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Drucker CB, Bhardwaj A, Benalla O, Crawford RS, Sarkar R. Modeling variability in the inferior vena cava into fenestrated endografts for retrohepatic caval injuries. J Vasc Surg Venous Lymphat Disord 2019; 8:62-72. [PMID: 31843249 DOI: 10.1016/j.jvsv.2019.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 06/24/2019] [Indexed: 01/04/2023]
Abstract
OBJECTIVE Injury of the retrohepatic inferior vena cava (IVC) is rare, but extremely fatal. Open repair of these injuries is challenging. Various maneuvers, including atriocaval shunting and total vascular isolation, have been described, but are poorly tolerated in the severely injured patient. Endovascular repair is an attractive alternative strategy, but effective hemostasis of complex injuries requires an endograft that excludes the injury while permitting flow from the hepatic veins. Unfortunately, IVC and hepatic vein anatomy is highly variable and has not been clearly described in injured patients. Our purpose was to characterize critical human IVC morphology in trauma patients, and develop the design parameters of an off-the-shelf fenestrated endograft intended for caval deployment. METHODS One hundred consecutive adult trauma patients with an admission computed tomography scan including a portal venous phase of the abdomen were reviewed. Specific anatomic measurements including segmental IVC lengths and diameters were obtained. Multiple theoretical endografts were modeled to optimize caval coverage in the retrohepatic segment, assuming 10% to 40% oversizing for seal. RESULTS This sample population had a mean age of 50 years, height of 173 cm, and weight 84 kg. Seventy-one percent were male and 89% had a blunt mechanism of injury. The median caval length from the renal veins to right atrium was 111 mm (interquartile range [IQR], 102-120 mm), diameter was 22 mm (IQR, 19-26 mm), and hepatic venous orifice area was 336 mm2 (IQR, 267-432 mm2). All patients had a landing zone of at least 12 mm in the suprahepatic and 10 mm in the suprarenal segments. Three models of graft length were developed to accommodate patients with segmental and overall dimensions in the smallest half, third quartile, and fourth quartile. These could provide 95% of patients with coverage of the retrohepatic segment without risk of hepatic or renal vein occlusion. Four graft diameters were developed for cross-sectional fit. Graft diameters of 20, 24, 30, and 38 mm could provide adequate coverage in, respectively, 11%, 35%, 49%, and 16% of patients. These combinations of graft length and diameter would accommodate 93% of patients. CONCLUSIONS We defined human IVC morphology essential for endovascular therapy and developed parameters for fenestrated IVC endografts to address retrohepatic caval injuries in trauma patients. Although additional study and testing are required, this proof-of-concept study supports the hypothesis that exclusion of the most devastating retrohepatic IVC injuries can be achieved with a reasonable number of off-the-shelf fenestrated endografts. These findings form the basis for additional research toward the development of novel devices for endovascular therapy of these often lethal injuries.
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Affiliation(s)
- Charles B Drucker
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, Md
| | - Abhishek Bhardwaj
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Oussama Benalla
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md
| | - Robert S Crawford
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Emory University School of Medicine, Atlanta, Ga
| | - Rajabrata Sarkar
- Division of Vascular Surgery, University of Maryland Medical Center, Baltimore, Md; Center for Aortic Disease, University of Maryland Medical Center, Baltimore, Md.
