Endovascular repair of para-anastomotic aortic aneurysms

Editor's Choice -- European Society for Vascular Surgery (ESVS) 2024 Clinical Practice Guidelines on the Management of Abdominal Aorto-Iliac Artery Aneurysms

OBJECTIVE

The European Society for Vascular Surgery (ESVS) has developed clinical practice guidelines for the care of patients with aneurysms of the abdominal aorta and iliac arteries in succession to the 2011 and 2019 versions, with the aim of assisting physicians and patients in selecting the best management strategy.

METHODS

The guideline is based on scientific evidence completed with expert opinion on the matter. By summarising and evaluating the best available evidence, recommendations for the evaluation and treatment of patients have been formulated. The recommendations are graded according to a modified European Society of Cardiology grading system, where the strength (class) of each recommendation is graded from I to III and the letters A to C mark the level of evidence.

RESULTS

A total of 160 recommendations have been issued on the following topics: Service standards, including surgical volume and training; Epidemiology, diagnosis, and screening; Management of patients with small abdominal aortic aneurysm (AAA), including surveillance, cardiovascular risk reduction, and indication for repair; Elective AAA repair, including operative risk assessment, open and endovascular repair, and early complications; Ruptured and symptomatic AAA, including peri-operative management, such as permissive hypotension and use of aortic occlusion balloon, open and endovascular repair, and early complications, such as abdominal compartment syndrome and colonic ischaemia; Long term outcome and follow up after AAA repair, including graft infection, endoleaks and follow up routines; Management of complex AAA, including open and endovascular repair; Management of iliac artery aneurysm, including indication for repair and open and endovascular repair; and Miscellaneous aortic problems, including mycotic, inflammatory, and saccular aortic aneurysm. In addition, Shared decision making is being addressed, with supporting information for patients, and Unresolved issues are discussed.

CONCLUSION

The ESVS Clinical Practice Guidelines provide the most comprehensive, up to date, and unbiased advice to clinicians and patients on the management of abdominal aorto-iliac artery aneurysms.

Efficacy of non-obstructive aortic angioscopy for detecting a thoracic aortic graft rupture: a case report

Background

Non-anastomotic thoracic aortic graft rupture is extremely rare and difficult to diagnose. Non-obstructive general angioscopy can help monitor the aortic intima and detect the locations of abnormal findings, while aortic angioscopy can detect vulnerable plaques in the aorta, which are difficult to visualize using conventional diagnostic methods. Herein, we report the case of a patient with non-anastomotic thoracic aortic graft rupture diagnosed using non-obstructive aortic angioscopy.

Case presentation

An 85-year-old man who had undergone total arch replacement 5 years prior complained of chest pain. Emergent contrast-enhanced computed tomography (CT) revealed an intra-mediastinal hematoma around the vascular graft of the ascending aorta and angiography revealed pooling of contrast medium on the dorsal side of the vascular graft. We suspected extravasation of the thoracic vascular graft. Aortic angioscopic examination revealed a red vascular graft defect that matched extravasation at the contralateral level of the prosthetic left common carotid artery branch. Subsequently, non-anastomotic thoracic aortic graft rupture was diagnosed. The patient underwent a two-debranching thoracic endovascular aortic repair (Zone 0) with a right subclavian artery-left common carotid artery-left subclavian artery bypass. Postoperative angiography revealed disappearance of the extravasation from the graft rupture site, patent grafted vessels with flow, and no endoleak. Follow-up CT at 6 months postoperatively showed no extravasation.

Conclusions

To our knowledge, this is the first report of non-anastomotic thoracic aortic graft rupture detected using non-obstructive aortic angioscopy. Aortic angioscopy can help establish a definitive diagnosis in patients with aortic graft rupture.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-022-01394-w.

Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair

The development of a paraanastomotic pseudoaneurysm is a serious complication after open prosthetic reconstruction of the aorta for occlusive or aneurysmal disease. Open repair of these lesions has previously been associated with high rates of morbidity and mortality. Endovascular repair may provide suitable treatment for proximal paraanastomotic aortic bypass graft pseudoaneurysms in patients who are poor candidates for open surgery. Bilateral renal artery coverage may be necessary to achieve adequate fixation and seal during life-threatening emergency cases of pseudoaneurysm rupture. Due to the infrequency of reported cases, the consequences of bilateral renal artery occlusion during these complex procedures are poorly understood. We present a case of a proximal paraanastomotic aortobifemoral bypass pseudoaneurysm rupture that was managed using endovascular repair with intentional coverage of both renal arteries. We also review the contemporary literature on endovascular management of paraanastomotic aneurysms and discuss the role of bilateral renal artery coverage in treating select patients with complex ruptured aortic pathology.

The Incidence of Para-Anastomotic Aneurysm After Open Repair Surgery for Abdominal Aortic Aneurysm Through Routine Annual Computed Tomography Imaging

OBJECTIVE

Open repair surgery (ORS) for an abdominal aortic aneurysm (AAA) remains an important treatment option, but the incidence of para-anastomotic aneurysms is unclear. The purpose of this study was to estimate the incidence of para-anastomotic aneurysms and reveal secondary complications through routine annual computed tomography (CT) imaging.

METHODS

One hundred and forty-seven patients who underwent ORS for AAA between January 2006 and December 2015 and received routine CT imaging surveillance were enrolled.

RESULTS

The follow up period was 7.1 ± 2.7 years. The total follow up time of all patients was 1 041.1 years, and 958 CT images were collected (0.92 CT scans/year/patient). A proximal para-anastomotic aneurysm was detected in five patients (3.4%). Four of the five patients had aneurysmal dilation at the initial ORS (proximal diameter >25 mm), which enlarged during follow up; thus, a de novo proximal para-anastomotic aneurysm was observed in one patient (0.7%). The time between surgery and the diagnosis of all proximal para-anastomotic aneurysms was 5.7 ± 1.4 years, and the de novo proximal para-anastomotic aneurysm was detected at 11.8 years. The incidence of all para-anastomotic aneurysms at five and 10 years was 2.2% and 3.6%, and the incidence of the de novo para-anastomotic aneurysm was 0% at five and 10 years. Nine synchronous thoracic aortic aneurysms (TAAs) and seven metachronous TAAs were detected, and 16 patients (10.9%) had a TAA. Neoplasms were detected in 18 of 147 patients (12.2%), and the most dominant neoplasm was lung cancer.

CONCLUSION

The incidence of para-anastomotic aneurysms was low; thus, abdominal and pelvic CT imaging every five years may be sufficient and consistent with the current AAA guidelines. In contrast, TAAs were diagnosed in a high percentage of patients, and based on these observations, routine CT imaging should be expanded to include the chest.

Endovascular treatment of proximal para-anastomotic aneurysms after previous surgical repair of infrarenal aortic aneurysms by the chimney technique

OBJECTIVES

To evaluate the use of chimney grafts in the treatment of para-anastomotic aneurysms after previous abdominal aortic aneurysms open repair with short neck.

METHODS

A retrospective analysis of prospectively collected data of consecutive patients who underwent endovascular repair for proximal aortic para-anastomotic aneurysms following previous open repair for infrarenal abdominal aortic aneurysms was performed. All included patients had a short infrarenal aortic neck (<10 mm) excluding standard endovascular aortic repair. Five patients were symptomatic at the admission needed urgent treatment.

RESULTS

Twelve patients with para-anastomotic aneurysms underwent placement of chimney grafts. The median time between the original operations to redo endovascular procedure was 11 years (interquartile range, 9.5 years). The mean infrarenal length was 4.3 mm (1-9 mm). A total of 28 chimneys grafts were deployed for the 12 patients. The technical success rate was 91.7%. At a median radiologic follow-up of 16 months (2.0-29.4, 95% confidence interval), one patient died, while two late endoleaks and two reinterventions at one and three years for type Ia endoleak were performed by proximal extension and triple chimney graft placement.

