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Tohmasi S, Fujitani RM, Duong WQ, Donayre CE, Kuo IJ, Chau AH, Kabutey NK. Intentional Bilateral Renal Artery Coverage During Ruptured Endovascular Paraanastomotic Pseudoaneurysm Repair. Ann Vasc Surg 2021; 79:440.e1-440.e6. [PMID: 34653639 DOI: 10.1016/j.avsg.2021.07.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 06/01/2021] [Accepted: 07/19/2021] [Indexed: 11/26/2022]
Abstract
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.
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Affiliation(s)
- Steven Tohmasi
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - Roy M Fujitani
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - William Q Duong
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - Carlos E Donayre
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - Isabella J Kuo
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - Anthony H Chau
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA
| | - Nii-Kabu Kabutey
- Irvine Medical Center, Division of Vascular and Endovascular Surgery, Department of Surgery, University of California, Orange, CA.
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Large pseudoaneurysm in proximal anastomosis of aorto-bifemoral bypass. ANGIOLOGIA 2021. [DOI: 10.20960/angiologia.00336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
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3
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Sakalihasan N, Michel JB, Katsargyris A, Kuivaniemi H, Defraigne JO, Nchimi A, Powell JT, Yoshimura K, Hultgren R. Abdominal aortic aneurysms. Nat Rev Dis Primers 2018; 4:34. [PMID: 30337540 DOI: 10.1038/s41572-018-0030-7] [Citation(s) in RCA: 292] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
An abdominal aortic aneurysm (AAA) is a localized dilatation of the infrarenal aorta. AAA is a multifactorial disease, and genetic and environmental factors play a part; smoking, male sex and a positive family history are the most important risk factors, and AAA is most common in men >65 years of age. AAA results from changes in the aortic wall structure, including thinning of the media and adventitia due to the loss of vascular smooth muscle cells and degradation of the extracellular matrix. If the mechanical stress of the blood pressure acting on the wall exceeds the wall strength, the AAA ruptures, causing life-threatening intra-abdominal haemorrhage - the mortality for patients with ruptured AAA is 65-85%. Although AAAs of any size can rupture, the risk of rupture increases with diameter. Intact AAAs are typically asymptomatic, and in settings where screening programmes with ultrasonography are not implemented, most cases are diagnosed incidentally. Modern functional imaging techniques (PET, CT and MRI) may help to assess rupture risk. Elective repair of AAA with open surgery or endovascular aortic repair (EVAR) should be considered to prevent AAA rupture, although the morbidity and mortality associated with both techniques remain non-negligible.
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Affiliation(s)
- Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium. .,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.
| | - Jean-Baptiste Michel
- UMR 1148, INSERM Paris 7, Denis Diderot University, Xavier Bichat Hospital, Paris, France
| | - Athanasios Katsargyris
- Department of Vascular and Endovascular Surgery, Paracelsus Medical University, Nuremberg, Germany
| | - Helena Kuivaniemi
- Division of Molecular Biology and Human Genetics, Department of Biomedical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University, Tygerberg, South Africa
| | - Jean-Olivier Defraigne
- Department of Cardiovascular and Thoracic Surgery, CHU Liège, University of Liège, Liège, Belgium.,Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium.,Department of Medical Imaging, Centre Hospitalier de Luxembourg, Luxembourg, Luxembourg
| | - Janet T Powell
- Vascular Surgery Research Group, Imperial College London, London, UK
| | - Koichi Yoshimura
- Graduate School of Health and Welfare, Yamaguchi Prefectural University, Yamaguchi, Japan.,Department of Surgery and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Rebecka Hultgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden.,Department of Vascular Surgery, Karolinska University Hospital, Stockholm, Sweden