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2
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Spanos K, Kölbel T, Kouvelos G, Tsilimparis N, Debus SE, Giannoukas AD. Endovascular treatment of para-anastomotic aneurysms after open abdominal aortic surgery. THE JOURNAL OF CARDIOVASCULAR SURGERY 2018; 61:159-170. [PMID: 29430886 DOI: 10.23736/s0021-9509.18.10145-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION The repair of long-term complications of open abdominal aortic repair such as para-anastomotic aneurysm (PAA) and pseudoaneurysm (PSA) is very challenging. The aim of this study was to assess the outcomes of endovascular repair of PAA/PSA after previous open aortic surgery for aneurismal or occlusive disease. EVIDENCE ACQUISITION A systematic review was undertaken; a search was performed (PRISMA) in MEDLINE, CENTRAL, Cochrane databases and key references of all studies of endovascular treatment of PAA/PSA after open aortic surgery. EVIDENCE SYNTHESIS Eighteen studies included totally 433 patients (86.3% males) with mean age of 71±2.5 years were identified. Most of the patients were asymptomatic (76%) and diagnosed with PAA (60.5%), while 81.6% had history of open aortic reconstruction for aneurismal disease. The mean diameter of para-anastomotic aneurysms was 59.7 mm (from 23 mm to 110 mm) and the mean duration until their diagnosis was 10±2 years. Standard bifurcated (23.7%), fenestrated (23.4%) and aorto-uni-iliac stent-grafts (16.3%) were mostly used. The technical success rate was 97.8% (391/400) with 1.4% (6/433) 30 day-mortality rate and mean hospital stay of 6±3 days. The mean 1- and 2- year survival rate was 87.8% and 78.8%, respectively. The follow-up ranged from 9 to 43 months, with presenting complications such as endoleak type I (24/378; 6.3%), type II (15/354; 4.3%), type III (3/378;0.8%), migration (4/378; 1%) and limb occlusion (5/310;1.6%). Additionally, 5.7% (19/332) of the patients underwent open conversion, while the total re-intervention rate was 11.4% (39/340; time of reintervention ranged from 7 to 30 months). In cases in which a stent was used for splanchnic vessels (renal artery: 188, superior mesenteric artery: 98, celiac artery: 64), the primary patency rate was 97.4% (341/350). CONCLUSIONS Endovascular treatment of PAAs and PSAs after previous open aortic surgery is a feasible and efficient option with high technical success rate, low 30-day mortality and good mid-term outcomes.
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Affiliation(s)
- Konstantinos Spanos
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany -
| | - Tilo Kölbel
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - George Kouvelos
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University Hospital of Larissa, Larissa, Greece
| | - Nikolaos Tsilimparis
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Sebastian E Debus
- Department of Vascular Medicine, German Aortic Center Hamburg, University Heart Center, Hamburg, Germany
| | - Athanasios D Giannoukas
- Department of Vascular Surgery, School of Health Sciences, Faculty of Medicine, University Hospital of Larissa, Larissa, Greece
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Laganà D, Guzzardi G, Petullà M, Martelli M, Ierardi AM, Del Sette B, Carrafiello GP. Endovascular Treatment of Aorto-Iliac-Femoral Anastomotic Pseudoaneurysms: A Multicentric Study. Ann Vasc Surg 2017; 45:213-222. [DOI: 10.1016/j.avsg.2017.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/28/2017] [Accepted: 05/31/2017] [Indexed: 11/24/2022]
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4
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Tasselli S, Perini P, Paini E, Milan L, Bonvini S. Use of a Thoracic Endograft in an Acute Abdominal Aortic Setting: Case Report and Literature Review. Vasc Endovascular Surg 2017; 51:493-497. [PMID: 28743219 DOI: 10.1177/1538574417718446] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE We report the case of a thoracic endograft used to achieve exclusion of a ruptured proximal paranastomotic abdominal aortic aneurysm (PAAA) as a consequence of aortic ballooning. CASE REPORT A type I proximal endoleak was evidenced following endovascular repair of a PAAA with an aortic cuff. The leak was treated with ballooning, which caused distal aortic rupture. A thoracic endograft was deployed inside the cuff, achieving complete exclusion. At 1 year, there are no signs of migration or endoleak with complete PAAA thrombosis, according to computed tomographic angiography. CONCLUSION In hostile proximal abdominal aortic neck, challenging anatomies, or urgent cases, the structural adaptability of thoracic endografts could provide safe and successful abdominal aortic endovascular exclusion.
