Aortic endograft thrombosis after colorectal surgery in lithotomy position

Endovascular Exclusion of Abdominal Aortic Aneurysms and Simultaneous Resection of Colorectal Cancer

BACKGROUND

No consensus exists on the optimal strategy for treatment of abdominal aortic aneurysm (AAA) associated with colorectal cancer (CRC). The purpose of this study was to evaluate the results of endovascular treatment of AAA with simultaneous resection of CRC.

METHODS

Twenty-two consecutive patients presenting with AAA associated with a CRC were treated by endovascular AAA exclusion and simultaneous CRC resection. Median diameter of the aneurysm was 6.5 cm (range, 4.8-8 cm). Two patients (9%) had grade I cancer, 5 patients (23%) grade II, 13 patients (59%) grade III, and 2 patients (9%) grade IV. The 2 surgical procedures were performed under the same general anesthesia. Aneurysm exclusion was achieved using an infrarenal aorto-bi-iliac endoprosthesis (13 patients) and using an aorto-bi-iliac endoprosthesis with suprarenal fixation (9 patients), with 1 patient receiving bilateral renal chimney stent implantation. In all cases, vascularization of the hypogastric arteries was preserved. After AAA exclusion, colic resection was carried out by laparotomy with right colectomy (7 patients) and anterior rectocolic resection (15 patients). In all patients, AAA exclusion was controlled by a computed tomographic angioscan (CTA) at 1 month and duplex ultrasound every 6 months, and at some later stage, it was through inclusion of CTA as part of oncology surveillance. The mean duration of follow-up was 42 months (10-120 months). The primary endpoint was composite and regrouped any death occurring during the first 30 days after procedures, any type I endoleak, any aortic reintervention, and any AAA-related mortality.

RESULTS

No patient died during the first 30 postoperative days, and no patient was lost to follow-up. No aortic endoprosthesis infection and no type I endoleak were observed. Five endoleaks arising from the lumbar arteries (n = 4) or from the inferior mesenteric artery (n = 1) were identified. As they were not associated with an increase of the AAA diameter >5 mm, they were not treated. 1 colic anastomotic leak and 2 incisional abscesses were successfully cured by local care only. Nine patients (41%) died of cancer evolution during the follow-up period.

CONCLUSIONS

In this series, treatment of AAA and CRC during the same operative session yields results comparable to those observed when surgery is performed in 2 distinct operative sessions. Synchronous treatment reduced waiting time of colic resection. It may also shorten total hospitalization duration, although this last hypothesis is not supported by comparison with a control group.

Reperfusion and Compartment Syndrome After Flexible Ureteroscopy in a Patient with an Iliac Vascular Graft

Background: Flexible ureteroscopy (fURS) is one of the main treatment options for urolithiasis less than 2 cm. Although fURS has no relative contraindication, some anatomical factors may need to be considered, as not all patients are suitable for the regular lithotomy position (LP). We report the case of a patient with a right iliac vascular graft that after an fURS without intraoperative incidences developed a reperfusion syndrome of the right lower limb.

Case Presentation: A 46-year-old male patient was referred for treatment and follow-up in the cystinuric clinic after being found to have a 3 cm pelvic stone with a Double-J catheter in place after two failed sessions of shockwave lithotripsy. The patient was placed in the LP and a standard ureteroscopy was done with no intraoperative complications. During the first hour in the recovery room, the patient developed severe pain in the right calf muscle stiffness, edema, and increased volume. A postreperfusion and compartment syndrome diagnosis was made with emergency fasciotomy.

Conclusion: To perform fURS, each case must be assessed individually. If a patient with an iliac vascular graft has to undergo fURS, the patient positioning must be modified by keeping the ipsilateral (or both) legs straight to avoid graft complications.

Meta-analysis of Outcomes Following Aneurysm Repair in Patients with Synchronous Intra-abdominal Malignancy

OBJECTIVES

The management of concomitant intra-abdominal malignancy (IAM) and abdominal aortic aneurysm (AAA) remains a challenge, even though malignancy is common in an elderly population. By means of systematic review and meta-analysis, the aim was to investigate outcomes in patients undergoing open (OAR) or endovascular AAA repair (EVAR) that have a concomitant malignancy.

METHODS

A systematic literature review was performed (Medline and EMBASE databases) to identify all series reporting outcomes of AAA repair (OAR or EVAR) in patients with concomitant IAM. Meta-analysis was applied to assess mortality and major morbidity at 30 days and long term.