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de Niet A, Reijnen MMPJ, Zeebregts CJ. Early results with the custom-made Fenestrated Anaconda aortic cuff in the treatment of complex abdominal aortic aneurysm. J Vasc Surg 2018; 69:348-356. [PMID: 30104097 DOI: 10.1016/j.jvs.2018.05.218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2018] [Accepted: 05/18/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective of this study was to investigate the feasibility of a specific custom-made fenestrated aortic cuff in the treatment of complex abdominal aortic aneurysms (AAAs). METHODS Between 2013 and 2016, a total of 57 custom-made Fenestrated Anaconda (Vascutek, Inchinnan, Scotland, UK) aortic cuffs were placed in 38 centers worldwide. All centers were invited to participate in this retrospective analysis. Postoperative and follow-up data included the presence of adverse events, necessity for reintervention, and renal function. RESULTS Fifteen clinics participated, leading to 29 cases. Median age at operation was 74 years (interquartile range [IQR], 71-78 years); five patients were female. Two patients were treated for a para-anastomotic AAA after open AAA repair, 19 patients were treated because of a complicated course after primary endovascular AAA repair, and 8 cases were primary procedures for AAA. A total of 76 fenestrations (mean, 2.6 per case) were used. Four patients needed seven adjunctive procedures. Two patients underwent conversion, one because of a dissection of the superior mesenteric artery and one because of perforation of a renal artery. Median operation time was 225 minutes (IQR, 150-260 minutes); median blood loss, 200 mL (IQR, 100-500 mL); and median contrast volume, 150 mL (IQR, 92-260 mL). Primary technical success was achieved in 86% and secondary technical success in 93%. The 30-day morbidity was 7 of 29 with a mortality rate of 4 of 29. Estimated glomerular filtration rate remained unchanged before and after surgery (76 to 77 mL/min/m2). Between preoperative and median follow-up of 11 months, estimated glomerular filtration rate was reduced statistically significantly (76 to 63 mL/min/m2). During follow-up, 9 cases had an increase in aneurysm sac diameter (5 cases >5 mm); 14 cases had a stable or decreased aneurysm sac diameter; and in 2 cases, no aneurysm size was reported. No type I endoleak was reported, and two cases with a type III endoleak were treated by endovascular means during follow-up. Survival, reintervention-free survival, and target vessel patency at 1 year were 81% ± 8%, 75% ± 9%, and 99% ± 1%, respectively. After 2 years, these numbers were 81% ± 8%, 67% ± 11%, and 88% ± 6%, respectively. During follow-up, the two patients with a type III endoleak needed endograft-related reinterventions. CONCLUSIONS Treatment with this specific custom-made fenestrated aortic cuff is feasible after complicated previous (endovascular) aortic repair or in complex AAAs. The complexity of certain AAA cases is underlined in this study, and the Fenestrated Anaconda aortic cuff is a valid option in selected cases in which few treatment options are left.
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Affiliation(s)
- Arne de Niet
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | | | - Clark J Zeebregts
- Division of Vascular Surgery, Department of Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Paredes-Mariñas E, Llort-Pont C, Castro-Bolance F, Riambau-Alonso V. Endovascular Treatment of Thoracic Aortic Pseudoaneurysm Through a Subclavian Approach in Patient with Aortoiliac Occlusive Disease: A Case Report. EJVES Short Rep 2018; 39:47-49. [PMID: 29922726 PMCID: PMC6005811 DOI: 10.1016/j.ejvssr.2018.05.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 12/17/2022] Open
Abstract
Introduction Thoracic endovascular aortic repair (TEVAR) has become the preferred option for treatment of thoracic aortic pathology, but lack of vascular access options is a common contraindication to TEVAR. Case report The authors report a case of a 67 year old male patient with multiple revascularisation procedures: bilateral axillofemoral bypass and thoracic aortofemoral bypass, both occluded. An anastomotic pseudoaneurysm of the thoracic aorta developed and detected on computed tomography angiography (CTA). A femoral artery approach could not be performed because of complete occlusion of both iliac arteries. A left subclavian artery approach was performed and through a Dacron prosthetic graft extension anastomosed to the proximal segment of the occluded axillofemoral bypass a distal component of a Zenith Alpha endograft (Cook®) was successfully deployed upside down. There was a good seal without endoleaks and no complications. Conclusion In patients with aortic bypass systematic follow up is important to detect anastomotic pseudoaneurysm and prevent its related complications. TEVAR may be offered for the treatment of thoracic aortic aneurysm pathology even in patients with a lack of vascular access. In the absence of a standard iliofemoral approach, use of an alternative subclavian approach may be considered. The reduction of the carrier system profiles allows performance of TEVAR with safety and efficiency. A femoral artery approach, the most common approach for TEVAR, cannot always be performed. Poor access is the leading cause of conversion to open repair. The use of an alternative subclavian approach may be considered. A dacron prosthesis extension can be used for introduction of TEVAR devices. The reduction of carrier system profiles allows performance of TEVAR safely and efficiently.