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Affiliation(s)
| | - Paolo Perini
- 2 Department of Vascular Surgery, University Hospital, Parma, Italy
| | - Elisa Paini
- 1 Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Luca Milan
- 1 Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
| | - Stefano Bonvini
- 1 Department of Vascular Surgery, Santa Chiara Hospital, Trento, Italy
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5
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Endovascular treatment of aneurysms using fenestrated-branched endografts with distal inverted iliac limbs. J Vasc Surg 2016; 64:600-4. [DOI: 10.1016/j.jvs.2016.02.058] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 02/19/2016] [Indexed: 11/23/2022]
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6
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Ziegler P, Perdikides TP, Avgerinos ED, Umscheid T, Stelter WJ. Fenestrated and Branched Grafts for Para-Anastomotic Aortic Aneurysm Repair. J Endovasc Ther 2016; 14:513-9. [PMID: 17696626 DOI: 10.1177/152660280701400412] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Purpose: To investigate the use of fenestration and branch artery stenting during endovascular stent-graft repair of para-anastomotic aneurysms (PAA). Methods: A retrospective review was conducted of 9 patients (all men; mean age 71 years, range 60–80) who received custom-designed fenestrated endoprostheses for PAA repair. Eight tubular fenestrated devices and 1 composite device (fenestrated tube plus modular bifurcated body) with a total of 31 fenestrations were used. Results: The mean operating time was 318±93 minutes (range 220–485); the mean fluoroscopy time was 77±38 minutes (range 39–158), during which a mean 121±81 mL (range 33–300) of contrast was used. Technical success was achieved in all cases. Over a mean follow-up of 12±5.5 months (range 6–24), 1 secondary intervention was carried out due to a break in a side branch stent-graft; 2 transient renal impairments and 1 permanent renal insufficiency unrelated to renal artery patency were observed. So far, no vessel loss has emerged. Conclusion: Conventional repair of PAA has been a standard procedure for many years, though it carries high surgical risk as well as perioperative mortality. Fenestrated endografts may be a promising alternative in selected patients.
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Stringari C, Perkmann R, Zaraca F. Endovascular repair of a paraanastomotic aneurysm with inverted limb infrarenal bifurcated graft. Ann Vasc Surg 2013; 28:493.e5-10. [PMID: 24295882 DOI: 10.1016/j.avsg.2013.03.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2013] [Revised: 03/21/2013] [Accepted: 03/29/2013] [Indexed: 11/19/2022]
Abstract
A typical complication after conventional aortic prosthetic reconstruction is paraanastomotic aneurysm formation. Endovascular exclusion of paraanastomotic aneurysms has been shown to be a viable alternative to open surgical repair and to greatly reduce morbidity and mortality rates. We present a case report of asymptomatic proximal anastomotic pseudoaneurysm, measuring 4.5 cm in diameter, that was successfully treated by endovascular repair with a custom-made inverted limb infrarenal bifurcated graft.
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Affiliation(s)
- Carlo Stringari
- Department of Vascular and Thoracic Surgery, Regional Hospital Bozen, Bozen, Italy
| | - Reinhold Perkmann
- Department of Vascular and Thoracic Surgery, Regional Hospital Bozen, Bozen, Italy
| | - Francesco Zaraca
- Department of Vascular and Thoracic Surgery, Regional Hospital Bozen, Bozen, Italy.
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8
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Sucandy I, Abai B. Endovascular Repair of Delayed Para-anastomotic Pseudoaneurysm after Open Abdominal Aortic Aneurysm Repair: A Relatively Simple Technique for Successful Repair of a Potentially Catastrophic Complication. Am Surg 2013. [DOI: 10.1177/000313481307900809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Iswanto Sucandy
- Department of Surgery Abington Memorial Hospital Abington, Pennsylvania
| | - Babak Abai
- Department of Surgery Abington Memorial Hospital Abington, Pennsylvania
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9
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Nayeemuddin M, Pherwani AD, Asquith JR. Imaging and management of complications of open surgical repair of abdominal aortic aneurysms. Clin Radiol 2012; 67:802-14. [PMID: 22341185 DOI: 10.1016/j.crad.2011.12.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Revised: 12/12/2011] [Accepted: 12/03/2011] [Indexed: 10/14/2022]
Abstract
Open repair is still considered the reference standard for long-term repair of abdominal aortic aneurysms (AAA). In contrast to endovascular aneurysm repair (EVAR), patients with open surgical repair of AAA are not routinely followed up with imaging. Although complications following EVAR are widely recognized and routinely identified on follow-up imaging, complications also do occur following open surgical repair. With frequent use of multi-slice computed tomography (CT) angiography (CTA) in vascular patients, there is now improved recognition of the potential complications following open surgical repair. Many of these complications are increasingly being managed using endovascular techniques. The aim of this review is to illustrate a variety of potential complications that may occur following open surgical repair and to demonstrate their management using both surgical and endovascular techniques.
