Early results of endovascular aortic aneurysm surgery with aortouniiliac graft, contralateral iliac occlusion, and femorofemoral bypass

Endovascular wall-grafting for mycotic common iliac pseudo-aneurysm: Systemic mycoses

Mycotic pseudoaneurysms of the iliac arteries are extremely rare and are caused by infection of the artery wall. It is difficult to diagnose early due to its silent manifestation. We present a case of a 64-year-old man with an isolated left common iliac artery pseudoaneurysm caused by Candida albicans who presented with thrombophlebitis, abdominal pain, nausea and vomiting associated with fever, which was successfully treated with interposition grafting and antibiotic therapy. We present this case to highlight that aneurysms and other vascular lesions can affect different arteries in the body and may therefore only be discovered during routine investigations of non-specific symptoms.

Clinical outcomes after internal iliac artery embolization prior to endovascular aortic aneurysm repair

BACKGROUND

Aortic anatomy is important in determining the success or failure of endovascular aortic aneurysm repair (EVAR). Endoleak is another issue which should be addressed for a long-term durability of the procedure. Internal iliac artery (IIA) embolization is required to prevent type II endoleak when the iliac landing zone is not sufficient such that the iliac limb should be extended down to the external iliac artery (EIA). Pelvic ischemia is an important complication of IIA embolization, but its incidence and severity is not exactly known. Our experience suggests this to be common but not severe. In this study we reviewed the clinical outcomes of patients who underwent IIA embolization to facilitate EVAR at one of the major tertiary medical centers in South Korea.

METHODS

We performed a retrospective review of the patients who underwent IIA embolization prior to EVAR between November 2005 and June 2018 at a single tertiary medical center in South Korea. Patients were interviewed via telephone to determine the severity of buttock claudication according to a previously defined pain scale.

RESULTS

The majority of 139 patients in both the unilateral and bilateral IIA embolization groups experienced no (N.=83, 60.0%) or mild (N.=51, 36.7%) buttock claudication. Only three patients in the unilateral IIA embolization group reported that their symptoms affected daily life, but without need for any measures for pain relief. Symptom duration was longer in the bilateral embolization group (12.6 months) compared to the unilateral group (6.6 months) without statistical significance (P=0.559). There were no critical complications such as buttock necrosis, spinal cord ischemia, or ischemic colitis.

CONCLUSIONS

Based on our experience, IIA embolization does cause buttock claudication of a certain degree. However, the most of them experienced mild discomfort rather than such symptoms severely affect their quality of life. Considering the risks of general anesthesia and complications of surgical procedures, IIA reconstruction along with EVAR may not be necessary.

Endovascular treatment of complex diseases of the thoracic aorta-10 years single centre experience

BACKGROUND

Introduction of invasive endovascular techniques constituted a real a breakthrough in the treatment of aortic aneurysm dissection and rupture. We assessed the effectiveness and safety of thoracic endovascular aortic repair (TEVAR) in patients with thoracic aortic pathologies.

METHODS

Between 2007 and 2017, 118 patients with thoracic aortic pathology underwent TEVAR. Among them, 20 (16.9%) patients required hybrid procedures. Stent grafts indication were thoracic aortic aneurysm in 46 (39.0%) patients, type B dissection in 68 (57.6%) patients and other indications in 4 (3.3%). Procedural success rate, in-hospital and late mortality and morbidity were evaluated.

RESULTS

The patients were followed-up for a mean of 55 months (range, 6-118 months). The technical success rate was 96%. Five patients died during the first 30 days after procedure (mortality 4.2%), four due to ischemic stroke followed by multi-organ failure and another one hemodynamically significant type I endoleak. Most of them were noted in the first years of our study. Five others died during post-discharged period. Four patients developed neurological complications, including stroke (n=2; 1.7%) and paraparesis (n=2; 1.7%). There were 6 (5.1%) primary (5 type I and 1 type II) and 3 (2.5%) secondary endoleaks (1 type I and 2 type III). Secondary interventions were required in 8 subjects. There was one case of stent collapse and two retrograde aortic dissection.

CONCLUSIONS

Treatment of descending aortic diseases by using stent graft implantation has become the method of choice, decreasing the risk of open surgery, especially in patients with severe clinical state and comorbidities. However, effectiveness and safety may be achieved by experience team.

Custom-made Stent-Grafts for Aortic Aneurysm Repair Using Gianturco Z Stents and Woven Polyester: Healing in an Animal Model

The purpose of this study was to evaluate the healing at 6 months of aortic stent-grafts custom-made by using Z stents and woven polyester in an animal model. Stent-grafts were built by a published method using autoexpandable stainless steel stents continuously compiled with polyester sutures and covered with a woven polyester membrane. Fourteen stent-grafts of 3 different designs were deployed under fluoroscopic control into the thoracic and the abdominal aorta of 7 adult sheep. At 6 months, all the implants of the sheep that survived the implantation were angiographed and harvested for macroscopy and microscopy. All stentgrafts were implanted successfully and remained patent from then to the explantation procedure. All stent-grafts implanted among the 6 of 7 (86%) animals that survived after the implantation remained patent, stayed free from local complications, and did not migrate during more than 6 months. In all these cases during this period, the implant functioned as a satisfactory aortic substitute while the aortic segment containing the graft kept a normal structure. There was no adverse effects of the presence of the implant upon the aorta or the animal. Stent-grafts home-made according to the described methods gave results at 6 months in this animal model compatible with a safe clinical application among humans.

Relocation of the Iliac Artery Bifurcation to Facilitate Endoluminal Treatment of Abdominal Aortic Aneurysms

Purpose:

To report a surgical technique to preserve the internal iliac arteries (IIAs) and facilitate endovascular repair of abdominal aortic aneurysms (AAAs) with extensive iliac artery involvement.

Technique:

A new iliac artery bifurcation is created surgically through an 8-cm lower left abdominal incision by implanting the IIA onto the distal external iliac artery either directly or by using a tube graft interposition. Careful technique is required to avoid embolic complications, but after relocating the bifurcation, aortic endografting can be performed, either simultaneously or staged, depending upon patient characteristics.

Conclusions:

Relocation of the iliac artery bifurcation appears to be a good alternative to preserve pelvic arterial flow in selected candidates for endoluminal AAA repair.