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Johnson CE, Ham SW, Ziegler KR, Weaver FA, Rowe VL, Han SM. Use of Double-Barrel Gore Excluder Bifurcated Endografts for Renal Artery Incorporation in an Urgent Endovascular Repair of a Thoracoabdominal Aortic Aneurysm. Ann Vasc Surg 2017; 49:309.e1-309.e6. [PMID: 29197608 DOI: 10.1016/j.avsg.2017.09.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Accepted: 09/20/2017] [Indexed: 10/18/2022]
Abstract
Total endovascular repair of a thoracoabdominal aortic aneurysm (TAAA) in an urgent setting requires an advanced endovascular skill set and an innovative approach. We describe a novel technique of treating a symptomatic Crawford extent 4 TAAA with a combination of multilayered parallel endografting and double-barrel Gore Excluder bifurcated endografts to achieve complete aneurysm exclusion with visceral and bilateral renal artery incorporation. A 75-year-old male presented with a symptomatic 10 cm Crawford extent 4 TAAA. Severe medical comorbidities, including chronic obstructive lung disease and cardiac arrhythmia, as well as prior open infrarenal aortic aneurysm repair made him high risk for an urgent re-do open repair. His previous open infrarenal aortic replacement created a short distance between the lowest renal artery and the flow divider of the aortic graft, which posed a challenge in using a bifurcated aortic endograft as a distal component of the previously described multilayered parallel endografting. Therefore, celiac and superior mesenteric arteries were treated with a multilayered parallel grafting configuration, whereas bilateral renal arteries were incorporated using side-by-side bifurcated modular stent grafts in double-barrel fashion. Contralateral gates served as cuffs for renal artery branch stent grafts, and ipsilateral limbs were deployed within the common iliac arteries. The patient recovered well and was discharged 3 days after repair. Follow-up imaging at 1 month demonstrated patent celiac, superior mesenteric, and bilateral renal artery flow, with no endoleak and stable aneurysm sac. The patient is doing well clinically 1 year after the operation.
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Affiliation(s)
- Cali E Johnson
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA.
| | - Sung W Ham
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Kenneth R Ziegler
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Fred A Weaver
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Vincent L Rowe
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA
| | - Sukgu M Han
- Comprehensive Aortic Center, CardioVascular Thoracic Institute Keck Medical Center of University of Southern California, Los Angeles, CA
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Laganà D, Guzzardi G, Petullà M, Martelli M, Ierardi AM, Del Sette B, Carrafiello GP. Endovascular Treatment of Aorto-Iliac-Femoral Anastomotic Pseudoaneurysms: A Multicentric Study. Ann Vasc Surg 2017; 45:213-222. [DOI: 10.1016/j.avsg.2017.05.040] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 05/28/2017] [Accepted: 05/31/2017] [Indexed: 11/24/2022]
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Trentadue M, Puppini G, Perandini S, Mezzetto L, Veraldi GF, Montemezzi S. Endovascular Repair of an Unusually Complex Anastomotic Pseudoaneurysm of an Aorto-Bisiliac Graft. Pol J Radiol 2017; 82:244-247. [PMID: 28533827 PMCID: PMC5424651 DOI: 10.12659/pjr.899825] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 08/29/2016] [Indexed: 11/21/2022] Open
Abstract
Background Anastomotic pseudoaneurysm is an underestimated complication of aorto-iliac grafts. Case Report This case report describes an unusual presentation of a pseudoaneurysm with a particularly complex anatomy involving both the left iliac branches, which hindered the interpretation of diagnostic studies and therapeutic management in a patient with multiple comorbidities. Conclusions The manuscript describes a successful management of such a complication by means of an elective endovascular approach.
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Affiliation(s)
- Mirko Trentadue
- Department of Radiology - Interventional Radiology Unit, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
| | - Giovanni Puppini
- Department of Radiology - Interventional Radiology Unit, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
| | - Simone Perandini
- Department of Radiology - Interventional Radiology Unit, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
| | - Luca Mezzetto
- Department of Vascular Surgery, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
| | - Gian Franco Veraldi
- Department of Vascular Surgery, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
| | - Stefania Montemezzi
- Department of Radiology - Interventional Radiology Unit, University Hospital of Verona, Polo Chirurgico "P. Confortini", Verona, Italy
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Gallitto E, Gargiulo M, Freyrie A, Bianchini Massoni C, Mascoli C, Pini R, Faggioli GL, Ancetti S, Stella A. Fenestrated and Branched Endograft after Previous Aortic Repair. Ann Vasc Surg 2016; 32:119-27. [DOI: 10.1016/j.avsg.2015.10.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2015] [Revised: 10/10/2015] [Accepted: 10/15/2015] [Indexed: 10/22/2022]
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Fenestrated endografting of juxtarenal aneurysms after open aortic surgery. J Vasc Surg 2014; 59:307-14. [DOI: 10.1016/j.jvs.2013.07.118] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2013] [Revised: 07/29/2013] [Accepted: 07/30/2013] [Indexed: 11/19/2022]
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Prusa AM, Nolz R, Wibmer AG, Schoder M, Lammer J, Polterauer P, Kretschmer G, Teufelsbauer H. Endovascular treatment of delayed rupture following prior abdominal aortic aneurysm repair achieves better survival rates. J Endovasc Ther 2013; 20:609-18. [PMID: 24093312 DOI: 10.1583/13-4260r.1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
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.