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Affiliation(s)
- M Nayeemuddin
- Department of Interventional Radiology, City General Hospital, University Hospital of North Staffordshire NHS Trust, Stoke-On-Trent, UK
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Coscas R, Greenberg RK, Mastracci TM, Eagleton M, Kang WC, Morales C, Hernandez AV. Associated factors, timing, and technical aspects of late failure following open surgical aneurysm repairs. J Vasc Surg 2010; 52:272-81. [PMID: 20670772 DOI: 10.1016/j.jvs.2010.03.007] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2009] [Revised: 03/03/2010] [Accepted: 03/04/2010] [Indexed: 11/19/2022]
Affiliation(s)
- Raphael Coscas
- Department of Vascular and Endovascular Surgery, Cleveland Clinic, Cleveland, Ohio 44195, USA
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11
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Endovascular Methods in the Treatment of Late Complications of Conventional Operations of Aneurysms At Aorto-Iliac Level. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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12
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Invited commentary. J Vasc Surg 2009; 50:485. [PMID: 19700088 DOI: 10.1016/j.jvs.2009.04.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2009] [Revised: 04/17/2009] [Accepted: 04/17/2009] [Indexed: 11/20/2022]
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13
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Cerná M, Köcher M, Utíkal P, Koutná J, Drác P, Bachleda P, Burval S, Kozák J, Thomas RP. Endovascular treatment of abdominal aortic paraanastomotic pseudoaneurysms after surgical reconstruction. Eur J Radiol 2009; 71:333-7. [PMID: 18450399 DOI: 10.1016/j.ejrad.2008.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/26/2008] [Accepted: 03/20/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Marie Cerná
- Department of Radiology, University Hospital, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
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Bianchi P, Nano G, Cusmai F, Ramponi F, Stegher S, Dell'Aglio D, Malacrida G, Tealdi DG. Uninfected para-anastomotic aneurysms after infrarenal aortic grafting. Yonsei Med J 2009; 50:227-38. [PMID: 19430556 PMCID: PMC2678698 DOI: 10.3349/ymj.2009.50.2.227] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 08/13/2008] [Accepted: 08/26/2008] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This single-institution retrospective review examines the management of uninfected para-anastomotic aneurysms of the abdominal aorta (PAAA), developed after infrarenal grafting. MATERIALS AND METHODS From October 1979 to November 2005, 31 PAAA were observed in our Department. Twenty-six uninfected PAAA of degenerative etiology, including 24 false and 2 true aneurysms, were candidates for intervention and retrospectively included in our database for management and outcome evaluation. Six (23%) patients were treated as emergencies. Surgery included tube graft interposition (n = 12), new reconstruction (n = 8), and graft removal with extra-anatomic bypass (n = 3). Endovascular management (n = 3) consisted of free-flow tube endografts. RESULTS The mortality rate among the elective and emergency cases was 5% and 66.6%, respectively (p = 0.005). The morbidity rate in elective cases was 57.8%, whereas 75% in emergency cases (p = 0.99). The survival rate during the follow-up was significantly higher for elective cases than for emergency cases. CONCLUSION Uninfected PAAA is a late complication of aortic grafting, tends to evolve silently and is difficult to diagnose. The prevalence is underestimated and increases with time since surgery. The mortality rate is higher among patients treated as an emergency than among patients who undergo elective surgery, therefore, elective treatment and aggressive management in the case of pseudoaneurysm are the keys to obtain a good outcome. Endovascular treatment could reduce mortality. Patients who undergo infrarenal aortic grafting require life-long surveillance after surgery.
