Vascular surgical society of great britain and ireland: endovascular aneurysm repair: the need for randomized controlled trials

The Vanguard Endovascular Stent-graft: Mid-term Results from a Single Centre

PURPOSE

Despite initial enthusiasm for endovascular aortic repair, few descriptions of longer-term follow-up of any endovascular device have been published. This paper represents the experience of a single centre with the Vanguard device over a 5-year period.

METHODS

Fifty-five patients with a median age of 71 years (range 45-87 years) and aneurysm diameter of 59 mm (45-84 mm) received a bifurcated Vanguard stent-graft between December 1995 and July 1999. Follow-up was according to the Eurostar criteria (clinical assessment, plain film radiography and computed tomography) at 1, 3, 6, 12, 18 and 24 months and then annually thereafter.

RESULTS

All primary stent deployments were successful. Median duration of surgery was 120 min (70-360 min). Median post-operative stay was 3 days (1-19 days) with a peri-operative mortality of 5.5%. In the follow-up period (median 40 months, range 6-64 months) there was one aneurysm associated death, and 14 deaths due to other causes. There have been three device migrations, 12 occluded graft limbs, four type II endoleaks and nine type III endoleaks. At 48 months, this has resulted in a survival rate of 67%, an endoleak free survival of 81% and intervention free survival of 59% (Kaplan-Meier).

CONCLUSION

Medium term results with the Vanguard device appear to be at least equivalent to open repair with regard to morbidity and mortality. Nevertheless, several delayed complications appear to be related to endograft limb distortion. Important lessons have been learnt in relation to the deployment of bifurcated endografts to reduce the incidence of secondary limb related problems.

Three year single centre experience with the AneuRx aortic stent graft

OBJECTIVES

To report the mid-term single-centre experience with the AneuRx self-expandable nitinol stentgraft for endovascular aneurysm repair.

PATIENTS AND METHODS

Between December 1996 and January 2000 a total of 128 patients were treated with an AneuRx bifurcated stentgraft. Of these, 77 patients had a minimum follow-up of 12 months. Patient operative and follow-up data were prospectively gathered.

RESULTS

Two (3%) conversions were necessary. Median hospital stay was 3 days. One superficial wound infection occurred. Periprocedural (30 days) mortality was 5% (four patients). Three graft occlusions were noted of which two required treatment. Fifteen patients developed 18 endoleaks (six type 1, eight type 2 and four type 3). Type 1 and type 3 endoleaks were treated by extension cuffs. Four type 2 endoleaks were treated with embolisation or direct lumbar puncture. Two-year freedom from endoleak was 76%. Graft migration occurred in six cases, resulting in a 2-year freedom from migration of 90%, kinking only once.

CONCLUSIONS

endovascular AAA treatment is feasible and so far mid-term results are without major problems. Extensive follow-up is essential as secondary problems may occur later. Long-term results are to be awaited.

Endovascular stent-graft in abdominal aortic aneurysms: the relationship between patent vessels that arise from the aneurysmal sac and early endoleak

PURPOSE

To determine the association of patent sac branch vessels (lumbar and inferior mesenteric arteries [IMAs]) with early endoleak rate after stent-graft repair of abdominal aortic aneurysm (AAA).

MATERIALS AND METHODS

Pre- and postoperative computed tomographic (CT) angiograms in 158 patients who underwent stent-graft AAA repair were retrospectively reviewed to determine the preoperative patency of IMAs and other sac branch vessels (feeders) and presence or absence of immediate postoperative endoleak. Relationships of early endoleak rate with total branch vessel, IMA, and lumbar artery patency and graft type were evaluated.

RESULTS

There was a significant association between patency of sac feeders and rate of early endoleak, especially type 2. As total patent feeders increased from zero to three to four to six, total endoleak rate increased from 6% (one of 17) to 35% (30 of 86); type 2 endoleak rate, from 0% to 25%. IMA patency was significantly associated with total early endoleak rate. Increasing lumbar artery patency also was associated with significantly higher total and type 2 endoleak rates: With zero to three lumbar arteries, the total endoleak rate was 17% and type 2 endoleak rate was 13%, as compared with 60% and 50%, respectively, with more than six patent lumbar arteries.

CONCLUSION

Sac branch vessel patency is associated with significantly higher early total and type 2 endoleak rates after stent-graft repair of AAAs; thus, patent sac branches play an important role in the pathogenesis of endoleaks.