Endovascular Repair of Aortic Aneurysms: Treatment of Complications

Purpose:

To evaluate the use of interventional procedures for treating complications following endovascular repair of aortic aneurysms.

Methods:

Fifty-five patients (49 men; mean age 67.5 years) underwent endoluminal stent-graft repair of traumatic (n = 4) or arteriosclerotic (n = 51) aortic aneurysms in the thoracic (n = 3) or infrarenal (n = 52) aorta. Follow-up of therapeutic success included periodic clinical examination, angiography, and spiral computed tomography.

Results:

Discounting the 25 (45%) cases of postimplantation syndrome that did not require treatment, there were 22 complications observed in 20 (36%) patients over a mean 10-month follow-up (range 1 to 27). There were 2 transrenal endograft maldeployments, 1 case of twisted graft limbs, 2 access site problems (1 patient), 12 endoleaks (11 patients), 1 late graft limb thrombosis, 1 symptomatic internal iliac artery occlusion, 2 myocardial infarctions, and 1 transient psychosis. Seven (13%) patients did not undergo specific therapy, while 4 (7%) required operation (2 crossover bypass grafts, 1 suture revision, and 1 graft replacement). Among 9 (16%) patients treated with interventional techniques, 7 underwent percutaneous coil embolization for 8 endoleaks (7 successfully resolved). One late stent-graft disconnection required an additional stent-graft, and 1 of the 2 malpositioned endografts was repositioned. All patients remain alive with no increase in the diameter of the aneurysm in any patient.

Conclusions:

Technical problems resulting from the endovascular repair of aortic aneurysms often respond to interventional treatment.

Endovascular AAA Exclusion: Will Stents with Hooks and Barbs Prevent Stent-Graft Migration?

Purpose:

To investigate if stents with hooks and barbs will improve stent-graft fixation in the abdominal aorta.

Methods:

Sixteen- to 24-mm-diameter Dacron grafts were deployed inside cadaveric aortas. The grafts were anchored by stents as in endovascular abdominal aortic aneurysm repair. One hundred thirty-seven stent-graft deployments were carried out with modified self-expanding Z-stents with (A) no hooks and barbs (n = 75), (B) 4 5-mm-long hooks and barbs (n = 39), (C) 8 10-mm-long, strengthened hooks and barbs (n = 19), or (D) hooks only (n = 4). Increasing longitudinal traction was applied to determine the displacement force needed to extract the stent-grafts. The radial force of the stents was measured and correlated to the displacement force.

Results:

The median (interquartile range) displacement force needed to extract grafts anchored by stent A was 2.5 N (2.0 to 3.4), stent B 7.8 N (7.4 to 10.8), and stent C 22.5 N (17.1 to 27.9), p < 0.001. Both hooks and barbs added anchoring strength. During traction, the weaker barbs were distorted or caused intimal tears. The stronger barbs engaged the entire aortic wall. The radial force of the stents had no impact on fixation, while aortic calcification and graft oversizing had marginal effects.

Conclusions:

Stent barbs and hooks increased the fixation of stent-grafts tenfold, while the radial force of stents had no impact. These data may prove important in future endograft development to prevent stent-graft migration after aneurysm exclusion.

A Method for Adjusting a Malpositioned Bifurcated Aortic Endograft

Purpose:

To report the successful application of a method to adjust a malpositioned bifurcated stent-graft after endovascular aortic aneurysm repair.

Method and Results:

A 62-year-old male patient underwent endovascular repair of a 5.1-cm abdominal aortic aneurysm (AAA) with a Vanguard bifurcated stent-graft. After complete deployment of the stent-graft, the intraoperative completion angiogram disclosed unexpected occlusion of the left renal artery. Intra-aortic adjustment of the bifurcated graft was possible with a crossover guidewire, which was pulled caudally. The method worked perfectly to restore blood flow to the left renal artery. The patient is well 16 months postoperatively without any evidence of endoleak or graft migration; the left renal artery remains open.

Conclusions:

A technique is demonstrated for intra-aortic repositioning of a bifurcated stent-graft to correct insufficient deployment. If required, this technique should be attempted before conversion to an open procedure.

Ruptured Abdominal Aortic Aneurysm: Endovascular Repair Does Not Confer Any Long-term Survival Advantage Over Open Repair

Recent studies have suggested that endovascular aneurysm repair (EVAR) may reduce the perioperative mortality of ruptured abdominal aortic aneurysm (AAA). Whether EVAR confers any long-term survival advantage over published results for open repair of ruptured AAA has not been established. We conducted a single-center retrospective study over a 10-year period (1994–2004) examining the long-term outcome of patients who have undergone endovascular repair of ruptured AAA. Fifty-four patients underwent endovascular repair of a ruptured AAA. The median age was 75 years (interquartile range 69.5–79.5 years); 42 (78%) patients were male. The perioperative mortality rate was 37%. During a median follow-up of 32 months (range 14–48 months), there were 5 aneurysm-related and 13 non-aneurysm-related deaths. Overall, the 3- and 5-year survival rates were 36% and 26%, respectively. EVAR does not appear to confer any overall survival advantage in the mid- to long term compared with the published results for open repair. The reasons for this remain unclear. Further, larger studies are required to confirm these results.

Rates of adverse events and correction procedures after elective versus emergent aortouni-iliac endografting during mid-term follow-up: A prospective cohort study

BACKGROUND

Due to preferential implantation of bifurcated devices during endovascular repair of infrarenal abdominal aortic aneurysms (AAA), longer-term results following aortouni-iliac (AUI) endografting are scarce. The aim of this study was to determine the rate of endoleaks as well as frequency of secondary correction procedures after elective and emergent AUI endografting.

METHODS

A prospectively gathered database at a tertiary care university hospital was retrospectively reviewed from January 2000 until January 2012. This interrogation identified 61 patients who had undergone AUI endografting to treat their AAA. Data retrieval obtained 47 patients with elective AAA repairs while 14 patients received emergent AUI endografting in case of rupture. Procedural outcomes, endoleaks, complications, and secondary interventions during mid-term follow-up were recorded for analysis.