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Affiliation(s)
- Alexander M Prusa
- 1 Departments of Vascular Surgery, Medical University of Vienna, Austria
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12
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Hyhlik-Dürr A, Bischoff MS, Peters AS, Attigah N, Attigha N, Geisbüsch P, Böckler D. [Endovascular therapy of para-anastomotic aneurysms of the aorta. Technical options]. Chirurg 2013; 84:881-8. [PMID: 23564196 DOI: 10.1007/s00104-013-2486-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- A Hyhlik-Dürr
- Klinik für Gefäßchirurgie und Endovaskuläre Chirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland,
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Ten Bosch JA, Waasdorp EJ, de Vries JPP, Moll FL, Teijink JA, van Herwaarden JA. The durability of endovascular repair of para-anastomotic aneurysms after previous open aortic reconstruction. J Vasc Surg 2011; 54:1571-8. [PMID: 21944919 DOI: 10.1016/j.jvs.2011.04.072] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2010] [Revised: 02/17/2011] [Accepted: 04/19/2011] [Indexed: 10/17/2022]
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Nolz R, Gschwendtner M, Jülg G, Plank C, Beitzke D, Teufelsbauer H, Wibmer A, Kretschmer G, Lammer J, Schoder M. Anastomotic pseudoaneurysms after surgical reconstruction: outcomes after endovascular repair of symptomatic versus asymptomatic patients. Eur J Radiol 2011; 81:1589-94. [PMID: 21536397 DOI: 10.1016/j.ejrad.2011.04.020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Revised: 04/01/2011] [Accepted: 04/06/2011] [Indexed: 11/26/2022]
Abstract
PURPOSE To compare perioperative and follow-up outcomes of symptomatic versus asymptomatic patients following endovascular repair of anastomotic pseudoaneurysms (APAs) of the abdominal aorta and iliac arteries. METHODS We retrospectively evaluated 17 patients (two women), with a mean age of 66.2 years (range 30-83 years). Endovascular treatment was performed in ten symptomatic, and seven asymptomatic patients electively. Data included technical success, perioperative (within 30 days) mortality and morbidity, as well as stent graft-related complications, reinterventions, and survival in follow-up. RESULTS Bifurcated (n = 13), aortomonoiliac (n = 3) endoprosthesis and one aortic cuff were implanted with a primary technical success rate of 100%. The overall in-hospital mortality and morbidity rate was 11.8% and 35.3%. The mean survival was 36.5 (range 0-111) months. There was a clear trend toward a lower overall survival within hospital and at one and three years for symptomatic patients compared to asymptomatic patients. (47.7 (CI: 0-138.8) versus 52.6 (CI: 28.5-76.8) months (p = 0.274)). During follow-up, late stent graft related complications were observed in six patients (35.3%) necessitating eight endovascular reinterventions. Additional three patients with primary fistulas between the APA and the intestine were treated by late surgical revision. CONCLUSION Endovascular therapy of APAs represents a considerable alternative to open surgical repair. Short proximal anchoring zones still pose a risk for endoleaks and unintentional overstenting of side branches with commercially available devices, but this might be overcome by use of fenestrated and branched stent grafts in elective cases.
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Affiliation(s)
- Richard Nolz
- Department of Radiology, Division of Cardiovascular and Interventional Radiology, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria.