CONCLUSION

The results of the present study show that ch-endovascular aortic repair is a safe technique for patients who suffered from proximal para-anastomotic aneurysms and having short neck unsuitable for standard endovascular repair. Longer follow up warranted to evaluate the durability of ch-endovascular aortic repair for this specific indication.

Successful Hybrid Zone 0 Landing Thoracic Endovascular Aortic Repair for Ascending Aortic Pseudoaneurysm after Bentall Procedure and Coronary Artery Bypass Grafting in Takayasu Arteritis

Pseudoaneurysm at the suture line is one of the most common complications in aortic surgery for Takayasu arteritis (TA) and is associated with a high mortality rate. A 52-year-old man with TA, who previously underwent the Bentall procedure and 2 redo surgeries for coronary artery obstruction and a pseudoaneurysm of a coronary button, was diagnosed with an anastomotic pseudoaneurysm in the ascending aorta. Hybrid zone 0 debranching thoracic endovascular aortic repair was performed, and the patient was discharged uneventfully on postoperative day 8.

Endovascular treatment of para-anastomotic aneurysms after open abdominal aortic surgery

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.

Novel Application of Branched Endograft for Preservation of Pelvic Circulation

BACKGROUND

Endovascular repair of a proximal anastomotic pseudoaneurysm (APSA) of an end-to-side aortobifemoral bypass (ABF) can lead to pelvic ischemia. We present a novel application of branched aortic endograft to repair such pseudoaneurysm while preserving flow into the ABF and native aortoiliac system.

METHODS

A 71-year-old male with history of aortoiliac occlusive disease resulting in lifestyle limiting claudication was treated with an aortobifemoral bypass in 1999. The patient developed an 8.8 cm pseudoaneurysm at the aortic anastomosis. CTA demonstrated patent right common and internal iliac arteries with an occluded right external iliac artery and occluded left common and external iliac arteries.

RESULTS

A 24 × 80 mm endograft with an 8 × 15 mm posterior branch based on the Cook Zenith device (Bloomington, IN) was delivered via a right femoral artery exposure. The preloaded wire of the main body was snared via left brachial access. A 10F sheath was advanced into the side branch of the graft to deliver a 10 × 10-mm Bard Fluency (Covington, Georgia) stent graft into the right common iliac artery. The branch was reinforced proximally with an 8 × 17 mm Boston Scientific Express (Marlborough, MA) stent. The patient was discharged after 5 days. At 1 month, CTA demonstrated patent ABF, patent branch graft into the pelvis, and exclusion of the pseudoaneurysm.

CONCLUSIONS

Branch grafts can provide minimally invasive revision of a failing ABF, in this case an APSA, while preserving pelvic circulation and lower extremity perfusion.

Use of a Thoracic Endograft in an Acute Abdominal Aortic Setting: Case Report and Literature Review

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.

Endovascular repair of proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysm reconstruction

Objective

To evaluate the safety, efficacy and durability of endovascular repair for proximal para-anastomotic aneurysms after previous open abdominal aortic aneurysms prosthetic reconstruction and share our experience.

Methods

We retrospectively reviewed the data of all patients with previous open abdominal aortic aneurysms prosthetic reconstruction who underwent endovascular repair for proximal para-anastomotic aneurysms between May 2003 and January 2013 in our center (Nuremberg South Hospital). Key clinical outcomes included technical success rate, peri-operative morbidity and mortality, mid-term complications, reinterventions and open conversion rates.