RESULTS

Fifty-five patients of the study cohort were male (90.2%) and mean age was 76.5 years (median: 77.2, Q1-Q3: 72.1-81.6). Patient demographics, comorbidities, procedural characteristics, as well as median follow-up length (39.8 months versus 34.9 months) were similar between groups. Endoleaks, complications, and rate of secondary correction procedures were not increased following emergent AUI endografting. The majority of these interventions comprised catheter-based or less invasive surgical procedures. All patients requiring major surgery (three open surgical conversions with endograft explantation and one open aortic banding) survived, while one patient sustained fatal myocardial infarction after a transluminal correction procedure.

CONCLUSION

Emergent AUI endografting was not associated with higher rates of adverse events or correction procedures during mid-term follow-up. Secondary interventions to maintain aneurysm exclusion could be carried out with low mortality.

Reprinted article "Realistic expectations for patients with stent-graft treatment of abdominal aortic aneurysms. Results of a European multicentre registry"

OBJECTIVE

The outcomes for patients after endovascular treatment of abdominal aortic aneurysm (AAA) are determined primarily by the endpoints of death and endoleaks, the latter representing continued risk of rupture. The data of a multicentre registry were analysed with regard to the early outcome of stent-graft procedures for AAA and the complications associated with this treatment. In addition, the results during follow-up were analysed by determining mortality and endoleak development as separate endpoints and as a combined endpoint defined as endoleak-free survival.

SETTING

38 European institutions of Vascular Surgery collaborating in a multicentre registry project.

PATIENTS AND METHODS

899 patients with AAA underwent between May 1994 and March 1998 elective endovascular repair (818 men and 81 women; mean age 69 years). 80 (8.9%) of the patients had medical conditions that excluded them from open repair. 818 (91%) of patients had a bifurcated device, 63 (7%) had a straight tube graft, and only 18 (2%) had an aorto-uni-iliac device. Clinical examination and contrast-enhanced computed tomography was performed at fixed follow-up intervals to assess increase or decrease of the maximum transverse diameter (MTD). Endoleaks observed at follow-up were discriminated into persistent endoleak and temporary endoleak. The latter is defined as single time observed endoleaks or with two or more negative imaging studies between observed endoleaks. Life-table analyses were used to calculate the rates of freedom-from-endoleak (no endoleak at any time), freedom-from-persistent endoleak (no persistent endoleak), patient survival, and persistent-endoleak-free-survival.

RESULTS

The median follow-up of this patient series was 6.2 months. The ratio between observed and expected follow-up data was 82% for the overall follow-up period. However, at 18 months of follow-up this rate was only 45%. The number of patients followed during this period was sufficient to allow statistically meaningful assessment. The MTD in patients with temporary endoleaks demonstrated a significant decrease at 6 to 12 months compared to preoperative values (mean 57 and 53 respectively, p = 0.004). In patients with persistent endoleaks there was no change between the preoperative and 6-month MTD (mean 57 and 60 mm respectively). At 6 and 18 months freedom-from-endoleak was 83% and 74% and freedom-from-persistent endoleak was 93% and 90%, respectively. The 18-month cumulative patient survival was 88% and the main outcome measure, the persistent endoleak-free-survival was 79%.

CONCLUSIONS

The MTD decreases in patients with temporary endoleak, but not in patients with persistent endoleak. Therefore, the use of the rate of freedom-from-persistent endoleak, reflecting absence of persisting endoleaks to estimate the prognosis with regard to the AAA, is justified. Determining persistent endoleak-free survival appears a rational approach to provide a realistic outlook for patients with stent-grafted AAA. The observed 18-month endoleak-free survival reflects a satisfactory mid-term result.

Ruptured abdominal aortic aneurysms: role of endovascular therapy

Ruptured abdominal aortic aneurysms historically have high mortality rates. Despite improvements in many open surgical techniques and perioperative care, these mortality rates have not significantly changed. Some of the reasons for the high mortality rates include the excessive blood loss and hypothermia that occur during open operative repair. The blood loss and hypothermia, combined with resuscitative dilutional coagulopathy, can lead to an irreversible spiraling coagulopathy that ultimately ends in the patient's demise. The availability of endovascular approaches to treat abdominal aortic aneurysms in the early 1990s offered an opportunity to substantially alter the treatment outcomes of ruptured abdominal aortic aneurysms. Endovascular repair offers many advantages, including rapid aortic control under local anesthesia, as well as an opportunity to limit the hypothermia and blood loss that occur with an open abdomen. This article will review the endovascular management of ruptured abdominal aortic aneurysms and describe the endovascular techniques for safe and effective treatment. Mt Sinai J Med 77:250-255, 2010. (c) 2010 Mount Sinai School of Medicine.

A standardized aortic aneurysm model for the assessment of endovascular stent-graft technology

Reliable models of aortic aneurysms are required to test endovascular stent-graft technology prior to human use. We describe the creation of a standardized prosthetic aneurysm in an ovine model to assess endovascular technology. In an adult ovine model under general anesthesia, a polyester sphere measuring 6 cm across was sutured onto the infrarenal aorta following aortotomy. Two weeks later an endovascular stent-graft was deployed in the aorta. Exclusion was confirmed on monthly ultrasound duplex and during angiography at three months and under terminal anesthesia at six months. Autopsy along with histology of the specimen were then performed. A total of 10 sheep underwent aneurysm implantation. Nine received a straight tube endovascular stent-graft (Lombard Medical, Abingdon, Oxon, UK) and seven completed the study. Five prosthetic aneurysms shrank during serial imaging with duplex ultrasound and angiography. However, two remained the same size. One of these had a type I endoleak whereas the other had endotension (type I endoleak confirmed at autopsy). This animal model provides a reliable and reproducible method of creating prosthetic aneurysms for assessing endovascular stent-grafts. It was possible to assess aneurysm exclusion non-invasively using duplex ultrasound. Aneurysms effectively excluded from the circulation shrank whereas those with an endoleak did not.

Endovascular aneurysm repair: current and future status

Endovascular aneurysm repair has rapidly expanded since its introduction in the early 1990s. Early experiences were associated with high rates of complications including conversion to open repair. Perioperative morbidity and mortality results have improved but these concerns have been replaced by questions about long-term durability. Gradually, too, these problems have been addressed. Challenges of today include the ability to roll out the endovascular technique to patients with adverse aneurysm morphology. Fenestrated and branch stent-graft technology is in its infancy. Only now are we beginning to fully understand the advantages, limitations, and complications of such technology. This paper outlines some of the concepts and discusses the controversies and challenges facing clinicians involved in endovascular aneurysm surgery today and in the future.

