ring for repair of inguinal hernias in children: a novel technique

Subcutaneous endoscopically assisted ligation (SEAL) is a technique for high ligation of the patent processus at the internal ring without a groin incision or dissection of the vas and vessels. Under endoscopic visualization through a single umbilical port, a suture is guided extraperitoneally around the internal ring, avoiding the vas and vessels. The safety, efficacy (recurrence risk), and cost-effectiveness of this unproven procedure must be tested against standard open repair in a trial.

Endovascular Management of Isolated Axillary Artery Aneurysm

The purpose of this paper is to report a case of axillary artery aneurysm, successfully treated by percutaneous transfemoral self-expandable polytetrafluoroethylene (PTFE) covered Wallgraft stent. A 20-year-old man presented with sudden-onset, severe aching pain of left upper limb that occurred while doing isometric exercise. He had feeble left brachial and radial pulses. Angiography revealed a 21 x 14 mm left axillary artery aneurysm with a 15 mm neck. There was an organized clot in the midpart of the left brachial artery. The aneurysm was successfully closed with a self-expandable 10 x 30 mm Wallgraft endoprosthesis PTFE graft stent, via the right femoral route. A check angiogram at 6 weeks of follow-up showed a patent stent with no endovascular leak. At 1 year of follow-up, the patient was asymptomatic with normal upper limbs pulsations. Axillary artery aneurysm may be treated with a stent graft, which is an effective, rapid, and definite treatment and is an acceptable alternative to standard open surgical repair.

An Analysis of Standard Open and Endovascular Surgical Repair of Abdominal Aortic Aneurysms in Octogenarians

While elective open abdominal aortic aneurysm (AAA) repair has been shown to be safe in selected octogenarians, very little is known about the role of endovascular AAA exclusion in this high-risk cohort. A retrospective review of our vascular surgical registry from January 1996 to December 2001 revealed 51 octogenarians that underwent infrarenal AAA repair. Since 1999 all octogenarians who presented for AAA repair were evaluated for preferential endovascular stent graft placement. Over the 6-year period, 35 patients underwent standard open repair while 16 patients were found to be anatomic candidates for and were treated with an endovascular stent graft. Hospital and office charts were reviewed to compare the endovascular cohort to the standard open cohort. Factors considered included patient comorbidities, perioperative data, and operative outcomes. Statistical analysis was done using Wilcoxon rank sum test and Fisher exact test. The median age for the entire group was 83 years. There were 11 females in the open group and 1 female in the endovascular group. There were no statistically significant differences in preoperative patient comorbidities between groups. Total mortality for the entire series was 11.8 per cent but this included 5 ruptured AAAs, all of which patients died, and 11 additional AAAs that were symptomatic, of which 1 patient died. Total nonruptured mortality for the entire series was 2.2 per cent (0% for the endo-group and 3.3% for the open group). There were statistically significant differences between the endovascular versus the open groups when comparing aneurysm diameter (5.6 cm vs. 6.2 cm; P = 0.016), estimated blood loss (225 cc vs. 2100 cc; P < 0.001), ICU days (0 vs. 3; P < 0.001), length of hospital stay (2 days vs. 12 days; P < 0.001), and patients with blood transfusions (1 vs. 27; P < 0.001). When comparing postoperative morbidities, 4 of the endovascular patients (25%) and 25 of the open patients (68.6%) had a complication (P = 0.006). In conclusion, endovascular stent graft treatment of nonruptured infrarenal AAAs in octogenarians led to significantly better outcomes and should probably be considered the preferred treatment whenever anatomically appropriate. Endovascular exclusion of ruptured AAAs may potentially improve future outcomes in this high-risk group.

Treatment of ruptured abdominal aneurysms with stent grafts: a new gold standard?

Ruptured abdominal aortoiliac aneurysms, when treated with open surgical repair, have high morbidity and mortality rates. Since 1994, the authors have used endovascular approaches to treat this entity. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guide wire into the supraceliac aorta, and arteriography. If aortoiliac anatomy was suitable, an endovascular graft (stent-graft) repair was performed. If the anatomy was unfavorable, standard open repair was performed. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 35 patients treated in this manner, 29 underwent endovascular graft repair, and 6 required open repair. Four patients died within 30 days (operative mortality rate, 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. The authors believe these techniques will become widely used for the treatment of ruptured aneurysms.