RESULTS

The literature review identified 36 series (543 patients) and the majority (18 series) reported on patients with colorectal malignancy and AAA. Mean weighted mortality for OAR at 30 days was 11% (95% CI: 6.6% to 17.9%); none of the EVAR patients died peri-operatively. The weighted 30-day major complication rate for EVAR was 20.4% (10.0-37.4%) and for OAR it was 15.4% (7.0-30.8%). Most patients had their AAA and malignancy treated non-simultaneously (56.6%, 95% CI, 42.1-70.1%). In the EVAR cohort, three patients (4.6%) died at last follow-up (range 24-64 months). In the OAR cohort 23 (10.6%) had died at last follow up (range from 4 to 73 months).

CONCLUSION

In this meta-analysis, OAR was associated with significant peri-operative mortality in patients with an IAM. EVAR should be the first-line modality of AAA repair. The majority of patients were not treated simultaneously for the two pathologies, but further investigation is necessary to define the optimal timing for each procedure and malignancy.

Management of Synchronous Abdominal Aortic Aneurysm and Complicating Colorectal Cancer

Concomitant management of synchronous abdominal aortic aneurysm (AAA) and colorectal cancer (CRC) is mandatory in cases in which both entities are life threatening for the patient. The endovascular aneurysm repair (EVAR) method can contribute toward concomitant management by offering the avoidance of an otherwise threatening vascular graft infection. We present a case of a complicating CRC and a synchronous AAA, which were successfully treated at the same hospitalization. The AAA was treated first by EVAR, and the colon resection followed 3 days later. The patient's postoperative course was uneventful. EVAR, if the standard criteria are met, could comprise an alternative and reliable solution for treating concomitant AAA and CRC even in the acute setting.

Management of concomitant abdominal aortic aneurysm and colorectal cancer

OBJECTIVE

To conduct a systematic review of the literature and perform an analysis of outcomes of treatment of concomitant colorectal cancer (CRC) and abdominal aortic aneurysm (AAA) with a focus on the different treatment options and the related therapeutic outcomes.

METHODS

A review of the English-language medical literature from 1980 to 2015 was undertaken using the PubMed and EMBASE databases to identify studies reporting surgical treatment of patients with concomitant CRC and AAA. The search identified 24 articles encompassing 254 patients (81% male; mean age 73.5 ± 6.1 years).

RESULTS

In 96 patients (37.9%) cancer resection was performed first, followed by AAA repair at a later stage (open aortic repair [OAR], 79.2%; endovascular abdominal aortic repair [EVAR], 20.8%). Eighty-two patients (32.3%) underwent AAA repair (OAR, 47.5%; EVAR, 52.5%) before CRC resection. Seventy-one patients (27.9%) underwent combined OAR and CRC resection, and just five (1.9%) were treated with EVAR and cancer surgery in a single stage. There were eight of 96 interval AAA ruptures (8.3%), mostly in the early postoperative period concerning aneurysms >6 cm in diameter. The mean interval between the two procedures was much shorter in patients treated with EVAR than OAR (11.5 ± 1.8 days vs 103.9 ± 42.3 days). The overall 30-day mortality rate was 10.9%. Data from observational studies showed no significant differences in 30-day mortality between patients treated in one or two stages (P = .89). No mortality was recorded in any of the EVAR-treated patients. There was only one graft infection recorded (0.4%).

CONCLUSIONS

Among different approaches, no significant differences in 30-day outcomes among patients treated in either two or one stage were evident. EVAR showed the lowest mortality and also diminished the delay between the two procedures in <2 weeks for a two-stage approach, although it has been associated with a significant risk for thrombotic events. The coexistence of AAA and CRC seems to favor the use of EVAR in treating those patients.

Lithotomy-related neurovascular complications in the lower limbs after colorectal surgery

AIM

To review the literature on lithotomy-related neurovascular complications (LRNVC) of the lower limbs after colorectal surgery.

METHOD

Electronic databases were searched for relevant articles, including Medline, EMBASE, Pubmed, CENTRAL and CINHL.

RESULTS

LRNVC after prolonged lithotomy position during colorectal surgery can be classified into vascular, neurological and neurovascular combined. Compartment syndrome (CS) is the most common clinical presentation. Seven case reports and 10 case series on 34 patients (27 men, 6 women) with CS have been reported. Risk factors included the lithotomy position and duration of surgery of more than 4 h.

CONCLUSION

In colorectal surgery, lower limb LRNCVs, and CS are rare. A high index of clinical suspicion and early decompression may reduce morbidity.

Management of concomitant cancer and abdominal aortic aneurysm

Background. The coexistence of neoplasm and abdominal aortic aneurysm (AAA) presents a real management challenge. This paper reviews the literature on the prevalence, diagnosis, and management dilemmas of concurrent visceral malignancy and abdominal aortic aneurysm. Method. The MEDLINE and HIGHWIRE databases (1966-present) were searched. Papers detailing relevant data were assessed for quality and validity. All case series, review articles, and references of such articles were searched for additional relevant papers. Results. Current challenges in decision making, the effect of major body-cavity surgery on an untreated aneurysm, the effects of major vascular surgery on the treatment of malignancy, the use of EVAR (endovascular aortic aneurysm repair) as a fairly low-risk procedure and its role in the management of malignancy, and the effect of other challenging issues such as the use of adjuvant therapy, and patients informed decision-making were reviewed and discussed. Conclusion. In synchronous malignancy and abdominal aortic aneurysm, the most life-threatening lesion should be addressed first. Endovascular aneurysm repair where possible, followed by malignancy resection, is becoming the preferred initial treatment choice in most centres.