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Affiliation(s)
- Paolo Bianchi
- Department of Vascular Surgery, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
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Carvalho ATYD, Santos VPD, Razuk Filho Á, Karakhaian W, Guedes Neto HJ, Castelli Jr. V, Caffaro RA. Fatores de morbimortalidade na cirurgia eletiva do aneurisma da aorta abdominal infra-renal: experiência de 134 casos. J Vasc Bras 2008. [DOI: 10.1590/s1677-54492008000300006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
CONTEXTO: O tratamento cirúrgico convencional do aneurisma da aorta abdominal (AAA) infra-renal pode resultar em complicações graves. A fim de otimizar os resultados na evolução do tratamento, é importante que sejam identificados os pacientes predispostos a determinadas complicações e instituídas condutas preventivas. OBJETIVOS: Avaliar a taxa de mortalidade operatória precoce, analisar as complicações pós-operatórias e identificar os fatores de risco relacionados com a morbimortalidade. MÉTODO: Foram analisados 134 pacientes com AAA infra-renal submetidos a correção cirúrgica eletiva no período de fevereiro de 2001 a dezembro de 2005. RESULTADOS: A taxa de mortalidade foi de 5,2%, sendo secundária principalmente a infarto agudo de miocárdio (IAM) e isquemia mesentérica. As complicações cardíacas foram as mais freqüentes, seguidas das pulmonares e renais. A presença de diabetes melito (DM), insuficiência cardíaca congestiva (ICC), insuficiência coronariana (ICO) e cintilografia miocárdica positiva para isquemia estiveram associadas às complicações cardíacas. A idade avançada, a doença pulmonar obstrutiva crônica (DPOC) e a capacidade vital forçada reduzida aumentaram os riscos de atelectasia e pneumonia. História de nefropatia, tempo de pinçamento aórtico prolongado e níveis de uréia elevados aumentaram os riscos de insuficiência respiratória aguda (IRA). A isquemia dos membros inferiores esteve associada ao tabagismo e à idade avançada, e a maior taxa de mortalidade, à presença de coronariopatia, tempos prolongados de pinçamento aórtico e de cirurgia. CONCLUSÃO: A taxa de morbimortalidade esteve compatível com a literatura nacional e internacional, sendo secundária às complicações cardíacas, respiratórias e renais. Os fatores de risco identificados no pré e transoperatório estiveram relacionados com essas complicações.
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Laganà D, Carrafiello G, Mangini M, Recaldini C, Lumia D, Cuffari S, Caronno R, Castelli P, Fugazzola C. Endovascular treatment of anastomotic pseudoaneurysms after aorto-iliac surgical reconstruction. Cardiovasc Intervent Radiol 2008; 30:1185-91. [PMID: 17508237 DOI: 10.1007/s00270-007-9047-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction. MATERIALS We retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter. RESULTS Immediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1-72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%. CONCLUSION Endovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.
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Affiliation(s)
- Domenico Laganà
- Department of Radiology, University of Insubria, Viale Borri, 57, 21100 Varese, Italy.
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Sfyroeras GS, Lioupis C, Bessias N, Maras D, Pomoni M, Andrikopoulos V. Endovascular treatment of a ruptured para-anastomotic aneurysm of the abdominal aorta. Cardiovasc Intervent Radiol 2008; 31 Suppl 2:S79-83. [PMID: 18214598 DOI: 10.1007/s00270-007-9206-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Revised: 08/13/2007] [Accepted: 09/25/2007] [Indexed: 10/22/2022]
Abstract
We report a case of a ruptured para-anastomotic aortic aneurysm treated with implantation of a bifurcated stent-graft. A 72-year-old patient, who had undergone aortobifemoral bypass for aortoiliac occlusive disease 16 years ago, presented with a ruptured para-anastomotic aortic aneurysm. A bifurcated stent-graft was successfully deployed into the old bifurcated graft. This is the first report of a bifurcated stent-graft being placed through an "end-to-side" anastomosed old aortobifemoral graft. Endovascular treatment of ruptured para-anastomotic aortic aneurysms can be accomplished successfully, avoiding open surgery which is associated with increased mortality and morbidity.