A comparison of 50 initial endoluminal endograft repairs for abdominal aortic aneurysm with 50 concurrent open repairs

Purpose To review the results of our initial experience with endovascular repair of abdominal aortic aneurysm (AAA) with respect to morbidity and mortality and to compare these outcomes with those of transabdominal repair. Methods We reviewed the first 50 consecutive endovascular AAA repairs performed at our institution from November 1999 to January 2002. Pre-operative risk factors, intraoperative variables and post-operative outcomes were assessed. All endovascular patients were followed with periodic examination, contrast-enhanced computed tomography and/or duplex scanning. Comparison was made to 50 patients undergoing standard open repair over a similar time period. Results Fifty patients underwent endovascular AAA repair (mean age 72.5, AAA size 5.5 cm). Endovascular devices employed were manufactured by Ancure (Guidant Corp.), and AneuRx (Medtronic). Preoperative risk factors were similar to patients undergoing transabdominal repair. Mean operative time was 169 minutes and estimated blood loss was 450cc with average blood replacement of .18 units. Median ICU stay was 0 days and mean hospital stay was 2.3 nights. There were no conversions to open repair, however there was one aborted endovascular attempt. Morbidity included MI (2%), colon ischemia (1%), acute renal insufficiency (4%) and leg ischemia (4%). There was one death within 30 days. Seven endoleaks were identified (6 type II and 1 type I) and were managed angiographically. Conclusions The short-term surgical morbidity and mortality rates for endovascular repair of AAA are acceptably low and are comparable to the transabdominal approach.

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.

Endovascular Treatment of Failed Prior Abdominal Aortic Aneurysm Repair

Failure of endovascular or conventional abdominal aortic aneurysm (AAA) repair may occur as a result of attachment site endoleak (type I) or paraanastomotic aneurysm and pseudoaneurysm formation. This study examined the results of the use of secondary endovascular grafts for the treatment of failed prior infrarenal AAA repair procedures. Forty-seven patients were treated with endovascular grafts. These included 14 patients with type I endoleaks (5 proximal, 8 distal, 1 proximal and distal) and 33 patients with paraanastomotic aneurysms after standard open surgical AAA repair (3 proximal aorta, 5 distal aorta, 21 iliac, 4 proximal and distal). The interval between the primary aortic procedure and the endovascular repair was significantly shorter for failed endovascular procedures (mean, 18.2 months; range, 1-42 months) than for failed conventional procedures (mean, 108.9 months; range, 12-216 months) (p <0.01). The endovascular devices used for correction of the failed AAA repairs were Talent (23), physician-made (19), AneuRx (2), Vanguard (2), and Excluder (1). Transrenal fixation was used for repair of all proximal anastomotic failures. Mean follow-up after reintervention was 12.2 months in patients with failed endovascular grafts and 10.6 months in patients with failed conventional grafts. Patient demographics were as follows: average age, 78 years; 36 male and 11 female; and 4.1 comorbid medical conditions per patient. The endovascular graft was successfully deployed in all 47 cases; 1 patient experienced a persistent proximal attachment site endoleak after endograft deployment. Endovascular grafts may be used to treat previously failed endovascular and conventional AAA repair procedures with good short- and intermediate-term results. Endovascular treatments in these cases may avoid the difficulties of aortic reoperation or AAA repair in the setting of prior endovascular aortic grafting.

Laparoscopic repair of large incisional hernias.

Traditional approaches to incisional hernias (IH)--particularly in cases with large fascial defects--are plagued by a significant recurrence rate as well as frequent wound infections. The laparoscopic repair of incisional hernias was designed to offer a minimally invasive and tension-free technique that yields less morbidity and fewer recurrences than the standard open repair. Several years ago, we adopted the laparoscopic technique in our department and set out to appraise its touted advantages. During the years 1997-2000, 103 patients underwent laparoscopic IH repair with implanted Dual Gore-tex mesh. Forty percent of them were obese, and 41% had undergone more than one previous attempt at conventional repair. All patients were discharged home within 24-72 hs. In three patients, the operation was converted to open surgery due to severe adhesions and technical difficulties. In two cases, inadvertent enterotomies were repaired laparoscopically, and since there was no major spillage, the repair was continued as planned, with no adverse consequences. Twelve patients underwent additional laparoscopic procedures at the initial operation. Two graft infections and four recurrences were observed during the 1-49 month follow-up period. Laparoscopic IH repair is technically feasible and safe in patients with large fascial defects as well as in obese patients. This operation decreases postoperative pain, hastens the recovery period, and reduces postoperative morbidity and recurrence.