Infrarenal Abdominal Aortic Aneurysm with Concomitant Urologic Malignancy: Treatment Results in the Era of Endovascular Aneurysm Repair

During diagnostic workup for urologic malignancies, an abdominal aortic aneurysm (AAA) is identified in a proportion of patients. In the era of open AAA repair, these patients presented a surgical dilemma with regard to the sequence of the operations: cancer treatment first or AAA repair first? Previous assessments have concluded that irrespective of the followed strategy, the early and mediumterm mortality from the two operative procedures in this patient category was significant. With the introduction of endovascular aneurysm repair (EVAR), the mortality and morbidity associated with the treatment of both pathologic conditions may be more favorable than with open aneurysm repair. The objective of this study was to assess, in an institutional series of patients receiving EVAR, the early and long-term survival and complication rates in patients with urologic malignancies. In a series of 385 patients receiving EVAR, 14 had a concomitant urologic malignancy: renal cell carcinoma (5 patients), prostate carcinoma (6 patients), and carcinoma of the bladder (3 patients). The first-month mortality was nil. Long-term survival was 80%, 83%, and 67% for the three tumor types, respectively. EVAR offers improved treatment in patients with concomitant AAA and urologic malignancy and should be considered the first choice for these patients.

Concurrent colorectal malignancy and abdominal aortic aneurysm: a multicentre experience and review of the literature

OBJECTIVES

There is lack of consensus regarding concurrent vs. staged approaches, and the prioritisation of staged procedures in cases presenting with colorectal carcinoma (CRC) and abdominal aortic aneurysm (AAA) synchronously. We aim to present our experience, review the literature on this therapeutic dilemma and examine the role of endovascular aortic repair (EVAR).

DESIGN, MATERIALS AND METHODS

An observational study of the experience of two centres and a systematic review of the published literature.

RESULTS

Twenty-four patients were identified from the prospective databases of two tertiary referral centres between 2001 and 2006. Intervention for both malignancy and aneurysm was performed in 13 patients. In 10 patients, cancer resection was performed initially and was followed by open aneurysm repair (n=3) or EVAR (n=7). Two patients (AAA diameters: 7.0 and 8.0cm) underwent EVAR prior to colonic resection. One patient was selected for synchronous surgery. There were no interval AAA ruptures, graft infection or postoperative mortalities. Literature review identified 269 such cases; of these 101 were treated by combined surgery. In staged surgery, there were nine interval aneurysmal ruptures and one aortic graft infection.

CONCLUSIONS

In our experience, staged management can be undertaken, without interval aneurysmal rupture. EVAR has an evolving role in preventing delay in CRC management, in high-risk patients, and during combined intervention.

Treatment of abdominal aortic aneurysm associated with colorectal cancer: presentation of 14 cases and literature review

PURPOSE

The coexistence of abdominal aortic aneurysm (AAA) and cancer is observed with increasing frequency, raising several questions about therapeutic and surgical strategies for management of both diseases. In this study, we present our experience on 14 patients affected by both colorectal cancer (CRC) and AAA, and we have also reviewed the literature from 1988 to 2005 for clinical experiences on this matter.

MATERIALS AND METHODS

From January 1988 to May 2006, 1,012 AAA and 1,480 CRC were observed and treated in our department; in 14 patients (1.3% of AAA and 0.9% of CRC), both diseases were coexistent. We also performed a literature review from 1987 to 2005, and we found 254 cases of AAA associated with CRC.

RESULTS

Priority was given for treatment of vascular disease. The diseases were treated in one stage in nine cases and in two stage in four patients; in the remaining case, only the CRC was treated due to patient's poor cardiac conditions. Postoperative (30-day) complications were seen in 1 of 14 patients (7.1%), whereas there were no postoperative deaths or prosthetic infections. In the literature review, treatment in one stage was performed in 102 cases and in two stage in 118 cases; in the remaining 25 cases, only one disease was treated (in 24 cases, for different reasons, only CRC was treated, whereas in the last case, only the AAA was treated, and the patient died in the postoperative period). Postoperative (30-day) morbidity and mortality in one-stage treatment were 8 and 4.5%, respectively, and 21.3 and 6% in two-stage treatments, respectively. In patients treated for only one disease, 30-day morbidity and mortality were 4 and 24%, respectively. Only one case of prosthetic infection was reported after a two-stage treatment.