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Endovascular treatment of late "endoleak" following open surgical repair using bypass and exclusion aneurysm repair. Ann Vasc Surg 2010; 24:552.e9-552.e14. [PMID: 20144525 DOI: 10.1016/j.avsg.2009.10.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2009] [Revised: 10/03/2009] [Accepted: 10/12/2009] [Indexed: 11/21/2022]
Abstract
BACKGROUND We sought to present endovascular management options of persistent or recurrent aneurysm sac flow ("endoleak") after operative retroperitoneal exclusion of infrarenal abdominal aortic aneurysm (AAA). METHODS Recurrent or persistent aneurysm perfusion was diagnosed in three patients primarily treated with aneurysm exclusion and bypass. The medical history, course of disease, and surgical management of these patients were reviewed. RESULTS Three patients primarily treated for infrarenal AAA by division of the aorta with suture closure of the proximal aneurysm end, ligation of the outflow vessels, and bypass of the excluded aortoiliac segment presented with persistent or recurrent AAA sac perfusion and growth. The feeding vessels were the iliac arteries in all cases. Endovascular repair using coil embolization and/or deployment of an occluder or stent-graft was successful in all patients with a follow-up of 42, 36, and 30, months respectively. CONCLUSION Open AAA repair using the exclusion and bypass technique is associated with the risk of persistent perfusion or reperfusion of the aneurysm sac, which is similar to an endoleak after endovascular aortic aneurysm exclusion. Endovascular therapy should be considered as first-choice treatment when feasible.
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Endovascular Methods in the Treatment of Late Complications of Conventional Operations of Aneurysms At Aorto-Iliac Level. POLISH JOURNAL OF SURGERY 2010. [DOI: 10.2478/v10035-010-0026-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Cerná M, Köcher M, Utíkal P, Koutná J, Drác P, Bachleda P, Burval S, Kozák J, Thomas RP. Endovascular treatment of abdominal aortic paraanastomotic pseudoaneurysms after surgical reconstruction. Eur J Radiol 2009; 71:333-7. [PMID: 18450399 DOI: 10.1016/j.ejrad.2008.03.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Revised: 02/26/2008] [Accepted: 03/20/2008] [Indexed: 11/17/2022]
Affiliation(s)
- Marie Cerná
- Department of Radiology, University Hospital, I. P. Pavlova 6, 775 20 Olomouc, Czech Republic
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Tsang JS, Naughton PA, Wang TT, Keeling AN, Moneley DS, Lee MJ, Kelly CJ, Leahy AL. Endovascular Repair of Para-Anastomotic Aortoiliac Aneurysms. Cardiovasc Intervent Radiol 2009; 32:1165-70. [PMID: 19629588 DOI: 10.1007/s00270-009-9653-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Revised: 06/17/2009] [Accepted: 06/23/2009] [Indexed: 10/20/2022]
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Bianchi P, Nano G, Cusmai F, Ramponi F, Stegher S, Dell'Aglio D, Malacrida G, Tealdi DG. Uninfected para-anastomotic aneurysms after infrarenal aortic grafting. Yonsei Med J 2009; 50:227-38. [PMID: 19430556 PMCID: PMC2678698 DOI: 10.3349/ymj.2009.50.2.227] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2007] [Revised: 08/13/2008] [Accepted: 08/26/2008] [Indexed: 11/27/2022] Open
Abstract
PURPOSE This single-institution retrospective review examines the management of uninfected para-anastomotic aneurysms of the abdominal aorta (PAAA), developed after infrarenal grafting. MATERIALS AND METHODS From October 1979 to November 2005, 31 PAAA were observed in our Department. Twenty-six uninfected PAAA of degenerative etiology, including 24 false and 2 true aneurysms, were candidates for intervention and retrospectively included in our database for management and outcome evaluation. Six (23%) patients were treated as emergencies. Surgery included tube graft interposition (n = 12), new reconstruction (n = 8), and graft removal with extra-anatomic bypass (n = 3). Endovascular management (n = 3) consisted of free-flow tube endografts. RESULTS The mortality rate among the elective and emergency cases was 5% and 66.6%, respectively (p = 0.005). The morbidity rate in elective cases was 57.8%, whereas 75% in emergency cases (p = 0.99). The survival rate during the follow-up was significantly higher for elective cases than for emergency cases. CONCLUSION Uninfected PAAA is a late complication of aortic grafting, tends to evolve silently and is difficult to diagnose. The prevalence is underestimated and increases with time since surgery. The mortality rate is higher among patients treated as an emergency than among patients who undergo elective surgery, therefore, elective treatment and aggressive management in the case of pseudoaneurysm are the keys to obtain a good outcome. Endovascular treatment could reduce mortality. Patients who undergo infrarenal aortic grafting require life-long surveillance after surgery.
