Endovascular treatment of infrarenal abdominal aortic aneurysms

Multiple endovascular aortic aneurysm repair graft failures and re-interventions over 15 years

Re-intervention on abdominal aortic aneurysm treated by endovascular aortic aneurysm repair for complications such as endoleak, graft migration, and graft failure is relatively common. However, re-do endovascular aortic aneurysm repair can be complex, as the failed graft still resides within the vessel. In addition, some re-do endovascular aortic aneurysm repairs call for an advanced custom graft, which can further increase the complexity and technical skill required. We describe a case of a 15-year-old endovascular aortic aneurysm repair originally implanted in a 71-year-old man, followed by three separate complications requiring intervention. We describe important procedural decisions taken into consideration when presented with failure of an older graft.

A retrospective study on endovascular management of iatrogenic vascular injuries

The purpose of this study was to evaluate the outcome of endovascular management of iatrogenic vascular injuries (IVIs). We retrospectively reviewed the clinical records of 19 consecutive patients who underwent endovascular therapy of IVIs. Endograft implantation was conducted in 13 patients, intravascular embolization using coil was performed in four patients, combined treatment involving endovascular balloon intervention and percutaneous thrombin injection was done in one patient and the remaining one patient received balloon compression for hemostasis. There were no deaths after the operation. In the patients with vessel rupture ( n = 9) or perforation ( n = 4), cessation of bleeding and restoration of blood flow were achieved following the endovascular treatments. Four cases of pseudoaneurysm and one case of arteriovenous fistula were successfully eliminated. At a median follow-up of 23.8 months (range 4–84), one patient suffered a mild cerebral infarction secondary to covered stent placement and one patient developed a partial renal infarction secondary to coil embolization. Additionally, stent collapse was found in one patient with stenosis of the iliofemoral vein, accounting for the failure to resolve the lower limb edema. In conclusion, endovascular therapy is an effective technique in the management of different types of IVIs, but is associated with minor ischemic complications.

The anterior visceral branches of the abdominal aorta and their relationship to the renal arteries

Variations in the anatomy of the abdominal aorta and its branches are of interest as vessel geometry not only determines flow dynamics, but is also crucial in the pathogenesis of vascular disease. The relationship between the anterior visceral and renal arteries is important when undertaking diagnostic arteriography and endovascular interventions. To examine these relationships, the length of the abdominal aorta was determined and measurements taken of the position of origin of the celiac artery, superior mesenteric artery (SMA), inferior mesenteric artery (IMA) and renal arteries, as well as the three-dimensional projection of each vessel from the aorta. The mean level of bifurcation of the aorta was at the lower third of the body of L4, with the celiac artery, SMA, renal arteries and IMA arising at the level of the T12/L1 intervertebral disc, upper third of the body of L1, lower third of the body of L1 and lower third of the body of L3, respectively. The horizontal projection of the celiac artery, SMA and IMA was to the left of the midline; in the sagittal plane, the celiac artery and SMA projected anteriorly and the IMA posteriorly; in the coronal plane all vessels projected inferiorly, with the SMA to the right and the IMA to the left. The celiac artery, SMA and both renal arteries all arise from the proximal half of the abdominal aorta within 45 mm of each other, with the origins of the renal arteries being remarkably consistent. It is concluded that the celiac artery and SMA are both useful landmarks for determining the position of the renal arteries.

Suprarenal fixation of endograft in abdominal aortic aneurysm treatment: focus on renal function

OBJECTIVE

The objective of this work was to evaluate any variation of renal function detected by renal scintigraphy after the suprarenal fixation of endografts for abdominal aortic aneurysm (AAA) repair.

SUMMARY BACKGROUND DATA

In the few articles that have considered this problem, renal function was evaluated only by biochemical tests, which are inadequate in demonstrating small changes in renal function and in appreciating the worsening of a single kidney's function.

METHODS

Between April 1999 and May 2002, 47 patients with an inappropriate infrarenal proximal neck had a suprarenal fixation for AAA. To assess renal function, a technetium-99m diethylene triamine penta-acetic acid (TC-DTPA) perfusion scintigraphy was performed preoperatively on the third postoperative day and at 6, 12 months, and then yearly thereafter. Worsening of renal function was defined as a decrease of glomerular filtration rate (GFR) > or =20% (detected with Gates method). Serum creatinine level was tested preoperatively and at the first and third postoperative day.