Abdominal Aortic Aneurysmorrhaphy and Cholelithiasis in the Era of Endovascular Surgery

The incidence of acute cholecystitis complicating standard abdominal aortic aneurysm (AAA) repair has been reported between 0.3 and 18 per cent. This has prompted considerable debate regarding the management of cholelithiasis discovered incidentally during open aortic reconstruction. This study seeks to determine the incidence of cholelithiasis and acute cholecystitis after endovascular AAA repair and evaluate options for management. Between February 1996 and October 2001 492 patients underwent endovascular AAA repair. All the procedures were performed in the operating room under fluoroscopic guidance. Epidural (98.9%), local (0.5%), or general (1.7%) anesthesia was used during these cases. The incidence of cholelithiasis and acute cholecystitis was evaluated by CT scan and abdominal ultrasound. Serum measurements of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total and direct bilirubin, and amylase were performed and clinical assessment was conducted at 1, 6, and 12 months postoperatively and annually thereafter. The mean age of these patients was 76.6 years; 84% were male. Comorbid medical conditions were present in all patients (average 3.5 conditions/patient). Follow-up ranged from 2 to 35 months (mean 12.8 months). Endovascular stent graft deployment was successful in 486 of the 492 patients (98.8%). Six patients were converted to standard open repair because of inability to achieve successful endovascular aneurysm repair. The perioperative major morbidity rate was 14.9 per cent. Minor morbidity rate was 8.5 per cent. The perioperative mortality rate was 1.9 per cent. No deaths were related to biliary disease. Cholelithiasis was identified in 64 (13%) patients preoperatively. One of 64 patients with a prior Billroth II reconstruction for peptic ulcer disease developed jaundice 8 days after AAA repair as a result of choledocholithiasis that required surgical repair. One patient without gallstones developed acute acalculous cholecystitis on postoperative day 16 as determined on pathologic analysis of the gallbladder. A third patient who had gallstones identified on preoperative CT scan developed calculous cholecystitis 16 months after endovascular AAA repair. These two patients underwent uncomplicated laparoscopic cholecystectomy and recovered uneventfully. The incidence of postoperative symptomatic cholelithiasis is 1.6 per cent (one of 64). The incidence of postoperative acute cholecystitis was 0.2 per cent (one of 486) and was unrelated to the presence of gallstones. The incidence of delayed symptomatic cholelithiasis was 1.6 per cent (one of 64). Endovascular repair of AAA does not appear to predispose the patient to the development of symptomatic cholelithiasis during the perioperative period. Therefore a preoperative or intraoperative diagnosis of cholelithiasis does not necessitate cholecystectomy in the setting of planned endovascular AAA repair. Patients who develop cholecystitis after endovascular AAA repair may be effectively treated by standard laparoscopic techniques.

Minimal incision aortic surgery: a competitive alternative to endovascular and standard open aortic repair

Endovascular repair of aortic aneurysms (EVAR) has established an important role in the practice of vascular surgery. However, currently available devices have demonstrated unpredictable patterns of clinical and mechanical failure, raising valid concern about long-term durability. Alternative less invasive modifications of standard open repair, such as minimal incision aortic surgery (MIAS), provide important treatment alternatives for younger healthy patients and high-risk patients with aneurysms that do not qualify for EVAR because of anatomic limitations. MIAS is cost efficient, durable, requires no costly equipment, and can be performed by currently trained vascular surgeons.

Clinical failures of endovascular abdominal aortic aneurysm repair: incidence, causes, and management.