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Affiliation(s)
- Paolo Bianchi
- Department of Vascular Surgery, University of Milan, IRCCS Policlinico San Donato, San Donato Milanese, Italy.
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Sharp WJ, Bashir M, Word R, Nicholson R, Bunch C, Corson J, Kresowik T, Hoballah J. Suprarenal Clamping Is a Safe Method of Aortic Control when Infrarenal Clamping Is not Desirable. Ann Vasc Surg 2008; 22:534-40. [DOI: 10.1016/j.avsg.2008.02.006] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2007] [Revised: 12/08/2007] [Accepted: 02/13/2008] [Indexed: 11/29/2022]
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21
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Laganà D, Carrafiello G, Mangini M, Recaldini C, Lumia D, Cuffari S, Caronno R, Castelli P, Fugazzola C. Endovascular treatment of anastomotic pseudoaneurysms after aorto-iliac surgical reconstruction. Cardiovasc Intervent Radiol 2008; 30:1185-91. [PMID: 17508237 DOI: 10.1007/s00270-007-9047-0] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
PURPOSE To assess the effectiveness of endovascular treatment of anastomotic pseudoaneurysms (APAs) following aorto-iliac surgical reconstruction. MATERIALS We retrospectively evaluated 21 men who, between July 2000 and March 2006, were observed with 30 APAs, 13 to the proximal anastomosis and 17 to the distal anastomosis. The patients had had previous aorto-iliac reconstructive surgery with a bypass due to aneurysm (15/21) or obstructive disease (6/21). The following devices were used: 12 bifurcated endoprostheses, 2 aorto-monoiliac, 4 aortic extenders, 1 stent-graft leg, and 2 covered stents. Follow-up was performed with CT angiography at 1, 3, and 6 months after the procedure and yearly thereafter. RESULTS Immediate technical success was 100%. No periprocedural complications occurred. Four patients died during follow-up from causes not related to APA, and 1 (treated for prosthetic-enteric fistula) from sepsis 3 months after the procedure. During a mean follow-up of 19.7 months (range 1-72 months), 2 of 21 occlusions of stent-graft legs occurred 3 and 24 months after the procedure (treated with thrombolysis and percutaneous transluminal angioplasty and femorofemoral bypass, respectively) and 1 type I endoleak. Primary clinical success rate was 81% and secondary clinical success was 91%. CONCLUSION Endovascular treatment is a valid alternative to open surgery and can be proposed as the treatment of choice for APAs, especially in patients who are a high surgical risk. Further studies with larger series and longer follow-up are necessary to confirm the long-term effectiveness of this approach.
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Affiliation(s)
- Domenico Laganà
- Department of Radiology, University of Insubria, Viale Borri, 57, 21100 Varese, Italy.
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22
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Sfyroeras GS, Lioupis C, Bessias N, Maras D, Pomoni M, Andrikopoulos V. Endovascular treatment of a ruptured para-anastomotic aneurysm of the abdominal aorta. Cardiovasc Intervent Radiol 2008; 31 Suppl 2:S79-83. [PMID: 18214598 DOI: 10.1007/s00270-007-9206-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2007] [Revised: 08/13/2007] [Accepted: 09/25/2007] [Indexed: 10/22/2022]
Abstract
We report a case of a ruptured para-anastomotic aortic aneurysm treated with implantation of a bifurcated stent-graft. A 72-year-old patient, who had undergone aortobifemoral bypass for aortoiliac occlusive disease 16 years ago, presented with a ruptured para-anastomotic aortic aneurysm. A bifurcated stent-graft was successfully deployed into the old bifurcated graft. This is the first report of a bifurcated stent-graft being placed through an "end-to-side" anastomosed old aortobifemoral graft. Endovascular treatment of ruptured para-anastomotic aortic aneurysms can be accomplished successfully, avoiding open surgery which is associated with increased mortality and morbidity.
