Treatment Of Aortic Aneurysm Disease Research Articles

Aortoiliac Calcification Correlates With 5-Year Survival After Abdominal Aorta Aneurysm Repair

Aortoiliac Calcification Correlates With 5-Year Survival After Abdominal Aorta Aneurysm Repair

The role of surgeon modified fenestrated stent grafts in the treatment of aneurysms involving the branched visceral aorta.

Acceptance of endovascular technology has followed a predictable pattern in the treatment of aortic aneurysm disease. Initially, endovascular aneurysm repair (EVAR) was used to treat infrarenal abdominal aortic aneurysms (AAA) only in patients deemed medically unsuitable for open surgical repair (OSR). With improvement in device design, increased operative experience and favorable mortality benefits in randomized control trials, EVAR is now the preferred method for treatment of AAA worldwide. As the results with OSR are even worse as one ascends the aorta into the visceral segment and above, it stands to reason that EVAR technology to accommodate the aortic branches should have a similar adoption in treatment of proximal AAA and thoraco-abdominal aortic aneurysm (TAAA) disease. The first devices trialed and approved for treatment of the visceral aorta are custom manufactured and have had excellent results in complex pathology. However, there are several temporal, engineering and anatomic limitations to custom, manufactured branched and fenestrated endografts. Surgeon modified endovascular aneurysm repair (SM-EVAR) is able to overcome many of these constraints and expands this technology to more patients with excellent short term results in select centers.

Role of Contrast-Enhanced Ultrasound in the Follow-up of Endo-Vascular Aortic Aneurysm Repair: an Effective and Safe Surveillance Method

The treatment of Aortic Aneurysm disease is a growing procedure due to increase of life expectancy in Western Countries and relative incidence. In the past ten years we observed a progressive growth of endovascular over open surgery procedures with a related decline in rupture related deaths. Endo Vascular Aortic Repair [EVAR] is a well known technique of treatment of abdominal aortic aneurysms, that has changed the surgical approach to abdominal aortic aneurysms, as it is performed with low perioperative morbility and mortality rate and shorter hospital stay. However although EVAR offers immediate advantages over open surgical repair, it carries the need of close lifelong surveillance due to specific possible complications including rupture, endoleaks, graft migration and enlargement of aneurysm sac size. Contrast Enhanced Computed Tomography [CTA] is actually considered the standard reference in EVAR followup. However CTA carries high costs, radiation exposure and potential renal impairment. In the last five years several studies have been published on the role of Contrast Enhanced UltraSound [CEUS] in EVAR follow-up asserting high accuracy of this evaluation technique with absence of renal impairment, without radiation risk and at low costs. Especially since introduction of second generation Contrast Agents this evaluation technique is gaining popularity in EVAR follow-up surveillance. The diffusion of CEUS investigations by using new generation of contrast medium with appropriate software represents without any doubt an important step in the EVAR surveillance and could open up new strategies in the evaluation of endovascular aortic procedures gaining a fundamental role in EVAR follow-up.

Fenestrated Endografts for Complex Abdominal Aortic Aneurysms

The treatment of aortic aneurysm disease using endovascular stent grafts has evolved over the past 20 years. Extending this approach to aneurysms involving the visceral aorta has required development of fenestrated endografts. By creating branches to accommodate visceral vessels, the proximal landing zone can be chosen based on the adequacy of the aortic wall, rather than the constraints of visceral vessels. This allows for a more stable repair, and permits a minimally invasive approach in even very complex aneurysms. As the technology becomes more widespread, the use of these grafts has emerged from an experimental form to standard of care in some jurisdictions. Thus, many patients who might have previously been considered high risk for aneurysm repair are now candidates for surgery. This article outlines the basic concepts behind the development of fenestrated endografts, their current use, and the future of the technology.

Minimally invasive cardiac surgery

Cardiac surgery has been the last of the surgical specialties to embrace the principles of minimal invasiveness. The complexity and invasiveness of the procedures have presented both a problem and an opportunity to make the procedures less invasive. Beginning with initial attempts at coronary artery bypass surgery through limited access with and without robotics, a number of other cardiac procedures currently are being performed by minimally invasive approaches. These include mitral valve repair, transapical aortic valve implant, limited access, and totally endoscopic pulmonary vein isolation for the treatment of atrial fibrillation and the treatment of aortic aneurysmal disease by thoracic endografting. The experience with less invasive surgery in other specialties has served as cross-fertilization for minimally invasive cardiac surgery.

Ten Years of Advancements in Interventional Cardiology

The past decade has seen the evolution of an exciting technology that has changed forever the treatment of aortic aneurysmal disease. From rather crude homemade stent-grafts constructed in the surgical suite to elegant commercially manufactured devices in a variety of configurations and sizes, the aortic endograft has experienced a meteoric rise in popularity to become a beneficial, minimally invasive therapy that can obviate the risk of rupture and death. There are now 3 approved endovascular devices on the market for infrarenal abdominal aortic aneurysm repair, and it is likely that additional and improved devices will become available in the future. This review revisits the developmental history of the aortic endograft, noting the ongoing refinements that have arisen from our experiences with the growing population of stent-graft patients. Although research continues to search for solutions to the problems of endoleak and migration, long-term results even with the earlier second and third-generation devices are better than has been achieved with open surgical repair.