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Affiliation(s)
- Giorgos S Sfyroeras
- Department of Vascular Surgery, The Red Cross Hospital of Athens, Athens, Greece
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Piscione F, Sarno G, Iannelli G, Di Tommaso L, Furbatto F, D'Andrea C, Accardo D, Chiariello M. Acute aortic syndromes at high surgical risk: the endovascular approach. EUROINTERVENTION 2008; 3:499-505. [DOI: 10.4244/eijv3i4a88] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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19
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Ziegler P, Perdikides TP, Avgerinos ED, Umscheid T, Stelter WJ. Fenestrated and Branched Grafts for Para-Anastomotic Aortic Aneurysm Repair. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[513:fabgfp]2.0.co;2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Mofidi R, Flett M, Milne A, Chakraverty S. Endovascular repair of an anastomotic leak following open repair of abdominal aortic aneurysm. Cardiovasc Intervent Radiol 2007; 30:1013-5. [PMID: 17533537 DOI: 10.1007/s00270-007-9076-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2006] [Revised: 12/19/2006] [Accepted: 01/12/2007] [Indexed: 10/23/2022]
Abstract
This report describes the case of an early postoperative anastomotic leak following elective open repair of an infrarenal abdominal aortic aneurysm which was successfully treated by endovascular stent-grafting. A 71-year-old man underwent open tube graft repair of abdominal aortic aneurysm. Twelve days later he presented with a contained leak from the distal anastomosis, which was confirmed on CT scan. This was successfully treated with a bifurcated aortic stent-graft. This case illustrates the usefulness of the endovascular approach for resolving this rare surgical complication of open repair of abdominal aortic aneurysm and the challenges associated with the deployment of such a device within an aortic tube graft.
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Affiliation(s)
- R Mofidi
- Department of Vascular Surgery and Radiology, Ninewells Hospital, Dundee DD1 9SY, UK.
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Di Tommaso L, Monaco M, Piscione F, Sarno G, Iannelli G. Endovascular Stent Grafts as a Safe Secondary Option for Paraanastomotic Abdominal Aortic Aneurysm. Eur J Vasc Endovasc Surg 2007; 33:91-3. [PMID: 16798027 DOI: 10.1016/j.ejvs.2006.05.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2005] [Accepted: 05/08/2006] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To describe our experience of endovascular repair of para-anastomotic aortic aneurysm. METHODS AND RESULTS From March 2001 to December 2004 we identified 6 patients with a para-anastomotic aortic aneurysms following previous open repair of abdominal aortic aneurysm. All patients were treated with endovascular surgery under epidural anaesthesia. There were no major complications, surgical conversions or deaths. Four patients received a bifurcated aortic stent-graft, and two an aorto-uniliac stent-graft followed by a femoro-femoral bypass. At follow-up (mean 26.1+/-10.2 months) there were no deaths, endoleaks or graft migrations observed. CONCLUSION Endovascular surgery, avoiding general anesthesia and re-laparotomy, is the ideal technique for treatment of this complication resulting from failed primary conventional AAA repair.
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Affiliation(s)
- L Di Tommaso
- Department of Cardiac Surgery, University Federico II of Naples, Italy.
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Adam DJ, Fitridge RA, Berce M, Hartley DE, Anderson JL. Salvage of failed prior endovascular abdominal aortic aneurysm repair with fenestrated endovascular stent grafts. J Vasc Surg 2006; 44:1341-4. [PMID: 17145439 DOI: 10.1016/j.jvs.2006.07.047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2006] [Accepted: 07/31/2006] [Indexed: 11/23/2022]
Abstract
Three patients with type I proximal endoleak after previous endovascular abdominal aortic aneurysm (AAA) repair were treated with fenestrated endovascular stent grafts. Six renal arteries, three superior mesenteric arteries, and one coeliac axis were targeted for incorporation by graft fenestration. The fenestration-renal ostium interface was secured with balloon-expandable stents and completion angiography demonstrated no endoleaks and antegrade perfusion in all target vessels. All patients made an uncomplicated recovery. Fenestrated endovascular stent grafts can be used to salvage failed prior endovascular AAA repair in patients who are considered unsuitable for other endovascular or open surgical interventions.