Results

Totally, 24 patients of proximal para-anastomotic aneurysm were treated by endovascular repair. Successful deployments of stent graft were achieved in all patients (100%). Median hospital stay was 6.7 days. One patient had minor type Ia endoleak and one patient developed wound infection. There were no early open conversions and deaths. During a median follow-up of 43 months (range, 7–67 months), computed tomography angiography revealed type Ia endoleaks in four patients (16.7%). The overall reintervention and open conversion rates during follow-up were 16.7% (4/24) and 4.2% (1/24), respectively. Estimates of freedom from reintervention were 91.7% at 1 year, 87.1% at 3 years and 80.9% at 5 years. There was significant difference in freedom from reintervention between proximal para-anastomotic aneurysms patients treated with tube and unibody bifurcated stent grafts (p = 0.034). The cumulative mortality rate was 12.5% (3/24), actuarial analysis for all patients estimated survival rates of 95.8% at 1 year and 87.3% at 5 years.

Conclusions

Proximal para-anastomotic aneurysms are severe complications after abdominal aortic aneurysm open reconstruction. Closer follow-up and prompt treatment are necessary. Endovascular treatment for proximal para-anastomotic aneurysms is effective, safe and durable. Unibody bifurcated stent graft proved to be suitable for most proximal para-anastomotic aneurysms with various anatomical features.

Endovascular repair of infrarenal focal aortic pathology with limited aortic coverage

BACKGROUND

Endovascular abdominal aortic aneurysm repair (EVAR) for degenerative abdominal aortic aneurysm (AAA) requires complete aortic exclusion to prevent ongoing aneurysmal degeneration in a diseased aorta. Focal infrarenal aortic pathology, such as penetrating atherosclerotic ulcer (PAU), saccular aneurysm, and/or intramural hematoma (IMH) may not necessitate complete aortic coverage. Here, we review our experience with endovascular management of focal aortic pathology with limited aortic coverage.

METHODS

A prospectively maintained institutional database of patients undergoing EVAR was retrospectively reviewed to identify all patients treated with a nonbifurcated device (Current Procedural Terminology code: 34,800). Patients without a diagnosis of PAU, saccular aneurysm, IMH, or iatrogenic pseudoaneurysm were excluded. Medical records and imaging studies were reviewed for confirmation of focal aortic pathology. Preoperative imaging and intraoperative details were reviewed. Outcome measures included technical success, symptom-free survival, and freedom from reintervention.

RESULTS

Eight patients were identified who underwent repair of a focal aortic defect with an endovascular tube graft from 2004-2011. Six patients underwent surgery for 7 saccular pseudoaneurysms and 2 patients had iatrogenic infrarenal pseudoaneurysms. Six saccular aneurysms were associated with PAU. Seven patients (88%) were men; the median age was 76 years (range: 50-85 years). Four patients (50%) had symptoms attributable to their aneurysm (2 abdominal pain, 1 gastrointestinal symptoms, 1 lower extremity emboli). Aneurysm repair was classified as urgent in 2 patients (25%). Six patients (75%) required placement of a single aortic component, the other 2 patients (25%) required 2 components. All devices used were Zenith (Cook, Inc., Bloomington, IN) ancillary components. The median device diameter was 22 mm (range: 18-28 mm), while the median device length was 56.5 mm (range: 39-80 mm). The technical success rate was 100%. There were no early graft-related complications. All symptomatic patients experienced improvement or resolution of symptoms. In all cases, radiologic follow-up at 1 month showed stable or decreasing aneurysm size. No endoleaks were detected and no patients have required reintervention to date.

CONCLUSIONS

The optimal management of many focal infrarenal aortic defects, particularly those that are incidentally discovered, remains unclear. Our experience with endovascular repair of focal aortic pathology with limited aortic coverage suggests this approach is technically feasible and associated with excellent early results.

Endovascular repair of a paraanastomotic aneurysm with inverted limb infrarenal bifurcated graft

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.

Endovascular treatment of delayed rupture following prior abdominal aortic aneurysm repair achieves better survival rates

PURPOSE

To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion.

METHODS

All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality.