CONCLUSIONS

From the analysis of the literature and our experience, it is evident that, when AAA and CRC are coexistent with preoperative diagnosis of both diseases, single-stage intervention, when feasible for patient in general and local conditions, has to be preferred due to the lower morbidity. Single-stage treatment avoids a second surgical and anesthesiologic trauma and eliminates the risks joined with the non-treated lesion, increasing, however, the magnitude of the operation. Endovascular therapy, for its less invasiveness, appears to be an adequate solution for one-stage treatment of the two diseases but its role is still subject of ongoing discussions.

Management of simultaneous abdominal aortic aneurysm and colorectal cancer: the rationale of mini-invasive approach

The concomitant occurrence of abdominal aortic aneurysm and malignancy represents a therapeutic dilemma. Both lesions should be treated to achieve best life expectancy; the main controversy remains whether to treat them simultaneously or as staged procedures. Recently, endovascular repair has been suggested as a potential alternative to open standard intervention. We present a case of synchronous abdominal aortic aneurysm and colorectal cancer treated simultaneously by minimally invasive surgery.

Endovascular versus open surgical repair of abdominal aortic aneurysm with concomitant malignancy

BACKGROUND

The management of patients with abdominal aortic aneurysm (AAA) and concurrent malignancy is controversial. This study retrospectively assessed the outcome of endovascular repair (EVAR) and open repair (OR) for the treatment of AAA in patients undergoing curative treatment for concomitant malignancies.

METHODS

All patients who underwent surgery for a nonruptured infrarenal AAA of > or =5.5 cm and concomitant malignancy between 1997 and 2005 were retrospectively reviewed.

RESULTS

Identified were 25 patients (22 men; mean age, 70.3 years) with nonruptured infrarenal AAA of > or =5.5 cm (mean size, 6.4 cm) and concomitant malignancy amenable for curative treatment. EVAR was used to treat 11 patients, and 14 underwent OR. The EVAR patients had a smaller mean aneurysm size (5.9 cm vs 6.8 cm; P = .006) than the OR patients. The mean cumulative length of stay for all patients who received treatment for both AAA and cancer was 12.8 days (range, 4 to 26) for EVAR and 18.2 days (range, 9 to 42 days) for OR. In the EVAR group, no patients died perioperatively; in the OR group, three patients died perioperatively (21.4%; P = NS). Postoperative complications occurred in one patient in the EVAR group and in seven in the OR group for a morbidity rate, respectively, of 9.1% and 50% (P = .04). One late complication (9.1%) occurred in the EVAR group. The mean follow-up was 37.7 months (range, 16 to 60 months) in the EVAR group and 29.6 months (range, 11 to 55 months) in the OR group. At 1 and 2 years, survival rates were 100% and 90.9% in the EVAR group and 71.4% and 49% in the OR group (log-rank P = .103)

CONCLUSIONS

With low morbidity and mortality, EVAR is a safe technique for the treatment of AAA in patients with concomitant malignancy and could be considered as an alternative to OR.

Endovascular Graft Limb Occlusion After an Anterior Resection for Rectal Cancer: Report of a Case

An endovascular aneurysm repair has become an important therapeutic option for the management of patients with aortic aneurysms. Early advantages of the endovascular technique have been well documented. Patients with aortic aneurysms undergoing these procedures are usually elderly, which increases the likelihood of comorbidities. With the increased use of vascular devices, potential complications such as graft limb occlusion need to be widely understood, so they can be recognized and treated early. We recently treated an 85-year-old man with acute endovascular graft limb occlusion after an elective anterior resection for rectal cancer, and we discuss some factors that may have contributed to this complication.

Aneurysm Sac Re-Expansion After Thrombolysis

PURPOSE

To present a case of delayed abdominal aortic aneurysm (AAA) re-expansion after thrombolysis for endograft limb occlusion.

CASE REPORT

A 68-year-old man underwent AAA exclusion with an AneuRx stent-graft in 1999. Five years later, he developed right limb thrombosis of the endograft. He underwent right limb thrombolysis and AngioJet thrombectomy. The patient experienced abdominal and back pain during the procedure, and the aneurysm sac, which had remained reduced in size for several years, acutely re-expanded. The patient was managed conservatively. The fluid that accumulated in the sac was reabsorbed, and the AAA returned to its previous dimensions at 1-month follow-up.

CONCLUSION

Symptomatic re-expansion of the aneurysm sac after AngioJet rheolytic thrombectomy may occur when the graft is stripped of neointima by the "power-pulse" spray of lytic agent, allowing serum to seep into the sac. Based on this experience, we advise caution when delivering thrombolytics using the AngioJet "power-pulse" spray mode in patients with a thrombosed stent-graft.