Long-term surveillance is paramount after implantation of the Vanguard stent-graft for abdominal aortic aneurysms

AIM

The aim of this study was to describe the results and long-term follow-up of the Vanguard endovascular graft for infrarenal abdominal aortic aneurysm (AAA) repair.

METHODS

Between February 1997 and October 1999, 76 patients were treated with a median aneurysm diameter of 52 mm (39-90 mm). All were followed up according to the Eurostar criteria.

RESULTS

The primary technical success rate was 100%. Perioperative mortality was 1.3%. During follow-up (median 75 months, 6-112 months) 9 aneurysm related deaths occurred. A total of 79 late complications occurred in 45 patients (64%). Complications were noticed more frequently in the group of aneurysms larger than 5.5 cm (P=0.014). Patients who ultimately developed aneurysm rupture after endovascular repair had more postoperative complications compared to the majority who did not rupture their aneurysm. (P=0.001) Secondary interventions were mandatory in 23 patients, surgical conversion in 9. At 72 months this has resulted in an overall survival rate of 57%, an aneurysm rupture free survival of 88%, a conversion free survival of 95%, an endoleak free survival of 83% and a secondary intervention free survival of 82% (Kaplan Maier).

CONCLUSION

The importance of life-long strict surveillance of patients treated with a Vanguard endograft was confirmed. Patients with graft-related complications should be treated accordingly.

Chronic contained rupture of an abdominal aortic aneurysm presenting as a Grynfeltt lumbar hernia. A case report

We report a unique case of chronic contained thoraco-abdominal aneurysm rupture presenting as a Grynfeltt lumbar hernia. A 79-year-old man presented with backpain and a bluish swelling in the left lumbar region in the presence of a non tender aortic aneurysm. CT scan confirmed contained rupture of a type IV thoraco-abdominal aortic aneurysm. The peri-aortic haematoma protruded through the lumbar wall causing a Grynfeltt lumbar hernia. The aneurysm was replaced through a thoraco-phreno-lumbotomy. The patient survived and is doing well six months postoperatively.

Combined open and endovascular repair of a true right subclavian artery aneurysm without proximal neck

A 52-year-old man, without a medical history, presented with an incidentally detected large, intrathoracic aneurysm of the right subclavian artery. The aneurysm was characterized by the absence of a proximal neck and extended distally close to the origin of the right vertebral artery. We successfully excluded this aneurysm with a combined endovascular and minimally invasive open repair, thereby avoiding a sternotomy or lateral thoracotomy: a stent-graft was placed from the proximal brachiocephalic trunk to the common carotid artery, completely covering the origin of the right subclavian artery. The right subclavian artery was oversewn just distally to the aneurysm and revascularization of the right arm was assured by a carotido-subclavian bypass. Clinical follow-up was uneventful and radiological follow-up by CT-scan showed discrete, but progressive shrinkage of the completely excluded aneurysm.

Hand-assisted Laparoscopy Versus Conventional Median Laparotomy for Aortobifemoral Bypass for Severe Aorto-iliac Occlusive Disease: A Prospective Randomised Study

OBJECTIVES

To demonstrate that hand-assisted laparoscopy for aortofemoral bypass for severe aorto-iliac occlusive disease reduces morbidity with earlier recovery of bowel function and shorter in-hospital stay.

DESIGN

Randomised controlled trial.

MATERIALS AND METHODS

Thirty-six consecutive patients with severe aorto-iliac occlusive disease (TASK C/D) without history of major abdominal surgery necessitating an aortobifemoral bypass were randomised between a hand-assisted laparoscopic (HALS) approach and a conventional medial laparotomy. Operative data, early recovery data, quality of life and vascular outcome were analysed.

RESULTS

No significant differences in operative data were found. Fluid and solid diet were resumed earlier (28.8 hrs vs. 76.9 hrs; p = 0.016) (45.6 hrs vs. 105.6 hrs; p = 0.02) and in-hospital stay was shorter (7.5 vs. 8.9 days; p = 0.005) in the HALS group. Six weeks post-operatively social functioning measured by the SF-36 survey score was better in patients randomised to HALS (p=0.023).

CONCLUSIONS

HALS is a less invasive approach for aortofemoral bypass.

Outcome of common iliac arteries after straight aortic tube-graft placement during elective repair of infrarenal abdominal aortic aneurysms

PURPOSE

To determine the relative rates of common iliac artery (CIA) expansion after elective straight aortic tube-graft replacement of infrarenal abdominal aortic aneurysms (AAA).