Iliac Conduit for Renal and Visceral Artery Access During Endovascular Repair of a Pararenal Aneurysm with a Fenestrated Stent-Graft

PURPOSE

To report a technique for fenestrated stent-graft repair involving a conduit implanted at the origin of a patent aneurysmal common iliac artery (CIA) in a patient with a pararenal aortic aneurysm and iliac artery occlusion.

CASE REPORT

A 60-year-old man with multiple comorbidities presented with an 8-cm abdominal aortic aneurysm (AAA) with no infrarenal neck according to computed tomography (CT). Both CIAs were aneurysmal; the left was occluded, as were the left internal and external iliac arteries and the inferior mesenteric artery. Two patent accessory renal arteries were depicted. Because an infrarenal neck was absent, treatment with a fenestrated endograft was performed under general anesthesia. The right CIA was approached via an oblique retroperitoneal incision. A 10-mm polytetrafluoroethylene tube graft was implanted on the origin of the right CIA aneurysm in an end-to-side fashion to facilitate delivery of a Zenith endograft constructed with 2 small fenestrations for the renal arteries, 1 large strut-free fenestration for the superior mesenteric artery, and a scallop for the celiac trunk. The proximal fenestrated body of the Zenith device was introduced via the right iliac artery by direct puncture of the common femoral artery. The conduit was used to cannulate the 3 fenestrations for subsequent deployment and for delivery of the distal Zenith aortomonoiliac device. The procedure was completed successfully, but 12 hours after surgery, the patient developed a significant right retroperitoneal hematoma, which was treated surgically. CT confirmed patency of all visceral arteries and no endoleak. One month after the initial procedure, he had recovered totally and was discharged.

CONCLUSION

Iliac conduits could widen the feasibility of fenestrated endografting in patients unfit for open surgery with pararenal aneurysms and challenging iliac anatomy. However, this adjunctive procedure has its own morbidity.

Systematic Review and Meta-analysis of 12 Years of Endovascular Abdominal Aortic Aneurysm Repair

BACKGROUND

Endovascular repair (ER) of abdominal aortic aneurysm (AAA) is a new technique, and reported rates of endoleak, conversion to open repair, rupture and mortality vary widely. The aim of this study was to estimate these rates from the published data, and examine how this has changed as more patients have undergone ER.

METHODS

A systematic review and meta-analysis of publications identified through searches of the electronic databases EMBASE and Medline. All publications quoting endoleak, conversion to open repair, rupture and mortality rates for a series of patients undergoing ER were included.

RESULTS

163 studies pertaining to 28,862 patients undergoing ER were identified as relevant for the review and meta-analysis. The pooled estimate for operative mortality was 3.3% (95% confidence interval 2.9 to 3.6%). The pooled estimate for type 1 endoleaks was 10.5% (95% confidence interval 9.0 to 12.1%), with an annual rate of 8.4% (95% confidence interval 5.7% to 12.2%). The pooled estimate of type 2,3 and 4 endoleaks was 13.7% (95% confidence interval 12.3 to 15.3%), with an annual rate of 10.2% (95% confidence interval 7.4% to 14.1%). The pooled estimate for primary conversion to open repair was 3.8% (95% confidence interval 3.2 to 4.4%), and for secondary conversion to open repair 3.4% (95% confidence interval 2.8 to 4.2%). The pooled estimate for post-operative rupture was 1.3% (95% confidence interval 1.1 to 1.7%), with an annual rupture rate of 0.6% (95% confidence interval 0.5% to 0.8%). Multivariate meta-regression analysis showed that rates of operative mortality, post-operative rupture and total number of endoleaks all fell significantly (p<0.05) over time.

CONCLUSIONS

This study demonstrates a low mortality and a gradual reduction in vascular morbidity and mortality associated with endovascular repair since it was first introduced.

Aorto uni-iliac modification of a bifurcated stent graft for endovascular aneurysm repair: Expanding the versatility of a modular device

As endografting technology advances, anatomical constraints limiting access and deployment have become less of a burden. While unsuitable candidates for endografting exist, these patients are becoming less frequent. To broaden the applicability of endovascular abdominal aortic aneurysm repair (EVAR), we have modified the bifurcated AneuRx device into a unilimb modular prosthesis, by placing an aortic extender cuff across the flow divider, thus excluding its contralateral limb. This technique was used with success in 3 groups of patients: with occlusion of 1 iliac artery, with a nontraversable iliac stenosis, or with a small calcific aortic bifurcation. In these patients, anatomy can make it difficult, if not impossible, to place a bifurcated stent graft. Whether as a planned preoperative procedure or as a ;;bail-out'' maneuver, this procedure has been successful in avoiding open surgical conversion.

Stent-Grafts for Unruptured Abdominal Aortic Aneurysms: Current Status

Aortic stent-grafts were introduced at the beginning of the 1990s as a less invasive method of dealing with aortic aneurysms in patients with poor cardiovascular reserve. The numbers of procedures performed worldwide has increased exponentially despite the current lack of any substantial evidence for long-term efficacy in comparison with the gold standard of open surgical grafting. This review summarizes the evolution of the abdominal aortic stent-graft, the techniques used for assessment and deployment, and the effect of the procedure on both the patient and the device. The recent publication of two national multicenter trials has confirmed that the endovascular technique confers a 2.5-fold reduction in 30-day mortality in comparison with open surgery. However, over 4 years of follow-up, there is a 3-fold increase in the risk of reintervention and the overall costs are 30% greater with endovascular repair. Although the improvement in aneurysm-related mortality persists in the mid-term, because of the initial reduction in perioperative mortality, the all-cause mortality rate at 4 years is actually no better than for open surgery. Longer-term data from the randomized trials are awaited as well as results from the latest trials utilizing state-of-the-art devices. Whilst the overall management of abdominal aortic aneurysms has undoubtedly benefited from the introduction of stent-grafts, open repair currently remains the gold standard treatment.

Endovascular AAA Repair With the Aortomonoiliac EndoFit Stent-Graft: Two Years' Experience

PURPOSE

To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA).

METHODS

From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months.

RESULTS

EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed.

CONCLUSIONS

In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory.

