Treatment Of Infrarenal Aortic Aneurysms Research Articles

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Treatment of infrarenal aortic aneurysm by minimally invasive retroperitoneal approach: Use of a video-assisted technique

We propose a technique for treating abdominal aortic aneurysm in which first a minilaparotomy (retroperitoneal) is performed to make a conventional arterial dissection; then, video assistance is used to control the left lumbar arteries and to make the aortic anastomosis. This technique can be performed with no significant laparoscopic capability.The patient was installed in a 20-degree right lateral decubitus. A transverse left 8- to 10-cm abdominal incision was made, followed by separation of the muscular structures. Retroperitoneal control of the proximal aortic neck and of both common iliac arteries was obtained by digital and instrumental dissection. A 30-degree laparoscope was then introduced through a 8- to 12-mm trocar and provided the light and magnification that facilitated the dissection of the posterior wall of the aortic neck and of the left flank of the aneurysm, looking for the lumbar arteries to be clipped. A suspended running suture to make the aorto-prosthetic anastomosis was facilitated by the magnification of the camera, especially during the passage of needles. Between March and September 2001, 32 patients fulfilled the anatomic conditions: an infrarenal aortic neck length of 2 cm or more, absence of hypogastric artery aneurysm, and no need for inferior mesenteric artery reimplantation. In 30 patients, the surgery was performed by using the planned minimally invasive approach, and extension of the incision was necessary in two patients.

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.

Renal function after aortic stent-grafting including coverage of renal arterial ostia

Considerable experience has been gained with endoluminal stent-graft techniques for the treatment of infrarenal aortic aneurysms. The inclusion of uncovered suprarenal stents eases the treatment of cases with a short, angulated, or bottlenecked proximal neck. However, few data have been published on the effect of a stent-graft crossing renal artery ostia on long-term renal function. We therefore retrospectively analyzed the influence of intra-aortic stent-grafts, including suprarenal fixation on long-term renal function. Thirty-nine patients who received a Gianturco Z stent across renal artery ostia as part of a made-to-measure stent-graft treating an infrarenal aortic aneurysm were evaluated at 6 (all patients) and 30 months (15 patients) after surgery. Renal function evaluation included serum creatinine level, creatinine clearance using the Cockcroft-Gault formula, and renal tomography. Initial technical success was achieved in all patients. There were no minor or major complications. Mean serum creatinine levels were 1.16 ± 0.25, 1.12 ± 0.28, and 1.24 ± 0.25 mg/dL before and 6 and 30 months after endoluminal stent-graft performance, respectively (P = not significant [NS]). Mean creatinine clearances were 60.3 ± 19.7, 63 ± 23, and 60.6 ± 17.5 mL/min before and 6 and 30 months after endoluminal stent-graft performance, respectively (P = NS). Only two patients (5%) had a decrease in glomerular filtration rate greater than 20% at 6 months. Both patients had renal insufficiency before endovascular grafting. Renal function was stable in all patients at 30 months' follow-up. We suggest that renal function is unaffected by coverage of renal arterial ostia with Gianturco Z stents. © 2002 by the National Kidney Foundation, Inc.

Serious complications that require surgical interventions after endoluminal stent-graft placement for the treatment of infrarenal aortic aneurysms

Background: Endoluminal stent-graft placement for the treatment of infrarenal abdominal aortic aneurysms has gained widespread acceptance because it is associated with lower peri-interventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. Methods and Results: Between September 1994 and December 1998, 150 patients (age, 69.6 ± 8.49 years; 142 men, 8 women) with abdominal aortic aneurysms were treated with the placement of an intravascular nitinol stent-graft (Stentor [55] and Vanguard-System [95]); there were eight tubular grafts and 142 bifurcated grafts. Initial placement of the stent-graft was successful in 144 patients. Mean follow-up was 49 ± 25 months. In 13.3% of stent-graft placements we encountered the following complications: 4 cases of migration or dislocation of the prosthesis (30.5 ± 7.4 months after placement); 2 ruptures of the aorta (26.7 and 15.0 months after placement); 3 recurrent thromboses of the stent-graft (25.5 ± 5.3 months after placement); 3 endoleaks (27.5 ± 15.7 months after placement); and 5 infections of the prosthesis (26.6 ± 16.5 months after placement). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a Dacron graft. Conclusions: (1) The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. (2) Explantation of the prosthesis and surgical repair is feasible but bears additional risks. (3) Because the onset of reperfusion of the excluded aneurysm cannot be predicted, all patients with infrarenal aortic stent-grafts require frequent computer tomographic follow-up. (4) Finally, the results call for further improvements in the design of the stent-graft. (J Vasc Surg 2001;34:198-203.)