RESULTS

Endograft deployment was technically successful in 44 patients (93.6%); clinical perioperative success was obtained in 46 patients (97.8%). In 12 patients (25.5%), a permanent reduction of the GFR was observed using postoperative TC-DTPA perfusion scintigraphy. By 99m TC-DTPA perfusion scintigraphy, a permanent reduction of GFR was observed postoperatively in 12 patients. A slight GFR reduction (<20%) was present in 7 (14.9%) patients, due to the planned occlusion of accessory renal arteries. A more significant GFR reduction (>20%) was present unexpectedly in 5 (10.6%) patients, in 3 of these a single kidney was involved, in 5 both with an increase of the serum creatinine level >20%.

CONCLUSIONS

Suprarenal fixation of endografts in AAA treatment is a safe procedure with good early and midterm procedural results and a risk of GFR impairment (>20%) of 10.6%.

Risk stratification and outcomes of transluminal endografting for abdominal aortic aneurysm: 7-year experience and long-term follow-up

PURPOSE

To determine early and late outcomes of transluminal endografting (TE) in patients with abdominal aortic aneurysm (AAA), stratified by predicted risk of procedure-related mortality with conventional operation.

MATERIALS AND METHODS

A retrospective study was conducted in consecutive risk-stratified AAA patients undergoing TE at a not-for-profit cardiovascular referral center from March 1994 through November 2000 with follow-up through February 2001. With use of conventional risk strata (0 = low, 1 = minimal, 2 = moderate, and 3 = high), predicted procedure-related mortalities were 0%-1% in stratum 0 (n = 40), 1%-3% in stratum 1 (n = 118), 3%-8% in stratum 2 (n = 116), and 8%-30% in stratum 3 (n = 31). Main outcome measures were: (i) TE procedural success, (ii) procedure-related mortality, (iii) major nonfatal complications, (iv) composite adverse outcome (ii + iii), (v) length of stay (LOS), (vi) freedom from AAA rupture, (vii) late survival, (viii) late complications, and (ix) endoleaks and their classification and management.

RESULTS

Women were significantly less likely than men to qualify for and undergo endografting: 24 of 91 (26.4%) women underwent TE, compared to 281 of 684 (41.1%) men. Of 305 attempted TE procedures, 291 (95.4%) were successful, four (1.3%) were urgently converted to open repair, and 10 (3.3%) were aborted. Procedure-related mortalities occurred in eight cases (2.6%) overall and one of 40 (2.5%), one of 118 (0.8%), four of 116 (3.4%), and two of 31 (6.5%) cases for risk strata 0-3, respectively. Perioperative survivors were significantly younger than nonsurvivors (74.3 y +/- 9 vs 81.6 y +/- 5.1; P =.0087). Forty-six patients (15.1%) had major complications. Composite adverse outcome was worse for patients in stratum 3 than those in stratum 1 (P =.0296) and those in strata 0, 1, and 2 combined (P =.026). Procedure-related mortality declined with institutional experience, from 4% among the first 100 patients undergoing TE to 1% among the last 105. For strata 0-3, median LOS were 2, 3, 3, and 4 days, respectively. Seventy patients (22.9%) had 75 endoleaks, of which 30 necessitated additional procedures, 17 self-resolved, and 22 were untreated as of March 1, 2001. Five patients with endoleak died of unrelated causes. One late-onset type IA endoleak (26 mo) resulted in the only AAA rupture and death in the follow-up period among the 291 patients who underwent successful transluminal endograft implantation. Actuarial survival rates at 1 year after TE were 90.3% +/- 1.9% for the overall study group and 97.5% +/- 2.5%, 94% +/- 2.5%, 86.9% +/- 3.3%, and 81.3% +/- 7.7% for risk strata 0-3, respectively. At 5 years, overall actuarial survival was 69.6% +/- 6.1%. Thirty-eight late deaths were attributable to post-TE AAA rupture (n = 1), AAA rupture late after failed TE with no further treatment (n = 1), other cardiovascular disorders (n = 7), cancer (n = 15), other causes (n = 10), and unknown causes (n = 4). Late deaths occurred in risk strata 0-3 at the following rates: two of 40 (5%), 10 of 118 (8.5%), 16 of 116 (13.8%), and 10 of 31 (32.3%), respectively (stratum 0 vs stratum 3, P =.0017; stratum 1 vs stratum 3, P =.003).