Endovascular grafts and other catheter-directed techniques in the management of ruptured abdominal aortic aneurysms

Abdominal aortoiliac aneurysms that are ruptured and treated with open surgical repair have high morbidity and mortality rates. We have employed endovascular approaches to treat this entity since 1994. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guidewire into the supraceliac aorta and arteriography. If aortoiliac anatomy was suitable, an endovascular graft repair was performed. If the anatomy was unfavorable, the aneurysm was repaired in a standard open fashion. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 36 patients so managed, 30 underwent endovascular graft repair and six required open repair. Four patients died within 30 days (operative mortality = 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques, including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. These techniques should become widely used for the treatment of ruptured aneurysms.

Surgical versus endovascular treatment of acute thoracic aortic rupture: a single-center experience

BACKGROUND

Surgical management of acute thoracic aortic ruptures is controversial, especially in patients with preexisting comorbidities; associated mortality and paraplegia rates remain high. It was our objective to evaluate whether treating these patients acutely with endovascular stent grafts would improve their outcome.

METHODS

From November 1999 to February 2002 a total of 54 patients, age 28 to 83 years, were admitted to our institution with an acute rupture of the thoracic aorta (24 ruptured aneurysms, 14 perforated type B dissections, 16 traumatic ruptures). Twenty-eight patients were managed surgically using cardiopulmonary bypass (group 1), and 26 patients were treated acutely with an endovascular stent graft (group 2). The resuscitation protocol and interval from onset of symptoms to treatment was comparable in both groups. Medical records were reviewed for prehospitalization and emergency department data, operative findings, and outcomes.

RESULTS

There were 5 of 28 deaths (17.8%) in the surgical group and 1 of 26 deaths (3.8%) in the endovascular group. In the surgical group 1 of 28 patients (3.6%) exhibited paraplegia; there were no cases of paraplegia in the endovascular group. There were 4 of 28 cases (14.3%) of renal failure in group 1 and 1 of 26 (3.8%) in group 2. In group 1, 8 patients (28.6%) required mechanical ventilation for more than 48 hours; there were 2 of 26 patients (7.7%) in group 2 with this ventilatory requirement. Three patients required a repeat thoracotomy for hemorrhage in the surgical group. There were two access failures in the endovascular group.

CONCLUSIONS

In the treatment of acute ruptures of the thoracic aorta, the immediate outcome of patients treated with endovascular stent grafts appears to be better than with management by conventional surgical repair.

Is cross-femoral bypass grafting a disadvantage of aortomonoiliac endovascular aortic aneurysm repair?

PURPOSE

The need for cross-femoral bypass grafting (CFBG) is considered by some to be a major disadvantage of endovascular aneurysm repair (EVAR) with the aortomonoiliac technique. To determine the durability of CFBG in this setting, we examined data from 148 consecutive high-risk patients in a clinical trial of EVAR with a custom-made aortomonoiliac endovascular stent graft.

METHODS

All data were collected prospectively. After hospital discharge, patients were evaluated at 1, 3, and 6 months and annually thereafter. All CFBG was constructed of expandable polytetrafluoroethylene.

RESULTS

During follow-up averaging 23.6 +/- 16.2 months, nine CFBG complications developed in 8 patients (5.4%), including disruption (n = 2), infection (n = 3), thrombosis (n = 2), and pseudoaneurysm (n = 3). Four patients with CFBG complications died, of consequences of infection (n = 2), intracranial hemorrhage during attempted CFBG thrombolysis (n = 1), and intracranial hemorrhage during anticoagulation (n = 1). There were no amputations. At life table analysis, freedom from CFBG complication was 96.3% +/- 1.6% at 12 months, 94.1% +/- 2.2% at 24, 36, and 48 months, and 86.2% +/- 7.8% at 60 months. Overall survival for this high-risk patient group was 83.4% +/- 3.1% at 12 months, 70.4% +/- 4.1% at 24 months, 56.5% +/- 5.3% at 36 months, and 44.8% +/- 6.4% at 48 months.

CONCLUSION

CFBG is durable, with a low rate of complications in patients undergoing aortomonoiliac EVAR. Need for CFBG should not discourage use of aortomonoiliac devices in patients with anatomy unfavorable for other EVAR approaches.

Mechanical properties of various z-stent designs: an endovascular stent-grafting perspective

PURPOSE

To comparatively assess the mechani-cal behavior of various clinically relevant Z-stent designs.

METHODS

A total of 16 Z-stents of original, biliary, spiral, and double-skirted designs (n=4 for each) were constructed using similar specifications for all. Stents were then evaluated for stiffness, snap opening force (SOF), flexibility, and displacement force using a novel tensiometer. Differences among the stents were determined using statistical methods. Stents explanted from dog aorta after a mean follow-up of 13 months were examined under a scanning electron microscope for surface defects.

RESULTS

Forces required for about 50% reduction in diameter were 1.88 +/- 0.16 N, 3.81 +/- 0.21 N, 2.76 +/- 0.22 N, and 3.35 +/- 0.19 N for original, biliary, spiral, and skirted designs, respectively. Differences among the four designs were statistically significant at almost all points of measurement (P < 0.0001). Biliary and skirted designs showed higher SOF values in the early measurements. Stents explanted from dog aorta after a mean duration of 13 months showed no obvious corrosion or breakage in the wire struts.

CONCLUSIONS

Significant differences exist among the various Z-stent designs in terms of their mechanical properties. Understanding them should help to select the appropriate stent for a given lesion. 316L stainless steel shows a favorable long-term tissue interaction.

Treatment of ruptured abdominal aneurysms with stent grafts: a new gold standard?

Ruptured abdominal aortoiliac aneurysms, when treated with open surgical repair, have high morbidity and mortality rates. Since 1994, the authors have used endovascular approaches to treat this entity. Patients with presumed ruptured aortoiliac aneurysms were treated with restricted fluid resuscitation (hypotensive hemostasis), transport to the operating room, placement under local anesthesia of a brachial or femoral guide wire into the supraceliac aorta, and arteriography. If aortoiliac anatomy was suitable, an endovascular graft (stent-graft) repair was performed. If the anatomy was unfavorable, standard open repair was performed. Only if circulatory collapse occurred was a supraceliac balloon placed and inflated using the previously positioned guidewire. Of 35 patients treated in this manner, 29 underwent endovascular graft repair, and 6 required open repair. Four patients died within 30 days (operative mortality rate, 11%). Only 10 patients required supraceliac balloon control. Endovascular grafts, when combined with hypotensive hemostasis and other endovascular techniques including proximal balloon control, may improve treatment outcomes with ruptured abdominal aortoiliac aneurysms. The authors believe these techniques will become widely used for the treatment of ruptured aneurysms.