METHODS

Five participating centers in this 2004 study entered patients they had managed by an aortoaortic tube graft for elective AAA repair. The procedures took place between January 1995 and December 2003. Postoperative computed tomography (CT) scans were obtained for all patients in 2004 to assess changes in CIA diameter. Measurements on preoperative and postoperative CT scans were all made at the same level using the same technique.

RESULTS

Entered in the study were 147 patients (138 men, 9 women) with a mean age of 68 years. Mean follow-up from aortic surgery to verification of CIA diameter on the postoperative CT scan was 4.8 years. Mean preoperative CIA diameter was 13.6 mm vs 15.2 mm postoperatively. No patient developed occlusive iliac artery disease during follow-up. Three patients (2%) required repeat surgery during follow-up for a CIA aneurysm. The 147 patients were divided into three groups based on preoperative CIA diameter shown in CT scan: group A (n = 59, 40.1%), both CIA were of normal diameter; group B (n = 53, 36.1%), ectasia (diameter between 12 and 18 mm) of at least one CIA; group C (n = 35, 23.8%), an aneurysm (diameter >18 mm) of at least one CIA. CIA diameter increased by a mean of 1 mm (9.4%) over 5.5 years in group A vs 1.7 mm (12.1%) over 4.3 years in group B and 2.3 mm (12.7%) over 4.2 years in group C. The three patients who required repeat surgery for a CIA aneurysm during follow-up were all in group C. Four variables were associated with aneurysmal change in CIA: initial CIA diameter, celiac aorta diameter on the preoperative CT scan, a coexisting aneurysm site, and the follow-up duration.

CONCLUSIONS

Tube-graft placement during AAA surgery is justified even for moderate CIA dilatation (<18 mm). CIA aneurysms with a preoperative diameter > or =25 mm enlarge more rapidly and warrant insertion of a bifurcated graft during the same surgical session as AAA repair. The evolutive potential of CIA between 18 mm and 25 mm in diameter justifies a bifurcated graft when the celiac aorta diameter is >25 mm or the patient's life expectancy is > or =8 years.

Cerebral ischemia after filter-protected carotid artery stenting is common and cannot be predicted by the presence of substantial amount of debris captured by the filter device

PURPOSE

Protected carotid artery stent placement is currently under clinical evaluation as a potential alternative to carotid endarterectomy. The current study was undertaken to determine the incidence of new ischemic lesions found on diffusion-weighted MR imaging (DWI) in nonselected patients after protected carotid artery stent placement using a filter device and to determine the potential relationship between these new ischemic lesions and the presence or absence of a clear amount of debris captured by the neuroprotection filter device.

MATERIALS AND METHODS

A nonrandomized cohort of 52 patients (40 men, 12 women) presenting with carotid occlusive disease underwent protected carotid artery stent placement using a filter device. DWI obtained 1 day before stent placement was compared with that obtained 1 day after stent placement. In addition, the macroscopic and microscopic analysis of debris captured by the filter device during the carotid stent placement procedure was assessed.

RESULTS

Neuroprotected carotid stent placement was technically successful in all 53 procedures but was complicated by a transient ischemic attack in 3 patients (5.6%). In 22 patients (41.5%), new ischemic lesions were found on DWI, and in 21 filter devices (39.6%), a substantial amount of atheromatous plaque and/or fibrin was found. No clear relationship between the presence of debris captured by the filter device and new lesions detected by DWI was found (P = .087; odds ratio 3.067).

CONCLUSION

Neuroprotected carotid artery stent placement will not avoid silent cerebral ischemia. Systematic microscopic analysis of debris captured by the filter device has no predictive value for potential cerebral ischemia after carotid artery stent placement.

Simultaneous Valve Replacement and Venous Patch Repair of Superior Mesenteric Artery Aneurysm Due to Infective Endocarditis: A Case Report

BACKGROUND

Peripheral mycotic aneurysm development is a rare systemic complication of infective endocarditis.

CASE REPORT

We report on a case of a mycotic aneurysm of the superior mesenteric artery in a 66-year-old man with infective endocarditis of the mitral valve. After the mitral valve was replaced by a mechanical valve, a laparotomy was performed. The mycotic aneurysm was excised and the vessel was repaired by sewing an autologous venous patch at the neck of the aneurysm. Five years after the operation, the patient is doing fine, with a normal morphology and patency of the superior mesenteric artery.

CONCLUSION

Our case demonstrates that simultaneous valve surgery and repair of a superior mesenteric artery mycotic aneurysm by sewing a vein patch in the neck of the artery is a viable treatment option.