CONCLUSIONS

TE is safe and confers durable protection against AAA rupture in treated populations. Still, protection is not absolute in patients with endoleaks, because late AAA enlargement and even rupture can occur. Given current knowledge, technology, and practice, careful patient selection and close surveillance of patients after implantation of transluminal endografts is essential.

Endoleaks following endovascular repair of abdominal aortic aneurysm: the predictive value of preoperative anatomic factors--a review of 100 cases

OBJECTIVE

The failure to maintain a secure exclusion of aortic aneurysms with intraluminally placed grafts has been termed endoleak. We performed a retrospective review of our first 100 transluminally repaired abdominal aortic aneurysms (AAAs) in an effort to identify preoperative factors that could predict which patients would have endoleaks.

METHODS

Between February 1993 and September 1998, 100 infrarenal aneurysms were treated with tube (39), bifurcated (45), and aortoiliac grafts (16). Endoleaks (early and late) developed in 34 patients. Preoperative computed tomography scans and angiograms for all patients were individually inspected by a single reviewer. Aortic characteristics analyzed included number of patent lumbar arteries, presence of a patent inferior mesenteric artery (IMA), calcification and thrombus at proximal and distal attachment sites, proximal aortic angulation, and graft-vessel size discrepancy at proximal and distal attachment sites. The prevalence of the preoperative factors was compared among patients with and without endoleaks.

RESULTS

Endoleaks developed in 44% of tube, 33% of bifurcated, and 47% of aortoiliac grafts (P =.51). Correlation between total number of patent lumbar arteries, presence of a patent IMA, and endoleaks was not significant (P =.44,.95). Calcification at either proximal or distal attachment site did not increase the risk of endoleaks (P =.50,.62). The presence of thrombus at the attachment site (proximally or distally) also failed to increase endoleak rates (P =.12,.78). Degree of proximal aortic angulation did not differ between groups (P =.39). Size discrepancies between graft and aorta or iliac vessels at proximal or distal sites did not significantly differ (P >.54, >.13). Subgroup analysis of endoleaks with different tube types also failed to demonstrate significant differences among the three graft types (P >.05).

CONCLUSION

Endoleaks develop in a significant number of endovascularly repaired AAAs. We were unable to demonstrate a statistically significant association with anatomic characteristics thought to predispose to the development of endoleaks. We find no predictive value associated with these anatomic factors.

Endograft treatment of anastomotic aneurysms following conventional open surgery for infrarenal aortic aneurysms

OBJECTIVE

to evaluate the use of endograft therapy for treating anastomotic aneurysm following open surgical repair of infrarenal aneurysms of the abdominal aorta.

METHODS

four male patients (age 47-75 years) at high surgical risk (ASA IV n=3, ASA III n=1) developed secondary aneurysms at the site of the central (four aneurysms) and additional peripheral (two aneurysms) anastomosis of their tube or bifurcation prosthesis an average of 13 years (range 1-23 years) after conventional open surgical correction of infrarenal aneurysm of the abdominal aorta. In two patients, there was covered rupture of the aneurysm sac. The aneurysm diameter was 4.8 cm, 8.0 cm, 7.4 cm, 7.0 cm, respectively (mean 6.8 cm). Follow-up included helical CT imaging at 1 week, 3 months and 6 months postoperatively.

RESULTS

anastomotic aneurysm was successfully treated in all four cases. No evidence of endoleak was observed during the follow-up period. Two patients died 14 and 18 days after surgery due to myocardial infarction and cerebrovascular accident. The endovascular repair of the two patients who died was intact.

CONCLUSION

although no long-term results are available, the use of a graft-in-graft method to repair anastomotic aneurysms following conventional implantation of tube or bifurcation prostheses appears to be effective, particularly in patients at high surgical risk.