Durability of aortouniiliac endografting with femorofemoral crossover: 4-year experience in the Evt/Guidant trials

OBJECTIVES

We evaluated mid-term results of the multicenter EVT/Guidant aortouniiliac endograft (AI) trial and ascertained the durability of this endovascular technique in patients unable to undergo standard bifurcated endografting.

METHODS

From November 1996 to December 1998, 121 patients were enrolled to receive the AI device on the basis of complex iliac artery anatomy contraindicating bifurcated endografting. Clinical data were centrally collected, and radiographic data were evaluated by core facility.

RESULTS

AI placement was technically successful in 113 of 121 patients. At operation, patients who underwent AI had significantly more arrhythmias, congestive heart failure, and peripheral occlusive disease (P <.05) compared with patients who underwent open aneurysmorrhaphy in the EVT/Guidant trials, indicating comorbid features in this anatomic cohort. Distal AI attachment was performed to the external iliac artery in 40 (36%) patients. Median follow-up was 38 months. In the AI group, overall aneurysm diameter decreased over the duration of study from 54.4 +/- 9.6 mm to 44.4 +/- 16.4 mm (P =.004). At 24 and 36 months after repair, reduction in aneurysm size was associated with absence of endoleak (P =.003 and P =.008, respectively). Aneurysms shrunk or remained stable in 109 (96.5%) patients. Endoleak was identified in 52.3% of patients at discharge, and at follow-up in 30.9% at 1 year, 34.8% at 2 years, 28.6% at 3 years, and 30.4% at 4 years. Type II endoleak predominated. Leak from failure to completely occlude contralateral iliac flow accounted for 8 of 58 endoleaks (13.8%) at discharge. Sixteen patients (14.2%) underwent postoperative endoleak treatment; in one of these patients open conversion was necessary at 20 months. Post-procedure thigh or buttock claudication developed in 16 patients (14.2%). Thirteen patients (81.3%) had either distal attachment in the external iliac artery or contralateral type IIA occlusion. Fifteen patients (13.3%) required intervention because of reduced limb flow; one of these patients underwent open conversion at 27 months, and another underwent axillofemoral grafting at 28 months. Device migration was confirmed in 2 (1.8%) patients, without current clinical sequelae. Whereas no femorofemoral graft thromboses occurred, graft infection developed in 3 patients (2.6%). During follow-up, aneurysm in 2 patients ruptured. Late death occurred in 41 patients (36.3%). Twenty-four patients (58.5%) died of cardiopulmonary disease; one death was endograft-related after aneurysm rupture; and one death was related to femorofemoral bypass infection. Actuarial survival was 78.4% (95% confidence interval [CI], 71%-86%) at 2 years and 63.4% (95% CI, 54%-73%) at 4 years.

CONCLUSIONS

In patients with significant comorbid conditions and complex iliac anatomy unfavorable for bifurcated endografting, AI with femorofemoral bypass grafting is safe and effective. In most patients this endovascular option provides satisfactory mid-term results.

Adjunctive procedures for the treatment of proximal type I endoleak: the role of peri-aortic ligatures and Palmaz stenting

PURPOSE

To investigate the feasibility, efficacy, and long-term effects of peri-aortic ligatures and Palmaz stenting used to treat proximal type I endoleak after endovascular repair (EVR) of abdominal aortic aneurysm (AAA).

METHODS

An 8-year single-center experience with proximal type I endoleak was reviewed; the records of the 55 identified cases were examined to ascertain the methods of treatment used. Among these, all 22 patients who were treated with peri-aortic ligatures and Palmaz stenting were segregated for analysis.

RESULTS

The 22 patients (14 men; mean age 74.6 years, range 66-85) with proximal type I endoleak (18 early, 4 late) selected for analysis underwent 23 secondary procedures: 15 involving peri-aortic ligatures and 8 Palmaz stent implantations. Of the 18 early endoleaks, 11 were treated intraoperatively and 7 were observed. Ten (45%) patients died within 30 days of endoleak treatment: 8 had early endoleaks. Five of the 10 deaths occurred in patients successfully treated with peri-aortic ligatures (3/10) or Palmaz stenting (2/7). The 12 (54%) surviving patients suffered no aneurysm-related deaths or secondary endoleaks over a median follow-up of 20 months (range 4-75).

CONCLUSIONS

Endoleak is an important mode of failure after endovascular repair. Peri-aortic ligatures and Palmaz stenting are feasible techniques for the treatment of proximal endoleak; however, the perioperative mortality of peri-aortic ligatures was higher when compared with other less invasive techniques. In contrast to other therapeutic options, these methods are more effective in the short and medium term.

Aortomonoiliac stent-grafts for abdominal aortic aneurysm repair: association with iliofemoral crossover grafts

PURPOSE

To analyze the outcome of endovascular exclusion of abdominal aortic aneurysm (AAA) using aortomonoiliac stent-grafts.

METHODS

Fifty-seven consecutive patients (49 men; median age 70, range 56-89) with AAA >5 cm were treated in a 6-year period with the conical ELLA stent-graft. Forty-two (73.9%) patients were classified ASA (American Society of Anesthesiologists) IV and 6 as ASA V. In the majority of cases, the implantation procedure featured device delivery through the external iliac artery, transrenal placement of a bare stent in selected cases, and an iliofemoral crossover graft through a prevesical tunnel.

RESULTS

Successful deployment was achieved in 56 (98.2%) patients. Mean time to discharge was 8.7 days (range 2-125). Two patients died in the 30-day period. Nine endoleaks occurred in 8 (14%) patients; 4 required further intervention. Mean follow-up was 35.3 months (range 1-66), during which 5 patients died from unrelated causes. No late endoleak, graft occlusion, device twisting/migration, or aneurysm rupture was observed. No correlation between type I endoleaks and unfavorable proximal neck or iliac artery anatomical characteristics could be found. Primary technical and clinical success rates were 86.0% and 94.7%, respectively.

CONCLUSIONS

In this approach, the crossover graft remains in a retropubic space and consequently does not have all the disadvantages of a subcutaneously placed prosthesis. The results achieved in this group of high-risk patients support recommendation of this technique as a simple and safe alternative to bifurcated systems.