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Affiliation(s)
- Giorgos S Sfyroeras
- Department of Vascular Surgery, The Red Cross Hospital of Athens, Athens, Greece
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23
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Ziegler P, Perdikides TP, Avgerinos ED, Umscheid T, Stelter WJ. Fenestrated and Branched Grafts for Para-Anastomotic Aortic Aneurysm Repair. J Endovasc Ther 2007. [DOI: 10.1583/1545-1550(2007)14[513:fabgfp]2.0.co;2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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24
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Post PN, Kievit J, van Bockel JH. Optimal follow-up strategies after aorto-iliac prosthetic reconstruction: a decision analysis and cost-effectiveness analysis. Eur J Vasc Endovasc Surg 2004; 28:287-95. [PMID: 15288633 DOI: 10.1016/j.ejvs.2004.06.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/03/2004] [Indexed: 10/26/2022]
Abstract
OBJECTIVE The primary aim of ultrasound follow-up after aorto-iliac prosthetic reconstruction is to correct false aneurysms before rupture occurs. We investigated whether follow-up improves the life expectancy of patients and sought to identify the most cost-effective follow-up strategy. DESIGN OF THE STUDY A Monte Carlo Markov decision model was constructed. The occurrence of false aneurysms was modelled as a time-dependent process for each anastomotic site, based on published series. Using this model, the impact of various follow-up strategies was investigated for three types of prostheses, aorto-distal tube, aorto-bi-iliac, and aorto-bi-femoral prostheses. Main outcome measures were discounted quality adjusted life years (dQALYs), discounted costs, and (discounted) cost-effectiveness (CE) ratios. RESULTS Follow-up of patients with aorto-distal tube and aorto-bifemoral prostheses did not result in an improvement life expectancy and was not cost-effective, QALYs 7.53 and 7.62 years, respectively. The results for aorto-distal tube and aorto-bifemoral prostheses were not sensitive to any variation in the model parameters. In the base case analysis, the life expectancy of patients with aorto-bi-iliac prostheses was 7.50 QALYs (95% confidence interval 7.46-7.54) whether or not they underwent routine follow-up. However, patients aged 54 years or younger gained 0.11 QALYs with annual follow-up (p<0.05). The most cost-effective strategy was annual follow-up that starts 10 years after the initial operation, and continues up to 30 years after surgery (4600 Euro; CE ratio 21,000 Euro per QALY). When perioperative mortality of elective reconstruction of false aneurysms is 2% or lower (e.g. when endovascular treatment is used), a small improvement is observed (7.56 vs. 7.50 QALYs; p<0.05; CE ratio 35,000 Euro per QALY). CONCLUSIONS Annual follow-up of aorto-bi-iliac prostheses should be restricted to patients aged 54 or younger and not start before 10 years after surgery. The same strategy can only be considered for older patients if mortality for secondary intervention is lower than 2%. Since patients with aorto-distal tube and aorto-bi-femoral prostheses do not benefit from follow-up for the detection of false aneurysms, this practice should be discouraged in these patient groups.
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Affiliation(s)
- P N Post
- Department of Medical Decision Making, Leiden University Medical Center, Leiden, The Netherlands
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van Herwaarden JA, Waasdorp EJ, Bendermacher BLW, van den Berg JC, Teijink JAW, Moll FL. Endovascular repair of paraanastomotic aneurysms after previous open aortic prosthetic reconstruction. Ann Vasc Surg 2004; 18:280-6. [PMID: 15354628 DOI: 10.1007/s10016-004-0002-0] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The aim of this study was to evaluate the effectiveness of endovascular repair of anastomotic and true aortic and iliac aneurysms occurring after prior polyester graft repair for abdominal aortic aneurysms (AAA) or aortoiliac obstructive disease. Between July 1999 and January 2003, 14 patients underwent endovascular treatment of aortic pseudoaneurysms (n = 6) or iliac aneurysms (2 patients with pseudoaneurysms and 6 patients with true aneurysms) occurring 4 to 18.4 years (mean, 8.8 years) after open aortic surgery. No patient had symptoms or positive parameters for infection of the original polyester graft. Eleven patients, including one patient with both a proximal anastomotic and a true iliac aneurysm, were treated with AneuRx (n = 8), Talent (n = 2), or Quantum LP (n = 1) bifurcated stent grafts. Three patients with an infrarenal anastomotic pseudoaneurysm were treated with a tube stent graft (Talent [n = 2] and AneuRx [n = 1]). Endovascular stent grafts were successfully inserted in all patients. Procedure-related complications or death was not seen. During a median follow-up of 12 months (range, 3-40) all anastomotic and/or true aneurysms treated with bifurcated stent grafts maintained excluded. However, two out of three patients, treated with a tube graft for proximal aneurysm exclusion, were converted. In both patients the tube stent graft did not migrate from the level of the renal arteries but fixation failed between the stent graft and the previous polyester graft, creating endotension in the thrombus of the aneurysm sac. In one of these patients the old anastomotic aneurysm ruptured 16 months after stent graft placement and the patient died 1 day after conversion because of mesenterial ischemia. At 1 year follow-up the second patient was converted successfully after enlargement of his anastomotic aneurysm due to similar disconnection between the stent graft and the polyester graft. From this experience with endovascular stent grafts, we conclude that these can be used successfully to exclude anastomotic or true aneurysms after open aortic surgery. Exclusion of aneurysms at the proximal anastomosis with tube stent grafts is apparently not durable because of the insecure distal fixation in polyester grafts. Endovascular repair with bifurcated stent grafts, however, seems to be effective at midterm follow-up.