RESULTS

The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011).

CONCLUSION

Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Use of flow-diverting stents to treat para-anastomotic iliac artery aneurysms after previous open aortic prosthetic reconstruction

PURPOSE

To present a series of para-anastomotic iliac artery aneurysms treated with flow-diverting stents.

CASE REPORTS

Three patients (2 men, 1 woman; ages 70, 73, and 78 years) with previous open aortoiliac reconstructions received a 12-mm-diameter Cardiatis Multilayer Stent to treat 4 para-anastomotic iliac artery aneurysms in an attempt to preserve their ipsilateral hypogastric arteries. After 1-year follow-up, all aneurysms were successfully excluded, with complete sac thrombosis in three and partial thrombosis in one. The diameter of the aneurysm was reduced in all by a median 6 mm. At 1 year, patency of the hypogastric artery was maintained in only the patient with partial sac thrombosis. No patient developed buttock claudication.

CONCLUSION

The use of flow-diverting stents for para-anastomotic iliac artery aneurysms resulted in reduction of iliac aneurysm diameter. However, intended patency of the ipsilateral hypogastric artery was not always observed. The feasibility of the technique has therefore not been shown for this specific indication.

Endovascular repair of abdominal aortic para-anastomotic pseudoaneurysm

Para-anastomotic aneurysms are either true aneurysms or pseudoaneurysms. The latter tend to be asymptomatic until rupture. Para-anastomotic aneurysms should be approached surgically, despite the high morbidity and mortality associated with their treatment. This report describes the case of a 68-year-old woman who presented with a para-anastomotic pseudoaneurysm secondary to infrarenal aortic aneurysmectomy. We chose to use an endovascular approach, and results were good. Endovascular techniques are increasingly becoming the method of choice in the treatment of anastomotic pseudoaneurysms.

[Endovascular therapy of para-anastomotic aneurysms of the aorta. Technical options]

BACKGROUND

Open repair of para-anastomotic aneurysms (pAAA) after conventional aortoiliac repair is associated with a high perioperative mortality and morbidity. Endovascular treatment options have evolved over the last decade. The aim of this article is to demonstrate and review these endovascular strategies.

MATERIAL AND METHODS

Between 01/2009 and 06/2012, a total of 12 patients received endovascular treatment for proximal (n = 7) or distal (n = 5) pAAA (n = 2 contained rupture). A retrospective analysis of these patients was performed. Median age was 71.5 years (range 55-87 years). The median time interval between primary operation and endovascular repair of the pAAA was 15 years (range 1-31 years) and median follow-up was 1.3 years (range 0 days - 3 years). Endovascular exclusion of the pAAA was achieved by implantation of an aortouniiliac endograft (n = 6), chimney graft (n = 1), fenestrated endograft (n = 2) and iliac extension (n = 3).

RESULTS

Technical success could be achieved in all patients and in-hospital mortality was 16.8  % (n = 2). No patient required a reintervention but during follow-up one additional patient died due to gastrointestinal bleeding. No primary or secondary type I/III endoleaks were observed.

CONCLUSIONS

Despite a not negligible mortality rate endovascular treatment of para-anastomotic aneurysms and anastomotic pseudoaneurysms appears to be a safe alternative for conventional open repair.

Stent graft repair of paraanastomotic aneurysms after open descending thoracic and thoracoabdominal aortic aneurysm repair

BACKGROUND

After open thoracic and thoracoabdominal aortic aneurysm repair, anastomotic aneurysms can form at or near the suture lines of the graft. Endovascular repair is an alternative to complicated reoperative open surgery. We report on our experience with endovascular treatment of these lesions.

METHODS

A prospectively maintained database of endovascular thoracic aortic aneurysm repairs (TEVARs) performed at Mount Sinai Medical Center was reviewed and the initial procedures, comorbidities, clinical presentation, aneurysm characteristics, type of endograft, adjunctive procedures, and follow-up were analyzed.