Stent-graft migration after endovascular repair of abdominal aortic aneurysm

PURPOSE

To report the incidence of graft migration in patients after endovascular repair of abdominal aortic aneurysms (AAA) and assess the significance of neck diameter changes in patients with and without suprarenal stent implantation.

METHODS

The medical records and imaging studies of 176 consecutive patients (175 men; median age 71 years, range 48-88) who had endovascular AAA repair with the Nottingham aortomonoiliac system were reviewed. The following parameters were recorded: preoperative neck diameter and length, presence of intraoperative and late graft migrations, time to onset of late migration, length of late migration, and neck diameter changes in patients with documented late graft migration. The patients were divided into 2 groups based on the placement of an endograft with or without suprarenal bare stent fixation. Median follow-up was 15 months (range 1-48).

RESULTS

There were 15 (8.5%) graft migrations (6 intraoperative and 9 late). Of those, 14 (10.9%) were in the 128-patient infrarenal fixation group and 1 (2.1%) in the 48-patient suprarenal stent group. Median neck diameters on preoperative and postoperative computed tomography scans in patients with late migration were 22.2 mm and 23.0 mm, respectively (p>0.05). The median time to graft migration was 14 months after the original operation (range 6-36).

CONCLUSIONS

Distal device migration occurred frequently with the Nottingham system. Late graft migration was not associated with neck enlargement. Endografts with a suprarenal stent may have a decreased incidence of graft migration.

Emergency endovascular interventions for ruptured thoracic and abdominal aortic aneurysms

BACKGROUND

The purpose of our study was to show the effectiveness of endovascular stent grafts in the treatment of acutely ruptured abdominal and thoracic aortic aneurysms as an alternative to the conventional surgical approach in an emergency setting.

METHODS

From October 1996 to October 1998 we deployed 9 emergent endovascular stent grafts--6 in the abdominal aorta and 3 in the thoracic aorta. Aortic rupture was confirmed before surgery with spiral-computed tomographic scan. The average interval from onset of symptoms to treatment was 4.5 hours. We used commercially manufactured stent grafts: 4 Corvita (Corvita Inc/Schneider Corp/Boston Scientific Corp, Natick, Mass), 3 Talent (World Medical Inc, Surise, Fla/Medtronic, Sunnyvale, Calif), and 2 Vanguard (Boston Scientific Corp, Natick, Mass).

RESULTS

Deployment of the stent grafts was successful in all cases. Two patients died in the follow-up period (120 months) from myocardial infarction. No cases were seen of paraplegia or stent migration. However, 2 endoleaks, 1 in-stent stenosis, 1 temporary renal failure, and 1 brief episode of myocardial ischemia occurred.

CONCLUSION

Our experiences with emergency endovascular stent grafting show that the procedure is technically feasible, with less morbidity and mortality than conventional open surgery, in selected patients.

A hybrid endovascular procedure to preserve internal iliac artery patency during endovascular repair of aortoiliac aneurysms

PURPOSE

To demonstrate the feasibility of a hybrid endovascular procedure to preserve blood flow in the internal iliac arteries (IIA) during aortoiliac endografting.

TECHNIQUE

When aneurysmal dilatation makes the distal neck in the common iliac artery (CIA) too short for an adequate seal, the CIA bifurcation is exposed via an extraperitoneal approach after endograft deployment. Via an arteriotomy in the CIA, the distal end of the stent-graft is sutured to the CIA bifurcation under direct vision to preserve IIA blood flow. This approach has been successful in preserving IIA blood flow in 5 of 7 endograft procedures; in the other 2, IIA occlusion was a predictable event.

CONCLUSIONS

Direct suturing of an aortoiliac stent-graft to the CIA bifurcation via an extraperitoneal approach is a useful method of maintaining IIA perfusion. However, further study is required to identify patients at high risk of pelvic ischemia who would benefit from such intervention.

Color duplex ultrasonography of the superior mesenteric artery after placement of endografts with suprarenal stents

After endovascular repair of abdominal aortic aneurysm with endografts with suprarenal stents, the proximal uncovered stent may cross the origin of the superior mesenteric artery. Effects on splanchnic circulation are unknown and may include development of stenosis at the vicinity of the stent. The criteria of high-grade superior mesenteric artery stenosis using color duplex ultrasonography have been previously reported. The purpose of this study is to examine the incidence of high-grade superior mesenteric artery stenosis in patients with endografts with suprarenal stents using color duplex ultrasonography. Candidates for the study were patients who had placement of an aortic endograft with a suprarenal stent and were able to undergo ultrasonography of the superior mesenteric artery. After reviewing computed tomography scans, patients who had the origin of the superior mesenteric artery crossed by the suprarenal stent underwent color duplex ultrasonography of this vessel. Presence of turbulence or narrowing of the superior mesenteric artery, or a peak systolic velocity greater than 2.75 m/sec, or an end-diastolic velocity greater than 0.45 m/sec were considered significant for the presence of high-grade superior mesenteric artery stenosis. There were 24 patients (21 males, three females), median age 71 years (range, 59-83). The suprarenal stent was crossing the superior mesenteric artery in 17 of 24 patients (71%). Color duplex ultrasound was technically successful in 13 of 17 (76%). The test was performed after a median follow-up of 9 months (range, 3 days to 34 months). No patient had evidence of turbulence or narrowing of the superior mesenteric artery during ultrasonography. The median peak systolic velocity was 0.92 m/sec (range, 0.53-1.21 m/sec). No patient had peak systolic velocity greater than 2.75 m/sec. The median end-diastolic velocity was 0.10 m/sec (range, 0.09-0.14 m/sec). No patient had end-diastolic velocity greater than 0.45 m/sec. Color duplex ultrasonography did not demonstrate the presence of high-grade superior mesenteric artery stenosis during early follow-up of patients with endografts with suprarenal stents. Longer follow-up of larger series of patients is needed to determine the long-term effects of suprarenal stents on splanchnic circulation.

Endovascular repair of ruptured abdominal aortic aneurysm--a challenge to open repair? Results of a single centre experience in 20 patients

INTRODUCTION

The mortality from ruptured abdominal aortic aneurysm (AAA) remains in the region of 50% despite advances in critical care. Endovascular repair of AAA has been shown to be associated with reduced physiological stress in the elective setting. It is hypothesised that the reduced physiological stress associated with EVAR may improve the outcome in patients with ruptured AAA.