Suitability for endovascular aneurysm repair in an unselected population

BACKGROUND

Tertiary referral centres report that up to 60 per cent of patients may be suitable for endovascular repair of abdominal aortic aneurysm (EVAR). The aim of this study was to determine the percentage of abdominal aortic aneurysms (AAAs) presenting to a county-wide vascular service that were suitable for EVAR, and to examine the outcome of subsequent AAA repair in relation to aneurysm morphology.

PATIENTS AND METHODS

All patients being assessed for AAA repair between January 1998 and December 1999 underwent spiral computed tomography angiography to determine aneurysm morphology and suitability for EVAR. Subsequent outcome for all patients in the study was recorded in a prospective vascular database.

RESULTS

A total of 115 patients was assessed. Sixty-three aneurysms (55 per cent) had one or more absolute contraindications to EVAR, a further 13 (11 per cent) had at least one relative contraindication, and 39 (34 per cent) had no contraindication. Of patients with no absolute contraindication to EVAR, ten underwent successful EVAR, five did not meet recognized criteria for surgery, one awaits EVAR, four remain under observation, one awaits open repair, and 31 underwent open repair without death.

CONCLUSION

Only 30 per cent of unselected AAAs presenting to a vascular service are entirely suitable for EVAR; most of these patients can safely undergo open AAA repair. These data suggest that increased use of EVAR is only possible by deploying devices in suboptimal morphology, and in treating patients who would not normally be considered for open AAA repair.

Endoleak as a predictor of outcome after endovascular aneurysm repair: AneuRx multicenter clinical trial

OBJECTIVE

The purpose of this study was to determine whether evidence of blood flow in the aneurysm sac (endoleak) is a meaningful predictor of clinical outcome after successful endovascular aneurysm repair.

METHODS

We reviewed all patients in Phase II of the AneuRx Multicenter Clinical Trial with successful stent graft implantation and predischarge contrast computed tomographic (CT) imaging. The clinical outcome of patients with evidence of endoleak was compared with the outcome of patients without evidence of endoleak. The CT endoleak status before hospital discharge at 6, 12, and 24 months was determined by each clinical center as well as by an independent core laboratory. Endoleak status at 1 month was assessed with duplex scanning examination or CT at each center without confirmation by the core laboratory.

RESULTS

Centers reported endoleaks in 152 (38%) of 398 patients on predischarge CT, whereas the core laboratory reported endoleaks in 50% of these patients (P <.001). The center-reported endoleak rate decreased to 13% at 1 month. Follow-up extended to 2 years (mean, 10 +/- 4 months). One patient had aneurysm rupture and underwent successful open repair at 14 months. This patient had a Type I endoleak at discharge but no endoleak at 1 month or at subsequent follow-up times. There were no differences between patients with and patients without endoleak at discharge in the following outcome measures: patient survival, aneurysm rupture, surgical conversion, the need for an additional procedure for endoleak or graft patency, aneurysm enlargement more than 5 mm, the appearance of a new endoleak, or stent graft migration. Despite a higher endoleak rate identified by the core laboratory, neither the endoleak rate reported by the core laboratory nor the endoleak rate reported by the center at discharge was significantly related to subsequent outcome measures. Patients with endoleak at 1 month were more likely to undergo an additional procedure for endoleak than patients without endoleaks. Patients with Type I endoleaks at discharge and patients with endoleak at 1 month were more likely to experience aneurysm enlargement at 1 year. However, there was no difference in patient survival, aneurysm rupture rate, or primary or secondary success rate between patients with or without endoleak. Actuarial survival of all patients undergoing endovascular aneurysm repair was 96% at 1 year and was independent of endoleak status. Primary outcome success was 92% at 12 months and 88% at 18 months. Secondary outcome success was 96% at 12 months and 94% at 18 months.

CONCLUSIONS

The presence or absence of endoleak on CT scan before hospital discharge does not appear to predict patient survival or aneurysm rupture rate after endovascular aneurysm repair using the AneuRx stent graft. Although the identification of blood flow in the aneurysm sac after endovascular repair is a meaningful finding and may at times indicate inadequate stent graft fixation, the usefulness of endoleak as a primary indicator of procedural success or failure is unclear. Therefore, all patients who have undergone endovascular aneurysm repair should be carefully followed up regardless of endoleak status.

Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease

OBJECTIVE

The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease.

METHODS

We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils.

RESULTS

The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients.

CONCLUSIONS

These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy.

Mid-term results of endovascular versus open repair for abdominal aortic aneurysm in patients anatomically suitable for endovascular repair

OBJECTIVES

to prospectively evaluate the mid-term results of endovascular and open repair in patients with abdominal aortic aneurysm (AAA) anatomically suitable for endovascular repair.

MATERIAL AND METHODS

between January 1995 and March 1999, among 438 patients treated for AAA, 180 (41%) were suitable for endovascular repair as assessed by computed tomography (CT) scan and angiogram. Seventy-three were treated by various commercially available endovascular grafts (EV) and 107 by open repair (OR). Postoperatively, patients were followed every 6 months with clinical examination, duplex scan and in the EV group, CT scans. Patients>> demographic data, intra- and postoperative events were recorded prospectively in a computerised database and compared for each group.

RESULTS

median age, sex ratio, preoperative risk factors and aneurysm diameters were not statistically different between the two groups. Respectively in the EV and OR, the average duration of operation was 149+/-73 mn, and 133+/-44 mn (NS), blood loss 96 ml+/-28 and 985 ml+/-113 (p<0.01), duration of hospitalisation 7 days+/-2 and 13 days+/-7 (p<0.01). The one-month mortality was 2.7% (n=2) for EV and 2.8% (n=3) for OR. The rate of cardiac and pulmonary complications was significantly higher in the OR group (6. 9% versus 19.6%, p=0.017). At a mean follow-up of 1 year, the cumulative survival rate was 82.2%+/-7.5 for EV and 96%+/-2.12 for OR (log-rank test p=0.043). No patients died of rupture, but three patients had to be converted to open surgery. Twenty-two percent (n=16) patients in the EV and 7.5% (n=8) in the OR were submitted to a subsequent minor or major reintervention (p=0.007). At 1 year, the cumulative rates free of any reintervention were respectively 78. 8%+/-6.7% and 92.9%+/-2.7% (p=0.001). In the EV there were 17 early endoleaks (23.3%). At the end of patient's follow-up seven endoleaks (9.6%) persisted. The primary success rate defined by the absence of endoleak and the absence of reintervention was 54 (74%) with EV and 101 (94%) with OR (p=0.001).

CONCLUSION

EV is a promising technique. However, with current devices and indications the immediate benefits, mainly less blood loss, fewer cardiac and pulmonary complications, and shorter hospitalisation time, are outweighed by a higher rate of reinterventions to treat endoleak, or to maintain patency of the graft.

Management of abdominal aortic aneurysms

Rupture of an abdominal aortic aneurysm (AAA) remains a common vascular catastrophe in all emergency departments. Currently, the natural history of AAAs indicates that risk of rupture increases considerably when the aneurysm is greater than 5 cm in diameter. Appropriate management of aneurysms is elective repair for patients with a good operative risk whose aneurysm is between 5 and 6 cm. For patients with a serious medical comorbidity, the threshold for AAA repair is usually 6 cm. Surgical management is generally safe with extraordinarily durable results. Another current option is an investigational endovascular stent graft, but the long-term outcome for these new devices remains unknown. In addition, optimal medical management should include careful control of hypertension and smoking cessation. The current prognosis for healthy patients who undergo elective aneurysm repair is excellent.

Endovascular repair of abdominal aortic aneurysms: where do we stand?

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Mid-term results of a second generation bifurcated endovascular graft for abdominal aortic aneurysm repair: the French Vanguard trial

PURPOSE

The purpose of this study was to evaluate prospectively the results of the bifurcated Vanguard endovascular graft for abdominal aortic aneurysm (AAA) repair.

METHODS

Seventy-five patients, with a median age of 69.6 years (range, 48 to 88 years) and asymptomatic AAAs, were recruited in 14 French vascular institutions. An independent committee validated the indications for endovascular repair, and all the implantations were supervised by a well-trained medico-technical assistant. Further independent committees reviewed patient data, clinical data, and imaging follow-up examination. The main endpoints were implantation success, mortality, morbidity, reinterventions, and aneurysm evolution assessed with serial computed tomographic (CT) scanning.