RESULTS

Of the 135 TEVAR procedures performed between June 2001 and December 2008, 9 patients had anastomotic aneurysms after a previous open repair. The mean age was 66.7 (range 41-89) years, 67% of whom were male. Of these 9 patients, 5 had a descending thoracic repair, 3 had a type IV repair, and 1 had a type II thoracoabdominal repair. Aneurysm formation occurred in the following regions: proximal anastomosis (n = 2); intercostal patch (n = 1); distal anastomosis (n = 3); visceral patch (n = 2); and midgraft (n = 1). The initial technical success rate was 100%, with 8 patients receiving a thoracic tube graft and 1 a modular bifurcated device. Two patients required an adjunctive carotid-subclavian bypass and 2 required extraanatomic revascularization of the visceral arteries. Mean follow-up was 16.5 months. There was 1 perioperative death secondary to a postoperative myocardial infarction. Three patients developed an endoleak with 1 requiring an intervention. One patient required an open thoracoabdominal repair at 3 months for a penetrating ulcer at the visceral segment and another died from a ruptured thoracic aneurysm proximal to the stent graft at 72 months. Two more died during the follow-up period of non-aneurysm-related causes. Five patients had paraanastomotic shrinkage or no change and 1 had an increase in size, and 3 had no follow-up imaging.

CONCLUSIONS

Stent graft repair of paraanastomotic aneurysms after open descending thoracic and thoracoabdomninal repair is a reasonable option when patients have suitable anatomy. These patients, however, require close follow-up for the development of aneurysmal degeneration adjacent to the stent graft repair.

Residual infrarenal aortic neck following endovascular and open aneurysm repair

BACKGROUND

The effectiveness of open and endovascular aneurysm repair of aortic abdominal aneurysms (AAAs) can be jeopardised by deterioration of the residual infrarenal neck of the aneurysm.

OBJECTIVE

The study aims to determine the length of the residual infrarenal aortic segment after endovascular and open aneurysm repair.

METHODS

In a multicentre randomised controlled trial comparing open and endovascular AAA repair, 165 patients were discharged after open AAA repair (OR) and 169 after endovascular repair (EVAR). Immediately after the operation, surgeons were asked to enter in the case record form whether the level of their anastomosis after open repair was within or beyond 10 mm of the caudal renal artery. Postoperative computed tomography (CT) scans that were obtained within 6 months after surgery were used for comparative analysis. The distance between the caudal renal artery and the proximal anastomosis of the (endo-) graft was measured using axial CT slices and a standardised protocol. CT images were available and suitable for analysis in 156 (95%) of 165 OR patients and in 160 (95%) of 169 EVAR patients. Data are presented as median (range). Differences were analysed using the Mann-Whitney test.

RESULTS

The distance from the caudal renal artery to the proximal anastomosis was 24 mm (16-30 mm) in the OR group versus 0 mm (0-6 mm) in the EVAR group (p < 0.0001, Mann-Whitney). In 140 of 156 (90%) patients, at least 1 cm of untreated infrarenal neck persisted after OR and in 17 of 160 (10%) after EVAR. In 84 of the 156 open repair patients (54%), the surgeon had indicated that the proximal anastomosis was within 10 mm of the caudal renal artery. Only five surgeons (6%) were accurate in this respect.

CONCLUSION

After open repair, a longer segment of the infrarenal aortic neck is left untreated compared with endovascular repair and this length is underestimated by most surgeons. Long-term studies are required to determine the consequences of this difference.

Endovascular repair of isolated iliac artery aneurysms

PURPOSE

To retrospectively evaluate a 12-year experience with endovascular repair of isolated iliac artery aneurysm (IAA).