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MESH Headings
- Aged
- Aged, 80 and over
- Anastomosis, Surgical
- Aneurysm, False/diagnostic imaging
- Aneurysm, False/surgery
- Angiography, Digital Subtraction
- Aorta, Abdominal/diagnostic imaging
- Aorta, Abdominal/pathology
- Aorta, Abdominal/surgery
- Aortic Aneurysm, Abdominal/diagnostic imaging
- Aortic Aneurysm, Abdominal/surgery
- Aortic Rupture/diagnostic imaging
- Aortic Rupture/etiology
- Aortic Rupture/surgery
- Blood Vessel Prosthesis Implantation
- Follow-Up Studies
- Humans
- Iliac Aneurysm/diagnostic imaging
- Iliac Aneurysm/surgery
- Iliac Artery/diagnostic imaging
- Iliac Artery/pathology
- Iliac Artery/surgery
- Length of Stay
- Male
- Middle Aged
- Postoperative Complications/diagnostic imaging
- Postoperative Complications/etiology
- Postoperative Complications/surgery
- Renal Artery/diagnostic imaging
- Renal Artery/injuries
- Renal Artery/surgery
- Reoperation
- Stents
- Tomography, X-Ray Computed
- Treatment Outcome
- Vascular Surgical Procedures
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Affiliation(s)
- Joost A van Herwaarden
- Department of Vascular Surgery, St Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands.
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Mercier O, Coggia M, Javerliat I, Di Centa I, Colacchio G, Goëau-Brissonnière O. Total laparoscopic repeat aortic surgery. J Vasc Surg 2004; 40:822-5. [PMID: 15472615 DOI: 10.1016/j.jvs.2004.07.022] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
We report our initial experience with total laparoscopic repeat aortic surgery between June 2002 and October 2003. There were 4 patients, 3 men and 1 woman, ages 83, 67, 49, and 61 years, respectively. First operations were performed to treat aortoiliac occlusive disease. Repeat aortic surgery was indicated to treat para-anastomotic aneurysms (n = 2) and graft occlusion (n = 2). All patients underwent total laparoscopic surgery. There were no postoperative deaths. Only 1 patient had postoperative complications that required complementary surgical treatment. All patients were alive with patent revascularization after a mean follow-up of 14, 17, 20, and 12 months, respectively.
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Affiliation(s)
- Olaf Mercier
- Department of Vascular Surgery, Ambroise Paré University Hospital, and Faculté de Médecine Paris-Ile-de France-Quest, Versailles Saint Quentin en Yvelines University, Boulogne-Billancourt, France
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Menard MT, Nguyen LL, Chan RK, Conte MS, Fahy L, Chew DKW, Donaldson MC, Mannick JA, Whittemore AD, Belkin M. Thoracovisceral segment aneurysm repair after previous infrarenal abdominal aortic aneurysm surgery. J Vasc Surg 2004; 39:1163-70. [PMID: 15192553 DOI: 10.1016/j.jvs.2003.12.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome. METHODS We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping. RESULTS Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis. CONCLUSION Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.
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Affiliation(s)
- Matthew T Menard
- Division of Vascular and Endovascular Surgery, Department of Surgery, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA.
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Gawenda M, Zaehringer M, Brunkwall J. Open Versus Endovascular Repair of Para-Anastomotic Aneurysms in Patients Who Were Morphological Candidates for Endovascular Treatment. J Endovasc Ther 2003. [DOI: 10.1583/1545-1550(2003)010<0745:overop>2.0.co;2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Wronski J, Jargiello T, Zubilewicz T, Michalak J, Szczerbo-Trojanowska M. Endovascular repair of a recurrent infrarenal aortic aneurysm. Eur J Vasc Endovasc Surg 2002; 24:550-2. [PMID: 12443755 DOI: 10.1053/ejvs.2002.1698] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Affiliation(s)
- J Wronski
- Department of Vascular Surgery, University School of Medicine, Lublin, Poland
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