Multicenter evaluation of a self-expanding carotid stent system with distal protection in the treatment of carotid stenosis

PURPOSE

Carotid artery stent placement may be limited by the embolization of atheromatous material. We evaluated the safety and feasibility of the Medtronic Self-Expanding Carotid Stent (Exponent) in combination with the Medtronic Interceptor Carotid Filter System for the treatment of carotid stenosis among patients at high risk for carotid endarterectomy.

METHODS

Patients at high risk for carotid endarterectomy but amenable to percutaneous treatment with stent placement were enrolled. Clinical follow-up was performed at 30 days and 6 and 12 months postprocedure. The National Institutes of Health Stroke Scale was assessed before and within 3 days postprocedure and at 30 days and 6 months postprocedure. Angiography was performed pre- and postprocedure, and carotid duplex scans were performed at baseline and at 30 days and 6 months.

RESULTS

Fifty-two carotid procedures were performed in 51 patients (mean age, 69 years; 84% of patients were men). The major adverse event (MAE) rate (death, stroke, and myocardial infarction [MI]) at 30 days was 5.9%: 2 strokes and a single death from periprocedural MI. MAE rates after 6 and 12 months were 5.9% and 11.8%, respectively. The delivery success rate was 94.2% (49/52) for the Interceptor Filter System and 95.9% (47/49) for the Exponent Stent. The mean diameter stenosis of the target lesion was reduced from 62.4% preprocedure to 21.2% postprocedure.

CONCLUSION

High delivery success rates were achieved with a low rate of MAE (death, stroke, or MI) in a high-risk population. Treatment of carotid artery disease with the Exponent Carotid Stent combined with distal protection from the Interceptor Filter System is effective and safe.

Endovascular repair for aorto-enteric fistula: a bridge too far or a bridge to surgery?

PURPOSE

To review our experience of endovascular treatment of aorto-enteric fistula (AEF).

METHODS

Between March 1999 and March 2005, 15 patients in five university and teaching hospitals in Belgium and The Netherlands were treated for AEF by endovascular repair. Twelve (80%) were male. The mean age was 67 years. Thirteen (87%) had had previous aortic or iliac surgery, 1.7-307 months before. All patients showed clinical or biochemical signs of bleeding. Eight (53%) were in shock, five (33%) had systemic signs of infection. Eight (53%) patients were treated in an emergency setting. Ten (67%) were treated with an aortouniiliac device, three (20%) with an aortobiiliac device, one with a tube graft and one with occluders only. All patients received antibiotics postoperatively for a prolonged period of time.

RESULTS

All AEF were successfully sealed, the 30-days mortality was nil. Mean hospital stay was 20 (2-81) days. One patient died 2.7 months later of postoperative complications, one died of lung cancer. Until now, there are no signs of reinfection in four (27%) patients (mean follow-up 15.7 (1-44) months). However, reinfection or recurrent AEF occurred in nine (60%) patients after 9.5 (0.61-31) months. Seven patients were reoperated successfully, two patients died after reintervention.

CONCLUSION

Endovascular sealing of AEF is a promising technique, which provides time to treat shock, local and systemic infection, and co-morbidity. This creates a better situation to perform open repair in the future with possibly better outcome. Danger of reinfection remains high. Endovascular sealing of AEF should, therefore, be seen as a bridge to open surgery when possible.

Progressive growth of a pelvic collection five years after endovascular aneurysm repair: an atypical presentation of an asymptomatic contained rupture

We report a case of an unusual and late presentation of an asymptomatic contained rupture after modular stent-graft implantation to treat an aortobiiliac aneurysm. Follow-up computed tomography (CT) scans 4 and 5 years after endovascular aneurysm repair showed a homogeneous, nonenhancing, but clearly growing, pelvic collection. CT-guided drainage of the collection was performed, and cultures of the evacuated brown fluid were negative for any infection. Control CT scan after drainage showed a complete collapse of both the collection and the previously excluded iliac aneurysms. A direct communication between the sterile pelvic collection and the excluded iliac aneurysm was suggested on this CT imaging and confirmed afterwards by surgery. From these imaging and surgical findings, this pelvic collection can be considered as an atypical presentation of an asymptomatic contained rupture of the excluded aneurysm.

Hand-assisted Laparoscopic Aortobifemoral Bypass for Occlusive Disease. Early and Mid-term Results

OBJECTIVES

To evaluate the early and mid-term results of hand-assisted laparoscopic surgery (HALS) for aorto-iliac reconstruction.