Despite well-documented good early results and benefits of endoluminal stent graft repair of abdominal aortic aneurysm (J Vasc Surg 2002;35:1137-44.)(AAA), the long-term outcome of this method of treatment remains uncertain. In particular, concern exists that late effectiveness and durability are inferior to that of open repair. To determine the incidence and causes of clinical failures of endovascular AAA repair, a 7-year experience with 362 primary AAA endografts was reviewed. Clinical failures were defined as deaths within 30 days of the procedure, conversions (early and late) to open AAA repair, AAA rupture after endoluminal treatment, or AAA sac growth of more than 5 mm in maximal diameter despite endograft repair. Endoleak status per se was not considered unless it resulted in an adverse event. If clinical problems arose but could be corrected with catheter-based therapies or limited surgical procedures, thereby maintaining the integrity of successful stent graft treatment of the AAA, such cases were considered as primary assisted success and not classified as clinical failures. The average follow-up period was 1.5 years. Six deaths (1.6%) occurred after the procedure, all in elderly patients or patients at high risk. Five patients (1.4%) needed early conversion (immediate, 2 days) to open repair for access problems or technical difficulties with deployment, resulting in an implantation success rate of 98.6%. Eight patients (2.2%) underwent late conversion for a variety of problems, including AAA expansion (n = 4), endograft thrombosis (n = 1), secondary graft infection (n = 2), and rupture at 3 years (n = 1). Rupture occurred in an additional two patients for a total incidence rate of 0.8%. AAA sac growth of greater than 5 mm was observed in 20 patients (5.6%), four of whom have undergone successful catheter-based treatments to date. Overall, 39 patients (10.7%) needed catheter-based (n = 45) or limited surgical (n = 4) reinterventions for a variety of late problems that were successful in 92%. In our 7-year experience, one or more clinical failures of endovascular AAA repair were observed in 31 patients (8.3%). Reinterventions were necessitated in a total of 10.7% of patients but were usually successful in maintaining AAA exclusion and limiting AAA growth. These results emphasize that endovascular repair provides good results and many benefits for most properly selected patients but is not as durable as standard open repair.

Endovascular repair of abdominal aortic aneurysms: risk stratified outcomes.

The impact of co-morbid conditions on early and late clinical outcomes after endovascular treatment of abdominal aortic aneurysm (AAA) was assessed in concurrent cohorts of patients stratified with respect to risk for intervention. As a minimally invasive strategy for the treatment of AAA, endovascular repair has been embraced with enthusiasm for all prospective patients who are suitable anatomical candidates because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. From April 1994 to March 2001, endovascular AAA repair was performed in 236 patients using commercially available systems. A subset of patients considered at increased risk for intervention (n = 123) were categorized, as such, based on a preexisting history of ischemic coronary artery disease, with documentation of myocardial infarction (60%) or congestive heart failure (35%), or due to the presence of chronic obstructive disease (21%), liver disease, or malignancy. Perioperative mortality (30-day) was 6.5% in the increased-risk patients as compared to 1.8% among those classified as low risk (P = NS). There was no difference between groups in age (74 +/- 9 years vs. 72 +/- 6 years; mean +/- SD), surgical time (235 +/- 95 minutes vs. 219 +/- 84 minutes), blood loss (457 +/- 432 mL vs. 351 +/- 273 mL), postoperative hospital stay (4.8 +/- 3.4 days vs. 4.0 +/- 3.9 days), or days in the ICU (1.3 +/- 1.8 days vs. 0.5 +/- 1.6 days). Patients at increased risk of intervention had larger aneurysms than low-risk patients (59 +/- 13 mm vs. 51 +/- 14 mm; P <.05). Stent grafts were successfully implanted in 116 (95%) increased-risk versus 107 (95%) low-risk patients (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3% and 5%, respectively. The initial endoleak rate was 22% versus 20%, based on the first CT performed (either at discharge or 1 month; P = NS). To date, increased-risk patients have been followed for 17.4 +/- 15 months and low-risk patients for 16.3 +/- 14 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P <.05, Mantel-Cox test). Both cohorts had similar two-year primary and secondary clinical success rates of approximately 75% and 80%, respectively. Early and late clinical outcomes are comparable after endovascular repair of AAA, regardless of risk-stratification. Notably, 2 years after endovascular repair, at least one in five patients was classified as a clinical failure. Given the need for close life-long surveillance and the continued uncertainty associated with clinical outcome, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair.