Explantation of aortic stent-grafts

Endoluminal stent graft placement for the treatment of infrarenal aortic aneurysms (AAA) has gained widespread acceptance because it is associated with lower perinterventional morbidity than conventional transabdominal surgery. In this study the long-term morbidity of the procedure was evaluated. Between 9/94 and 12/98, 150 patients (age = 69.6 +/- 8.5 y; m = 142, f = 8) with AAA were treated by placing an intravascular nitinol stent graft (Stentor, n = 55; Vanguard-System, n = 95; 8 tubular grafts, 142 bifurcated grafts). Initial placement of the stent graft was successful in 144 patients. In 12 % of stent graft placements we encountered one of the following complications (n, days after stent placement): migration or dislocation of the prosthesis (4, 914 +/- 220 d), rupture of the aorta (2, 452 d/802 d), recurrent thrombosis of the stent graft (3, 478 +/- 359 d), endoleak (3, 955 +/- 472 d), infection of the prosthesis (5, 798 +/- 495 d). There was no correlation between the complications and the type of stent used. All of these patients were treated by surgical replacement of the prosthesis with a dacron graft. 1. The results suggest that most complications are due to a continuation of the disease process leading to loosening of the prosthesis. 2. Explantation of the prosthesis and surgical repair is feasible but bears additional risks. 3. Since the onset of reperfusion of the excluded aneurysm can not be predicted, all patients with infrarenal aortic stent grafts require frequent computer tomographic follow up. 4. Lastly, the results call for further improvements in the design of the stent graft.

Endoluminal Treatment of Infrarenal Aortic Aneurysms: Clinical Experience with the Talent Stent-Graft System

To evaluate the safety and efficacy of the Talent stent-graft (TSG) system in the endoluminal treatment of infrarenal abdominal aortic aneurysms (AAAs). Endoluminal treatment of an AAA was attempted in 30 men with a mean age of 70.5 years (range, 51-83 years). Seven patients had AAAs suitable for treatment with a tube graft. In the other patients, treatment with a bifurcated TSG was planned. All procedures were performed as a combined surgical-radiologic procedure in an angiographic room. Primary technical success was achieved in 25 of 30 patients (83%). Technical failures were due to misplacement of the TSG (n = 2) with proximal leakage as a consequence, inability to gain access via the iliac arteries (n = 1), and a distal leakage (n = 2). Secondary interventions (n = 2) and spontaneous thrombosis of a distal leak (n = 1) increased the secondary technical success rate to 93% (28 of 30). Two procedures were converted to open surgery (conversion rate = 6%). One patient died during the first 30 days after uncomplicated stent-graft insertion because of myocardial infarction (30-day mortality = 5%). No complications occurred during a mean follow-up of 15.4 months (range, 6-19 months). The maximum diameter of the AAA decreased in eight patients and remained unchanged in the remaining patients. No increase in diameter was observed. No late endoleak or migration of the TSG was observed. The TSG-system revealed satisfactory initial and early follow-up results. Treatment of AAAs with this stent-graft system is feasible. The technical success rate in carefully selected patients should be 90% or more. However, long-term observations are necessary to determine if the encouraging early results of this type of therapy can be preserved during long-term follow-up.

Experience with endovascular grafts in the treatment of infrarenal aortic aneurysms associated with proximal aortic dissection

BACKGROUND: Chronic abdominal and thoracic aortic dissections often present with concomitant infrarenal aortic dilatation. We conducted a retrospective review of 6 patients treated with endovascular stent grafts for coexisting aortic dissection and infrarenal aneurysm. METHODS: Six patients with suprarenal aortic dissections and infrarenal aortic aneurysms (AAA) had their AAAs treated with endovascular grafts. Grafts were constructed of balloon expandable Palmaz stents and expanded polytetrafluoroethylene graft. The device was inserted transfemorally and deployed under fluoroscopy. RESULTS: Successfully primary AAA exclusion was achieved in 5 patients. One patient required a supplemental stent placed above the endograft and into the true lumen to seal the endoleak. No aneurysm has enlarged, and all remain thrombosed for 9 to 24 months (mean 20). One type III dissection enlarged 2 weeks after endograft insertion. One patient had uncomplicated cephalad fenestration of a dissection by the endograft. CONCLUSIONS: Endovascular grafts may be used to treat coexisting AAA and aortic dissection. Attention to the site or sites of reentry of a dissection is essential to insure full aortic aneurysm exclusion. The fate of a chronic aortic dissection cephalad to an endovascularly treated AAA is unclear and will require longer follow-up.

Endovascular prostheses: evolution, state-of-the-art and perspectives of a new technology

The treatment of infrarenal aortic aneurysms by means of transluminally placed endovascular prostheses reflects significant progress in the field of vascular surgery. In the case of infrarenal aortic aneurysm it is possible to achieve technically successful implantation of such a prosthesis in well over 90 % of cases. The rate of clinical success, meaning lasting effective exclusion of the aortic aneurysm, cannot (yet) be definitively determined, since no long-term results are so far available. Secondary leaks are observed in at least 10 % of all patients, making a further therapy necessary (endorepair, conversion, embolization). Further development of endovascular prostheses will include optimization of the aortal/iliac attachment of the prostheses, a better configuration and the development of long-lasting materials that can be used for endovascular prostheses.

Fatal colonic ischaemia after stent graft for aortic aneurysm

The development of new technology has led to renewed interest among both surgeons and radiologists in the treatment of infrarenal aortic aneurysms by endovascular techniques. Parodi and Palmaz pioneered the endovascular repair of aortic aneurysms using a straight stent graft. 1 Chuter et al. developed a means of deploying a bifurcated graft via the transfemoral route 2 and other series have been reported recently. 3 However, all new techniques have a learning curve. We report a case of fatal internal iliac artery embolism associated with insertion of a stent graft used to treat a symptomatic abdominal aortic aneurysm.