DESIGN

Prospective survey.

MATERIALS AND METHODS

Between February 2002 and January 2004, 46 patients received an aortobifemoral bypass for advanced occlusive disease by HALS.

RESULT

There was one conversion to open surgery. Mortality was 4.5%. The median return to solid oral diet took 36 h (24-182), the median hospital stay was 5 days (3-26). Primary patency rate at 1 year was 97.5%. The incidence of incisional hernia was 19.5%.

CONCLUSIONS

HALS aorto-iliac reconstruction should be considered as a minimal invasive technique with good early and mid-term results.

Fibromuscular dysplasia of the superior mesenteric artery--case report and review of the literature

Fibromuscular dysplasia is a multifactorial arteriopathy most commonly affecting the renal and carotid arteries. In this report we present a case of visceral artery involvement, causing occlusion of the superior mesenteric artery and celiac trunk and resulting in visceral ischemia. Treatment consisted of superior mesenteric artery reimplantation. Visceral artery FMD can present as occlusive or aneurysmal disease and treatment depends on patient characteristics and symptoms.

Translumbar thrombin embolization of an aortic pseudoaneurysm complicating lumbar disk surgery

We report a case of translumbar embolization of an aortic pseudoaneurysm complicating lumbar disk surgery. The iatrogenic pseudoaneurysm was initially treated by open repair, but due to failure of this treatment, we opted for direct translumbar thrombin injection under computed tomography (CT) guidance. The patient recovered completely, and follow-up CT scans showed progressive shrinkage of the residual retroperitoneal hematoma. This minimally invasive treatment should be considered in selected cases as a valuable treatment option for pseudoaneurysms that arise from the aorta.

Endovascular stent-graft and first rib resection for thoracic outlet syndrome complicated by an aneurysm of the subclavian artery

PURPOSE

To report our experience with a combined endovascular and surgical approach for arterial thoracic outlet syndrome (TOS) complicated by an aneurysm of the subclavian artery.

METHODS

We treated three consecutive patients suffering from arterial thoracic outlet syndrome complicated by an aneurysm of the subclavian artery by the use of a stent-graft and a first rib resection. These patients were reviewed retrospectively.

RESULTS

At a mean follow-up of 37.3 months all patients were free of symptoms without late complications.

CONCLUSIONS

Endovascular stent-grafting followed by decompression of the costoclavicular space is an attractive alternative to the conventional surgical approach of complicated arterial TOS.

Hemobahn stent-grafts in the treatment of femoropopliteal occlusive disease

AIM

The aim of this study was to determine our results and indications for the Hemobahn stent-graft in femoropopliteal occlusive disease.

METHODS

Since 1999, 38 patients with femoropopliteal occlusive disease in 40 legs have been treated by endovascular dilation or recanalisation and additional endografting. All have been followed up prospectively at 6 month intervals by clinical examination, Doppler and duplex.

RESULTS

In 40 legs, 15 high grade stenoses were dilated and 25 occlusions needed first recanalization. Additional Hemobahn stent-graft deployment was successful in all cases (total grafts n=60). The median length of the stented segment was 15 cm. Immediate complications during the procedure were stent-graft thrombosis (n=1) and distal embolization (n=3), instantly treated with thrombolysis and thrombus aspiration. The median ankle-brachial index in rest increased from 0.5 preoperatively to 1 postoperatively. With a median follow-up time of 28.2 months (range from 1 to 48 months), there were 4 high grade stenoses and 13 stent-graft occlusions (1 year primary patency rate of 66%). All 4 stenoses were treated with balloon dilation (1 year assisted primary patency rate of 76%) and 4 of the occluded grafts were recovered by thrombectomy (n=1) or thrombolysis (n=3), resulting in a 1 year secondary patency rate of 87%.

CONCLUSIONS

The Hemobahn stent-graft can be used in the treatment of femoropopliteal occlusive disease with a low complication rate and acceptable patency rates in the short-term. We had the best results when there was no recanalization needed before.

Internal Iliac Artery Coil Embolization in the Prevention of Potential Type 2 Endoleak after Endovascular Repair of Abdominal Aortoiliac and Iliac Artery Aneurysms: Effect of Total Occlusion versus Residual Flow

PURPOSE

To evaluate whether the presence of type 2 endoleak after internal iliac artery (IIA) coil embolization in patients with residual antegrade flow through the coils is more frequent than in patients who presented with total occlusion of the IIA after embolization.