Efficacy of a bifurcated endograft versus open repair of abdominal aortic aneurysms: A reappraisal

Objective: Late complications and graft failures have recently cast serious doubts on the durability of endovascular repair of abdominal aortic aneurysms (AAA). The results of a multicenter trial comparing a bifurcated endograft (AB) with standard open repair (OR) were reviewed to assess the late findings of both methods of AAA treatment. Patients and Methods: In a multicenter study of AB versus OR conducted from December 1995 to February 1998, 242 patients with AAA successfully treated with an AB and 111 control patients treated concurrently with OR were followed up at least yearly. Twenty-five immediate conversions were excluded from late follow-up. All imaging modalities obtained during follow-up were reviewed by a core laboratory for AAA size, endoleaks, migration, and device integrity. Clinical outcomes at the yearly visits were compared. All death reports were reviewed to classify the cause of death. Results: Average follow-up for the AB group was 36 months, with 194 patients at 3 years and 55 patients at 4 years. The cumulative mortality rate was similar between the AB (15.7%) and OR groups (12.6%; P =.59). The significant early benefit to the AB group in cardiopulmonary complications was no longer evident by 3 years. However, the AB advantage in total and bowel complications, as well as the higher renal complication rates, persisted. At 3 years, 73.7% of patients showed a significant reduction of their AAA size, whereas 25.7% still had an endoleak. One migration and two single hook fractures were noted. Graftrelated reinterventions were performed in 50 patients (20%) without any deaths. Twenty-eight patients (11.6%) underwent interventions for limb flow compromise, whereas 25 were treated for endoleak. Late conversion to OR was required in five patients (2%). No AAA ruptures were encountered in either group. Conclusions: Rupture-free survival rates after treatment of AAA with the bifurcated AB are similar to those of the OR group. Notably the proximal attachment system is relatively stable and the AAA shrinks in three of four patients treated. Reinterventions are nonetheless required in nearly one of five patients. Although most late procedures are percutaneous, counseling regarding possible future interventions is necessary. (J Vasc Surg 2002;35:203-10.)

Minimal incision aortic surgery

Purpose: In this study we evaluated the clinical and economic impact of minimal incision aortic surgery (MIAS) for treatment of patients with abdominal aortic aneurysms (AAAs) and aortoiliac occlusive disease (AIOD). Method: Fifty patients with either AAA (34) or AIOD (16), prospectively treated with the MIAS technique, were compared with 50 patients (40 AAA and 10 AIOD) treated in the same time period with long midline incision and extracavitary small bowel retraction. MIAS was also compared with a cohort of 32 patients with AAA treated by means of endoaortic stent-grafts. Outcomes and cost (based on metric mean length of stay) were compared for the open and endoaortic techniques. Results: Patients who experienced no perioperative complications after the MIAS or endovascular repair technique had shorter hospital stays than patients with uncomplicated aortic repairs performed with a traditional long midline abdominal incision (3 days vs 3 days vs 7.2 days). Hospital stay was also significantly shorter for the less invasive procedures when perioperative complications were included (4.8 days vs 4.3 days vs 9.3 days). The MIAS and endovascular aortic repair groups had a shorter intensive care unit stay (≤ 1.0 day) and a quicker return to general dietary feeding (2.5 days) than patients treated with standard open repair (1.8 days, 4.7 days). The overall morbidity for the MIAS technique (14%) and endovascular technique (21%) was not significantly different from standard open repair (24%). The mortality rate for the different treatment groups was equivalent (MIAS, 2%; endovascular repair, 3%; standard repair, 2%). The MIAS was more cost-efficient than standard open repair ($12,585 vs $18,445) because of shorter intensive care unit and hospital stay and was more cost-efficient than endoaortic repair ($12,585 vs $32,040) because of reduced, direct intraoperative costs. Conclusions: MIAS is as safe as standard open or endovascular repair in the treatment of AAA and AIOD. MIAS is more cost-efficient than standard open or endoaortic repair. (J Vasc Surg 2001;34:47-53.)

Diameter changes in isolated iliac artery aneurysms 1 to 6 years after endovascular graft repair