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Affiliation(s)
- Donald J Adam
- Birmingham Heartlands Hospital, Birmingham, United Kingdom.
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Aun R, Saliture Neto FT, Lederman A, Waksman H. Tratamento endoluminal de aneurismas anastomóticos na aorta abdominal: relato de dois casos. J Vasc Bras 2006. [DOI: 10.1590/s1677-54492006000100011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Os aneurismas anastomóticos que envolvem a anastomose proximal de reconstruções do território aorto-ilíaco são graves, e as operações convencionais para sua correção são complexas e passíveis de graves complicações. Apresentamos dois casos de aneurismas de anastomoses proximais de enxerto aorto-bifemoral que ocorreram após 15 e 18 anos, respectivamente, de evolução dos enxertos e que foram corrigidos pela técnica endoluminal. Ambos os pacientes evoluíram bem e foram submetidos a controle pela tomografia computadorizada com 12 e 6 meses de evolução, respectivamente, com exclusão do aneurisma.
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Zhou W, Bush RL, Bhama JK, Lin PH, Safaya R, Lumsden AB. Repair of Anastomotic Abdominal Aortic Pseudoaneurysm Utilizing Sequential AneuRx Aortic Cuffs in an Overlapping Configuration. Ann Vasc Surg 2006; 20:17-22. [PMID: 16378150 DOI: 10.1007/s10016-005-9282-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Anastomotic aortic pseudoaneurysm is a known late complication following aortic repair and presents a considerable surgical challenge. We herein evaluate the endovascular alternative of using sequential AneuRx aortic cuffs to bridge the degenerative anastomotic pseudoaneurysms as a definitive treatment. Over a 3-year period, six patients with a mean age of 68.7 years (range 58-75) were identified who had proximal anastomotic aortic pseudoaneurysms secondary to previously implanted bifurcated aortic grafts (mean 15, range 12-20 years) following open surgical correction of aortoiliac occlusive disease. Five patients (83%) presented with concomitant palpable femoral anastomotic pseudoaneurysms and one patient (16%) had a pulsatile abdominal mass. All patients had computed tomographic (CT) scans confirming proximal anastomotic pseudoaneuryms without evidence of infection. The mean diameter of the pseudoaneurysms was 5.3 cm (range 4.0-7.0). Five patients were treated with endovascular methods, while one patient was not suitable for endovascular repair due to the diameter of the native aorta as seen on imaging study at the time of the procedure. AneuRx aortic extender cuffs (3.75 cm length) were deployed sequentially in five patients via a femoral approach. Devices were overlapped approximately 1.5 cm in order to achieve total exclusion of the pseudoaneurysms, and all concomitant femoral aneurysms were repaired surgically at the same time. Successful exclusion of the anastomotic pseudoaneurysm was achieved in four patients (80%) using a combination of two or three overlapping aortic cuffs. One patient had a small residual endoleak that had sealed by 1 month, evidenced by follow-up CT. The renal arteries were preserved in all patients. The average estimated blood loss and operative time were 355 +/- 25 cc and 84 +/- 21 min, respectively. The average length of hospital stay was 2.1 days, and there was no mortality or major morbidity. All patients underwent CT scanning surveillance at 6 and 12 months and yearly afterward. There was no evidence of late endoleak, aneurysmal expansion, or device migration during the mean follow-up of 10 months, ranging 6-27 months. Our study demonstrated that utilizing sequential AneuRx aortic cuffs applied in an overlapping configuration is an effective strategy for degenerative aortic anastomotic pseudoaneurysm from previously placed aortic grafts. Additionally, our study suggests this unique endovascular technique is an ideal alternative for creating a customized tube graft in challenging cases, particularly in high-risk patients.