MATERIALS AND METHODS

Records were reviewed of 45 patients who underwent unilateral (n = 37) or bilateral (n = 8) IIA coil embolization between 1998 and 2004 for endovascular repair of aortoiliac aneurysms (n = 32), iliac artery aneurysms (n = 12), pseudoaneurysm (n = 1), or distal type 1 endoleak after placement of an aortoiliac stent-graft (n = 8). A total of 53 IIAs were embolized by means of coils and/or microcoils. Computed tomography (CT) was used for follow-up in 40 patients, angiography was used in three, and color Doppler ultrasonography was used in three.

RESULTS

At the end of the embolization procedure, 23 IIAs were occluded and 30 IIAs demonstrated residual antegrade flow through the coils. Control CT demonstrated two type 2 endoleaks after endovascular stent-graft placement resulting from retrograde blood flow into the left IIA main branch via a patent iliolumbar artery. One of these two patients showed residual antegrade flow through the coils at the end of the IIA embolization procedure, and the other patient underwent complete coil embolization of the ostia of the anterior and posterior division but not of the main trunk of an aneurysmal IIA.

CONCLUSION

IIA coil embolization with residual antegrade flow through the coils causes no greater incidence of type 2 endoleak after aortoiliac or iliac stent-graft placement. However, care must be taken in case of a proximal postostial origin of the iliolumbar artery on the IIA, which may cause type 2 endoleak if not embolized.

Iatrogenic Main Renal Artery Injury: Treatment by Endovascular Stent-Graft Placement

We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperitoneal drainage procedure. Only a small number of cases of iatrogenic main renal artery perforations have been reported, none of them due to a percutaneous drainage attempt. Endovascular treatment by means of a coronary stent-graft was successful.

Minimal-access aortic surgery: the potentials of hand-assisted laparoscopy

In analogy with the good results of laparoscopic abdominal procedures minimal-access aortic surgery looks very promising. However, in spite of the many technical improvements that have already been made, totally laparoscopic and even laparoscopically assisted aortic surgery remains technically demanding. This explains the rather slow introduction of minimal-access aortic surgery in the vascular society. In anticipation of increasing surgical experience and better instrumentation that will make the technique feasible for each vascular surgeon, hand-assisted laparoscopy (HALS) can be a valuable intermediate approach. HALS offers an easy to perform and still clearly less invasive approach for all aorto-iliac reconstructions.

Endovascular abdominal aortic aneurysm treatment: device-specific outcomes

Endoluminal grafting, introduced now 13 years ago, has been greeted enthusiastically as an alternative treatment for infrarenal abdominal aortic aneurysms (AAAs). It is estimated that last year, over 30,000 implants were performed in Europe and the US. In this review, we want to touch on the actual results of the most commonly used devices. Comparison of device-specific outcomes remains difficult however since there are few comparative and certainly no randomized studies, which is explained by the fact that the indication to treatment and selection of the device depends largely on patient related and anatomical criteria, as well as on commitment to clinical trials.

Extracranial carotid artery stenting in surgically high-risk patients using the Carotid Wallstent endoprosthesis: midterm clinical and ultrasound follow-up results

The purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients--31.5%) or because of severe comorbidities (37 patients--68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 +/- 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.

A 16-year survey of Takayasu's arteritis in a tertiary Belgian center

AIM

To evaluate the clinical features, angiographic findings and evolution of Takayasu's arteritis in a Belgian tertiary center, and to compare the findings with published series of Western patients.

METHODS

Retrospective analysis of 15 patients with Takayasu's arteritis, satisfying the American College of Rheumathology criteria, in the period 1986 to 2002. Published series of Western patients were identified by means of a Medline search and citation-tracking.

RESULTS

Diagnosis was often delayed, with a median period of 9 months. Patients presented with a variety of symptoms and clinical signs and had on average 4.5 arterial segments involved at angiography. Twelve patients received corticosteroid treatment and 4 of them additional immunosuppressive drugs. Five patients underwent angioplasty and/or stenting and 8 patients had open surgical procedures. During follow-up, there were 2 cardiac deaths and 2 other patients died from intracranial hemorrhage. Comparison with published series of other Western patients did not reveal major differences of anatomical distributions of the lesions, but left the impression that more aggressive use of immunosuppressive drugs might have improved the outcome.

CONCLUSION

Takayasu's arteritis results in an important morbidity and mortality. More aggressive medical therapy may be advantageous, but this would require adequate investigation in a controlled trial for which a multicenter effort is needed because of the rarity of the disease.