Objective: Precise diameter changes in iliac artery aneurysms (IAAs) after endovascular graft (EVG) repair are yet to be determined. This report describes the midterm size changes in isolated IAAs 13 to 72 months after treatment with an EVG. Methods: From January 1993 to April 1999, 31 patients with 35 true isolated IAAs (32 common iliac and 3 hypogastric) had these lesions treated with EVGs and coil embolization of the hypogastric artery or its branches. The EVG used in this study consisted of a balloon-expandable stent attached to a polytetrafluoroethylene graft. Contrast-enhanced spiral computed tomographic scans were performed at 3- to 6-month intervals to follow the aneurysms for change in diameter and endoleaks. Results: Thirty patients had a decrease in the size of their iliac aneurysms with EVG repair. All EVGs remained patent. All patients, except for one, were followed up for 13 to 72 months (mean, 31 months). The pretreatment aneurysm size ranged from 2.5 to 11.0 cm in diameter (mean, 4.6 ± 1.62 cm). After EVG treatment, the aneurysms ranged from 2.0 to 8.0 cm in diameter (mean, 3.8 ± 1.36 cm). The change in aneurysm diameter ranged from 0.5 to 3.1 cm (mean, 1.1 ± 0.62 cm) with an average change of –0.516 ± 0.01 cm/y for the first year. Five patients died of their intercurrent medical conditions during the follow-up period. One of the patients had a new endoleak and an increase in common iliac aneurysm size 18 months after EVG treatment, despite an early contrast-enhanced computed tomographic scan that showed no endoleak. This patient's aneurysm ruptured, and a standard open surgical repair was successfully performed. Another patient had a decrease in hypogastric aneurysm size after EVG treatment and no radiographic evidence of an endoleak, but eventually the aneurysm ruptured. He was successfully treated with a standard open surgical repair. Conclusions: EVGs can be an effective treatment for isolated IAAs. Properly treated with EVGs, IAAs decrease in size. The enlargement of an IAA, even if no endoleak can be detected, appears to be an ominous sign suggestive of an impending rupture. IAAs that enlarge should be closely evaluated for an endoleak. If an endoleak is detected, it should be eliminated if possible. If an endoleak cannot be found, open surgical repair should be considered. (J Vasc Surg 2001;33:289-95.)

Mid-term results after endovascular repair of the abdominal aortic aneurysm

Purpose: As a minimally invasive strategy for the treatment of patients with abdominal aortic aneurysm (AAA), endovascular repair has been embraced with enthusiasm because of the promise of achieving a durable result with a reduced risk of perioperative morbidity and mortality. Our mid-term experience with endovascular AAA repair was assessed by examining early and late clinical outcome in concurrent cohorts of patients stratified either as low-risk or as at increased-risk for intervention. Methods: From April 1994 to December 1999, endovascular AAA repair was performed in 104 patients with commercially available systems. A subset of patients considered at increased risk for intervention (n = 51) were categorized as such based on a pre-existing history of ischemic coronary artery disease (73%), with documentation of myocardial infarction (57%) or congestive heart failure (29%), or because of the presence of chronic obstructive pulmonary disease, liver disease, or malignancy. Results: The perioperative mortality rate (30-day) was 7.8% for patients at increased risk compared with 1.9% among those classified as low-risk (P = NS). There was no difference between groups in age (72 ± 7 years vs 74 ± 7 years; mean ± SD), surgical time (221 ± 90 minutes vs 192 ± 68 minutes), blood loss (437 ± 402 mL vs 331 ± 238 mL), postoperative hospital stay (4.4 ± 2.7 days vs 4.2 ± 2.5 days), or days in the intensive care unit (1.2 ± 1.6 days vs 0.6 ± 1.3 days). Patients at increased risk of intervention had larger aneurysms than patients at low risk (58 ± 11 mm vs 52 ± 12 mm; P < .05). Stent grafts were successfully implanted in 47 (92%) patients at increased risk versus 50 (94%) patients at low risk (P = NS). Conversion rates to open operative repair were similar in increased-risk and low-risk groups at 3.9% and 5.7%, respectively. The initial endoleak rate was 21% versus 18% based on the first computed tomography performed (either at discharge or 1 month; P = NS). To date, patients at increased risk have been monitored for 14.6 ± 12.4 months, and patients at low risk have been monitored for 17.7 ± 15.0 months. Kaplan-Meier analysis for cumulative patient survival demonstrated a reduced probability of survival among those patients initially classified as at increased risk for intervention (P < .05, Mantel-Cox test). Both cohorts had similar 2-year clinical success rates of approximately 75%. Conclusion: Despite the use of an endovascular approach for aneurysm treatment, the risk of perioperative death and morbidity remains present for all patients including those who have no significant medical comorbidity. Moreover, although clinical success rates are comparable in both patient groups, 2 years after endovascular repair was performed, at least one in four patients was classified as a clinical failure. Given the continued uncertainty associated with clinical outcome and the need for close life-long surveillance, caution is dictated in advocating endovascular treatment for the patient who is otherwise considered an ideal candidate for standard open surgical repair. (J Vasc Surg 2001;33:S70-6.)