METHODS

A feasibility study of endovascular repair of ruptured AAA was undertaken at the University Hospital, Nottingham, U.K. between 1994 and 2000. Patients admitted with ruptured AAA were assessed by a team familiar with endovascular techniques for elective repair of AAA. After giving informed consent patients underwent spiral computed tomographic angiography (CTA) in the majority of cases. Patients were then transferred to the operating theatre for EVAR.

RESULTS

Twenty patients underwent repair of ruptured AAA. Of these 20 patients, seven were referred from another hospital. Eight patients were considered unfit for open repair. The median duration of procedure was 180 min (range 120-480) and median blood loss was 1200 ml (range 750-2000 ml). The overall peri-operative mortality was 45%. A number of intra-operative and peri-operative procedures (both open and endovascular) were required to ensure aneurysm exclusion and to deal with the complications of endovascular surgery.

CONCLUSIONS

Ruptured AAA remains a particularly hazardous condition to treat. There are a number of advantages of EVAR in this condition. A number of the problems early in the experience of EVAR have been addressed, but further experience is required to demonstrate its efficacy when compared with open repair.

Intrarenal color duplex examination of aortic endograft patients with suprarenal stents

PURPOSE

To report an experience using intrarenal color duplex ultrasonography (ICDU) to detect high-grade renal artery stenosis in patients who had endovascular repair of abdominal aortic aneurysm (AAA) with suprarenal stent fixation.

METHODS

Twenty-eight patients (25 men; mean age 71 years, range 58-83) who had endovascular AAA repair with suprarenal stenting at least 3 months prior to commencement of this study were screened with ICDU. Acceleration time (AT), peak systolic velocity (PSV), end diastolic velocity (EDV), and resistive index (RI) were measured. The Doppler waveform was quantitatively scored on a scale from 0 to 4. AT >0.07 seconds, RI <0.45, or a Doppler waveform score of 0 or 1 (indicating loss of early systolic peak) were indicative of high-grade renal artery stenosis.

RESULTS

Median follow-up was 15.5 months (range 3-34). ICDU was successful in 54 (98%) of 55 kidneys scanned. No AT values exceeded 0.07 seconds, all RIs were >0.45, and no waveforms had loss of early systolic peak, indicating that no patient had evidence of high-grade renal artery stenosis.

CONCLUSIONS

ICDU is a simple and affordable method that seems well suited to periodic screening in patients with suprarenal stents. Longer follow-up with a larger number of patients is needed before definite conclusions can be drawn about the effect of suprarenal stenting on renal circulation.

Overt colon ischemia after endovascular aneurysm repair: the importance of microembolization as an etiology

OBJECTIVE

The purpose of this study was to analyze the incidence, severity, and etiologic factors of the development of colon ischemia after endovascular aortoiliac aneurysm repair (EVAR).

METHODS

During the last 9 years we performed 278 elective EVARs using a variety of grafts. To facilitate these repairs, one hypogastric artery (HA) was coil embolized in 109 patients and both HAs were coil embolized in 13 patients. The preprocedural status of the inferior mesenteric, hypogastric, and iliac arteries as well as anatomical characteristics of the abdominal aortic aneurysm were determined arteriographically and by computerized tomographic scans. Postoperative colon ischemia was documented by colonoscopy or operative findings.

RESULTS

Colon ischemia occurred in eight patients (2.9%). Three patients with colon ischemia died and had evidence of widespread (cutaneous, renal, small bowel, and/or lower extremity) microembolization. One of these three had a colectomy and microscopic emboli were present. One other patient who required a colectomy also had pathologic evidence of colonic microembolization but survived. Four other patients with colon ischemia were treated conservatively and survived. In one patient, previous colectomy with interruption of mesenteric collaterals may have been a contributory cause of colon ischemia. Of the eight patients with colon ischemia, only one had unilateral HA occlusion, and none had bilateral HA occlusion. The other 121 patients with unilateral and bilateral HA occlusion had no evidence of colon ischemia.

CONCLUSIONS

Colon ischemia occurs after EVAR with an incidence approximating that of open repair. Colon ischemia was unrelated to HA interruption. Embolization appears to be a major cause of colon ischemia, although inadequate mesenteric collateral circulation may also play an etiologic role. Mortality with colon ischemia accompanied by widespread embolization was high, whereas colon ischemia without it was often mild and amenable to nonoperative management.

Mortality and morbidity following endovascular repair of abdominal aortic aneurysms: analysis of two single centre experiences

OBJECTIVE

to show how differences in anatomical and physiological risk factors can affect the outcome of endovascular repair of AAA by describing the experience of two centres with different selection policies.

METHODS

one hundred and thirty-five patients (group I) were treated at Queen's Medical Centre (Nottingham, U.K.) using 101 in-house made and 34 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 26 mm, 27 mm, 40 degrees, respectively. Seventy-six patients had ischaemic heart disease, 47 had left ventricular failure, median forced expiratory volume in one second (FEV1) was 83%, median creatinine was 100 micromol/l and median age was 72 years. Fifty patients (group II) were treated at Timone Hospital (Marseilles, France) using seven in-house made and 43 manufactured stent-grafts. Median diameter, length and angulation of the proximal aneurysm neck were 25 mm, 34 mm, 33 degrees, respectively. Thirteen patients had ischaemic heart disease, two had left ventricular failure, median forced expiratory volume in one second was 101%, median creatinine was 108 micromol/l and mean age was 72 years.

RESULTS

anatomical characteristics of the proximal neck were significantly worse in group I (p=0.02 for the three variables). Cardiac comorbidities were more frequent and mean FEV1 was lower in group I (p<0.0001 and p=0.001, respectively. Median aneurysm diameter was significantly greater in group I (65 mm) than in group II (53 mm) (p<0.001). Postoperative mortality was 9% and 0% in groups I and II respectively (p=0.03). The incidence of technical complications (groin wound complications and side branches endoleaks being excluded) was 20% and 0% in groups I and II, respectively (p=0.0006).

CONCLUSION

postoperative mortality and technical complication rates were significantly greater in group I than in group II, readily explained by poorer general condition and worse anatomical characteristics of the proximal neck in group I.