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Affiliation(s)
- Wei Zhou
- Division of Vascular Surgery and Endovascular Therapy, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA.
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Bössow D, Gross-Fengels W, Debus ES. Die endovaskuläre Versorgung von Nahtaneurysmen nach konventioneller Operation im Bereich der aortoiliakalen Achse — Methode der Zukunft? GEFÄSSCHIRURGIE 2005. [DOI: 10.1007/s00772-005-0407-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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van Herwaarden JA, Waasdorp EJ, Bendermacher BLW, van den Berg JC, Teijink JAW, Moll FL. Endovascular repair of paraanastomotic aneurysms after previous open aortic prosthetic reconstruction. Ann Vasc Surg 2004; 18:280-6. [PMID: 15354628 DOI: 10.1007/s10016-004-0002-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aim of this study was to evaluate the effectiveness of endovascular repair of anastomotic and true aortic and iliac aneurysms occurring after prior polyester graft repair for abdominal aortic aneurysms (AAA) or aortoiliac obstructive disease. Between July 1999 and January 2003, 14 patients underwent endovascular treatment of aortic pseudoaneurysms (n = 6) or iliac aneurysms (2 patients with pseudoaneurysms and 6 patients with true aneurysms) occurring 4 to 18.4 years (mean, 8.8 years) after open aortic surgery. No patient had symptoms or positive parameters for infection of the original polyester graft. Eleven patients, including one patient with both a proximal anastomotic and a true iliac aneurysm, were treated with AneuRx (n = 8), Talent (n = 2), or Quantum LP (n = 1) bifurcated stent grafts. Three patients with an infrarenal anastomotic pseudoaneurysm were treated with a tube stent graft (Talent [n = 2] and AneuRx [n = 1]). Endovascular stent grafts were successfully inserted in all patients. Procedure-related complications or death was not seen. During a median follow-up of 12 months (range, 3-40) all anastomotic and/or true aneurysms treated with bifurcated stent grafts maintained excluded. However, two out of three patients, treated with a tube graft for proximal aneurysm exclusion, were converted. In both patients the tube stent graft did not migrate from the level of the renal arteries but fixation failed between the stent graft and the previous polyester graft, creating endotension in the thrombus of the aneurysm sac. In one of these patients the old anastomotic aneurysm ruptured 16 months after stent graft placement and the patient died 1 day after conversion because of mesenterial ischemia. At 1 year follow-up the second patient was converted successfully after enlargement of his anastomotic aneurysm due to similar disconnection between the stent graft and the polyester graft. From this experience with endovascular stent grafts, we conclude that these can be used successfully to exclude anastomotic or true aneurysms after open aortic surgery. Exclusion of aneurysms at the proximal anastomosis with tube stent grafts is apparently not durable because of the insecure distal fixation in polyester grafts. Endovascular repair with bifurcated stent grafts, however, seems to be effective at midterm follow-up.
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MESH Headings
- Aged
- Aged, 80 and over
- Anastomosis, Surgical
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/surgery
- Angiography, Digital Subtraction
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/pathology
- Aorta, Abdominal/surgery
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/surgery
- Aortic Rupture/diagnostic imaging
- Aortic Rupture/etiology
- Aortic Rupture/surgery
- Blood Vessel Prosthesis Implantation
- Follow-Up Studies
- Humans
- Iliac Aneurysm/diagnostic imaging
- Iliac Aneurysm/surgery
- Iliac Artery/diagnostic imaging
- Iliac Artery/pathology
- Iliac Artery/surgery
- Length of Stay
- Male
- Middle Aged
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/etiology
- Postoperative Complications/surgery
- Renal Artery/diagnostic imaging
- Renal Artery/injuries
- Renal Artery/surgery
- Reoperation
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
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Affiliation(s)
- Joost A van Herwaarden
- Department of Vascular Surgery, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
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