RESULTS

All the grafts were successfully implanted, resulting in a 100% success rate on an intent-to-treat basis. At discharge, there were no deaths, six significant local complications (8%) that necessitated surgery, no vascular complications, and six systemic complications (8%). The average durations of intensive care unit and hospital stays were 26 +/- 6 hours and 6 +/- 2.54 days, respectively. Predischarge CT scan results showed five type I and 18 type II endoleaks (total, 30%). At the end of the follow-up period (mean duration, 18.35 +/- 4.12 months; range, 17 days to 24 months), seven patients (9%) had died: one from sepsis, five from unrelated causes, and one from aneurysm rupture. The 2-year cumulative survival rate was 86% +/- 5.9%. Twenty-one subsequent endovascular or vascular procedures were necessitated (28%) in 17 patients (23%) to treat graft limb occlusion or stenosis (n = 9 patients) or to seal an endoleak (n = 8 patients). The 2-year cumulative survival rate free of reintervention was 67% +/- 7%. On CT scans, the mean AAA diameter decreased from 54 mm +/- 8.9 (range, 45 to 80 mm) before surgery to 51.6 mm +/- 9.1 at 6 months and to 43.4 mm +/- 4.4 at the end of the follow-up period (P =.001). Persistent endoleak was significantly associated with an increase in diameter (4 of 5 [80%] vs 1 of 47 [2%]; P =.001).

CONCLUSION

In selected patients, the bifurcated Vanguard endovascular graft may be implanted with a low mortality and morbidity rate and a favorable mid-term survival rate. The decrease of the aneurysm size is a strong argument in favor of the efficiency of the device. However, lasting endoleaks with increased aneurysm diameter and occurrence of limb graft stenosis or occlusion raise concerns and justify a careful long-term follow-up monitoring of all patients who undergo treatment with endovascular technique.

An assessment of the current applicability of the EVT endovascular graft for treatment of patients with an infrarenal abdominal aortic aneurysm

OBJECTIVE

To determine the percentage of elective abdominal aortic aneurysms (AAAs)/aortoiliac aneurysms that currently can be repaired with endovascular grafts (EVGs), the reasons for rejection of EVGs, and the future role of EVG in the treatment of AAA.

METHODS

From January 1997 to May 1998, patients at three hospitals (a university hospital, a university-affiliated teaching hospital, and a Veterans Administration hospital with university faculty and residents) were evaluated for EVGs as part of a national clinical trial with grafts manufactured by Endovascular Technologies (EVT, Menlo Park, Calif). All patients at two hospitals and patients treated by the participating surgeons at the third hospital were screened for EVG. Patients with AAAs that were ruptured, symptomatic, or involved renal or mesenteric arteries and patients who declined treatment were excluded from the study. Evaluation included clinical examination, computed tomography scan, and selective arteriography. The decision to proceed with EVG was made by the vascular surgeon, with input and concurrence of medical personnel from a company with extensive experience in endograft repair. The main outcome measures were the determination of the percentage of elective AAAs currently being treated with an EVG and the reasons for exclusion of patients from EVG placement.

RESULTS

A total of 162 patients underwent elective treatment of an AAA, 22 (14%) with an EVG (14 bifurcated, eight tube) and 140 (86%) with traditional resection. Indications for not proceeding with an EVG included insufficient proximal cuff in 29 patients (21%), distal common iliac aneurysm or insufficient distal iliac neck in 29 patients (21%), proximal neck too large for an EVG in 24 patients (17%), symptomatic iliac stenosis in 23 patients (16%), iliac stenosis precluding introducer passage in 17 patients (12%), patient preference in 11 patients (8%), and calcification, kink, or extensive thrombus involving the proximal neck precluding safe graft attachment in seven patients (5%). Of the 22 patients treated with an EVG, three were converted to open resection, because of iliac stenosis in two patients and premature stent deployment in one patient (initial technical success rate, 86%).

CONCLUSION

Based on currently available technology, 80% of patients were not candidates for an EVG because of proximal calcification, short aortic or distal cuff, coexisting distal iliac aneurysm, and stenotic iliac disease. Even with the use of adjunctive procedures, most patients still require open repair. Significant changes in design will be necessary to apply these devices to most patients with an AAA.