Endograft Technology: Highlights of the Past 10 Years

The past decade has seen the evolution of an exciting technology that has changed forever the treatment of aortic aneurysmal disease. From rather crude homemade stent-grafts constructed in the surgical suite to elegant commercially manufactured devices in a variety of configurations and sizes, the aortic endograft has experienced a meteoric rise in popularity to become a beneficial, minimally invasive therapy that can obviate the risk of rupture and death. There are now 3 approved endovascular devices on the market for infrarenal abdominal aortic aneurysm repair, and it is likely that additional and improved devices will become available in the future. This review revisits the developmental history of the aortic endograft, noting the ongoing refinements that have arisen from our experiences with the growing population of stent-graft patients. Although research continues to search for solutions to the problems of endoleak and migration, long-term results even with the earlier second and third-generation devices are better than has been achieved with open surgical repair.

Endograft Technology: Highlights of the past 10 Years

The past decade has seen the evolution of an exciting technology that has changed forever the treatment of aortic aneurysmal disease. From rather crude homemade stent-grafts constructed in the surgical suite to elegant commercially manufactured devices in a variety of configurations and sizes, the aortic endograft has experienced a meteoric rise in popularity to become a beneficial, minimally invasive therapy that can obviate the risk of rupture and death. There are now 3 approved endovascular devices on the market for infrarenal abdominal aortic aneurysm repair, and it is likely that additional and improved devices will become available in the future. This review revisits the developmental history of the aortic endograft, noting the ongoing refinements that have arisen from our experiences with the growing population of stent-graft patients. Although research continues to search for solutions to the problems of endoleak and migration, long-term results even with the earlier second and third-generation devices are better than has been achieved with open surgical repair.

Early and Mid-term Results of Totally Laparoscopic Surgery for Aortoiliac Disease

The present article is the first in the literature reporting short- and medium-term results using a totally laparoscopic technique for aortoiliac disease.Forty-nine patients, 6 having an associated small aneurysm, were scheduled for totally laparoscopic surgery (TLS) for aortoiliac occlusive disease and 2 for treatment of aortic aneurysmal disease (AAA). Patients' characteristics, intraoperative, postoperative data and mid-term data were recorded.TLS was successfully completed in 45 patients. Of those patients, 41 received an aortobifemoral bypass; three, an iliofemoral bypass; and one, an aortoaortic bypass. Five patients were converted from TLS to video-assisted laparoscopic surgery using incisions varying in size from 7 cm to 11 cm. One patient underwent conversion to standard open surgery. One death occurred unrelated to the technique. Major perioperative complications related to the technique were few and presented in the early phase of the study: One intraoperative embolization to the lower limbs that needed embolectomy, and one acute aortic false aneurysm. Midterm results were favorable, demonstrating two limb graft thromboses. Hernias at trocar sites occurred in only 3.9%. The patients benefited from this procedure, which is considered definitive like its standard open counterpart. The conversion rate is lower than that reported for acute cholecystitis. Selection of patients has been less stringent during the second half of the study in term of inclusion of patients with AAA and of more TASC IV patients. Surgeons willing to learn this technique should attend dedicated courses. In the future, as this surgical innovation matures, controlled randomized studies should be initiated.

Development of a Transfemorally Delivered Endovascular Graft for Treatment of Aortic Aneurysms in a Canine Model

Advances in the treatment of atherosclerotic disease by transluminal angioplasty and intra-arterial stenting have led to the development of a transfemoral endovascular approach to the treatment of aortic aneurysmal disease. The authors investigated this technique using an endovascular graft employing self-expanding anchors for the exclusion of infrarenal aortic aneurysms. They investigated the technique of transfemoral endovascular aortic grafting in 13 male mongrel dogs weighing an average of 30 kg. Eleven animals had fusiform infrarenal aortic aneurysm models created. One week to three months after surgery all animals underwent midstream aortography under general anesthesia to examine aneurysm morphology. A 14 French catheter was introduced through the right common femoral artery, and under fluoroscopic guidance the endovascular graft was delivered in an infrarenal aortic position. Completion aortography was then performed to confirm placement. They tested two endovascular graft prototypes. The first employed a proximal anchor attached to the graft and a separately delivered distal anchor. Successful graft delivery was achieved in five of six attempts. Unsuccessful graft delivery occurred in 1 case because of an inability to negotiate aneurysm tortuosity. After delivery graft twisting occurred in 1 case and graft invagination occurred in 2 others upon the attempt to deliver the distal anchor. Successful exclusion was achieved in 3 of 4 remaining cases with an aneurysm model using this prototype. The second prototype employing proximal and distal anchors attached to the graft was successfully deployed in seven of seven attempts. Successful aneurysm exclusion was achieved in 5 of these 7 cases. Failure to exclude the aneurysm neck occurred in 2 cases. In this preliminary study the authors found the concept of endovascular delivery of a self-anchoring tube graft to be feasible. The optimal delivery system is flexible and possesses a small outer diameter to allow a transfemoral approach through moder ately tortuous iliac arteries. Accurate delivery is aided by intermittent fluoroscopic examination. Doubly anchored grafts are necessary to ensure aneurysm exclusion and prevent graft twisting. Self expanding anchors allow simple endovascular graft deploy ment in a single pass. Continued animal investigation into the fate of aortic side branches, distal embolization, and graft migration is necessary to ensure the eventual success of this technique.