METHODS

From August 1997 through July 2009, 91 patients (81 men; mean age 71 years, range 31-90) underwent endovascular treatment for isolated IAA at our department. Of these, 77 patients received stent-grafts either alone or in combination with coils or an Amplatzer vascular plug (n = 2); 1 patient received a Smart stent combined with coils, and 13 patients were treated with coil embolization only. The aneurysms were classified according to location: type I = common iliac artery (CIA), type II = internal iliac artery (IIA), type III = CIA and IIA, and type IV = external iliac artery with/without CIA and/or IIA involvement.

RESULTS

Primary technical success was 90.1% for all aneurysm types and 93.6%, 80%, 88.8%, and 93.3% for types I, II, III, and IV, respectively. Secondary technical success was 96.7% for all types and 97.8%, 95%, 100%, and 93.3%, respectively, for each type. Clinical success was 93.4% for all types and 97.8%, 85%, 100%, and 86.7%, respectively, by type. Complications in 18 (19.8%) patients included 7 type I endoleaks, 3 type II endoleaks, 2 enlarged aneurysm sacs (incomplete embolization), 5 cases of buttock claudication, and 2 stent-graft thromboses. Two patients were converted to open surgery; 10 underwent secondary interventions. Mortality rates were 1.1% (n = 1) at 30 death days and 23.1% (n = 21) over a mean follow-up of 45.9 months (no aneurysm-related death). Cumulative overall survival was 97.7% at 1 year and 47.6% at 10 years. Freedom from aneurysm-related complications was 88.6% at 1 year and 83.5% at 5 years.

CONCLUSION

Endovascular repair of isolated IAA is a safe and minimally invasive alternative to surgery. However, it may be associated with several complications and must, therefore, be carefully planned.

Stent grafting a ruptured para-anastomotic iliac aneurysm

In this case report, we present an 83-year-old man with a ruptured para-anastomotic aneurysm who underwent a stent graft in spite of his condition of acute shock. Our patient presented at the emergency room (ER) with acute abdominal pain. Shortly after arrival, he collapsed because of a ruptured para-anastomotic aneurysm after the previous aorto-bi-iliac aneurysm repair in 1984. He was charged with a cardiac history that made him unsuitable for surgery. We chose for resuscitation followed by inflation of an aortic balloon that made the patient hemodynamically stable. He then underwent iliac stent grafting and was discharged from the hospital at 22 days after the procedure. The mortality rate of patients with a ruptured para-anastomotic aortic aneurysm arriving at hospital ranges from 32% to 70%. Endovascular stent placement for ruptured iliac aneurysmal arteries can be a safe treatment in selected patients.

What to Do When Evidence is Lacking — Implications on Treatment of Aortic Ulcers, Pseudoaneurysms and Aorto-Enteric Fistulae

Present knowledge on natural history and how to treat penetrating aortic ulcers or different forms of pseudoaneurysms with or without infection is limited as there are only case reports and small series of unusual aortic pathology and its treatment available.

Material:

From our centre we collected 65 patients treated with open (n=15) or endovascular reconstruction (n=50) during a 20-year period in the abdominal aorta. These patients are presented including a review of contemporary treatment.

Results:

Endovascular reconstructions seem to reduce morbidity and mortality compared to otherwise extensive open surgery. Even for patients with infectious etiology (mycotic aneurysms, aorto-enteric fistula) endovascular treatment may be a first-hand option bridging to a more elective open repair. However, a large proportion of patients being unfit for further open surgery were solely treated endovascularly and had no major infectious complications in the follow-up. Registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.

Conclusion:

Endovascular technique is a promising technique for treatment of aortic pseudoaneurysms of different etiologies. We firmly recommend, despite the lack of evidence, that the work up of patients with penetrating aortic ulcers, mycotic or other types of pseudoanerysms as well as aorto-enteric fistulae should enclose both endovascular and open (or combined) treatment modalities. However, our knowledge of the natural history is limited. Therefore, registers of cases with unusual aortic pathology, not only of those treated but also of those managed conservatively, are needed to define who to treat and if endovascular or open repair should be recommended.