Emergency endovascular interventions for ruptured thoracic and abdominal aortic aneurysms

Anaesthetic Management of Planned or Emergency Endovascular Stent Graft Surgery for Thoracic Aneurysms and Dissections

We reviewed the intraoperative anaesthetic management and outcome of seven consecutive cases of endovascular stent graft surgery for thoracic aortic aneurysms or dissections over a period of 20 months in our institution. Seven males (median age 63) underwent endovascular stent graft surgery of the thoracic aorta under general anaesthesia. Four were emergency procedures for acute dissection or leaks of thoracic aneurysms. The duration of the procedures ranged from 120 to 300 minutes. Intraoperative stent migration occurred in one patient. Induced hypotension and immobilization were critical during stent deployment. Six out of the seven patients were discharged home between three to 20 days postoperatively. There was no 30-day mortality. One patient died sixty days postoperatively. Anaemia and respiratory complications were the most common postoperative problems encountered. None of the patients sustained spinal cord ischaemia, acute myocardial infarction or renal impairment. Endovascular stent graft surgery of the thoracic aorta is a relatively new alternative to conventional open surgery. Our experience suggests satisfactory short-term outcome even for patients with acute dissection. However, long-term survival and results require further evaluation.

Emergency endovascular repair of a ruptured descending thoracic aortic aneurysm in an octogenarian: report of a case

Emergency conventional surgical repair of the descending thoracic aorta remains a therapeutic challenge and is associated with a high risk of mortality. We describe a case of ruptured descending thoracic aortic aneurysm in an 87-year-old man who presented with chest and back pain. The patient underwent successful endovascular repair of the lesion with the use of Gore TAG thoracic endoprosthesis. Post-procedure computed tomography showed complete exclusion of the aneurysm without endoleaks. Endovascular repair is feasible and can be effective in such cases.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

An abdominal aortic aneurysm (AAA) (the pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular repair, has been shown to reduce early morbidity and mortality, as compared to conventional open surgery, for planned AAA repair. Emergency endovascular repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition.

OBJECTIVES

To compare the advantages and disadvantages of eEVAR in comparison with conventional open surgical repair for the treatment of RAAA.

SEARCH STRATEGY

The Cochrane Peripheral Vascular Diseases Group searched their trials register (last searched October 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) database (last searched Issue 4, 2006). We searched a number of electronic databases and handsearched relevant journals until March 2006 to identify studies for inclusion.

SELECTION CRITERIA

Randomised controlled trials in which patients with a confirmed ruptured abdominal aortic aneurysm were randomly allocated to eEVAR, or conventional open surgical repair.

DATA COLLECTION AND ANALYSIS

Studies identified for potential inclusion were independently assessed for eligibility by at least two reviewers, with excluded studies further checked by the agreed arbitrators. As no randomised controlled trials were identified at present no tests of heterogeneity or sensitivity analysis were performed.

MAIN RESULTS

There were no randomised controlled trials identified at present comparing eEVAR with conventional open surgical repair for the treatment of RAAA.

AUTHORS' CONCLUSIONS

There is no high quality evidence to support the use of eEVAR in the treatment of RAAA. However, evidence from prospective controlled studies without randomisation, prospective studies, and retrospective case series suggest that eEVAR is feasible in selected patients, with outcomes comparable to best conventional open surgical repair for the treatment of RAAA . Furthermore, endovascular repair in selected patients may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, and mortality.

Endovascular repair in management of thoracic aortic aneurysms

OBJECTIVE

Aneurysms of the thoracic aorta are still potentially life-threatening situations. The conventional operation is still associated with morbidity. Endovascular stent graft repair offers an alternative to conventional operation for management of aortic diseases. Our aim was to report our experience with endovascular stent graft repair of thoracic aortic aneurysms.

PATIENTS AND METHODS

Between November 2002 and October 2005, endovascular stent graft repair was performed in 26 patients: post-traumatic aortic aneurysm (n=4), Type B dissection (n=3) and descending thoracic aortic aneurysm (n=19). The deployed stent graft systems were Talent-Medtronic (n=14) and Excluder-Gore (n=12).

RESULTS

Successful deployment of the stent grafts in the appropriate position was achieved in all patients. There was neither hospital mortality nor paraplegia. Late and non-procedure related death occurred in only one patient (3.8%). An average of 40% shrinkage of the aneurysmal space was observed. There was no early mortality and endoleaks. The median intensive care unit and hospital stay times were 1 and 7 days (range 4-13 days), respectively. Post-operative computed tomography scans were obtained in all patients and complete thrombosis was observed in the false lumen of dissecan aneurysms (n=3) and sac of saccular aneurysms in 25 patients. Mean follow up time was 17.1+/-5.4 months.

CONCLUSIONS

Endovascular stent graft treatment for treatment of thoracic aorta aneurysm, Type B dissection and traumatic disease of the thoracic aorta is technically feasible. Although the short and mid-term results are encouraging the long term results will determine the future of this treatment.

Emergency Endovascular Treatment of Abdominal Aortic Aneurysms: Feasibility and Results

PURPOSE

To assess the feasibility and effectiveness of emergency endovascular treatment of abdominal aortic aneurysms (AAAs).

METHODS

During 36 months we treated, on an emergency basis, 30 AAAs with endovascular exclusion. In 21 hemodynamically stable patients preoperative CT angiography (CTA) was performed to confirm the diagnosis and to plan the treatment; 9 patients with hemorrhagic shock were evaluated with angiography performed in the operating room. Twenty-two Excluder (Gore) and 8 Zenith (Cook) stent-grafts (25 bifurcated and 5 aorto-uni-iliac) were used. The follow-up was performed by CTA at 1, 3, 6, and 12 months.

RESULTS

Technical success was achieved in 100% of cases with a 10% mortality rate. The total complication rate was 23% (5 increases in serum creatinine level and 2 wound infections). During the follow-up, performed in 27 patients (1-36 months, mean 15.2 months), 4 secondary endoleaks (15%) (3 type II, 2 spontaneously thrombosed and 1 under observation, and 1 type III treated by iliac extender insertion) and 1 iliac leg occlusion (treated with femoro-femoral bypass) occurred. We observed a shrinkage of the aneurysmal sac in 8 of 27 cases and stability in 19 of 27 cases; we did not observe any endotension.

CONCLUSIONS

Endovascular repair is a good option for emergency treatment of AAAs. The team's experience allows correct planning of the procedure in emergency situations also, with technical results comparable with elective repair. In our experience the bifurcated stent-graft is the device of choice in patients with suitable anatomy because the procedure is less time-consuming than aorto-uni-iliac stent-grafting with surgical crossover, allowing faster aneurysm exclusion. However, further studies are required to demonstrate the long-term efficacy of endovascular repair compared with surgical treatment.

Challenges, Controversies, and Advances in Aortic Catastrophes

Emergency physicians (EPs) are commonly faced with life-threatening entities. Particularly challenging are the aortic catastrophes, such as penetrating aortic ulcers (PAUs), intramural hematomas (IMHs), and atypical presentations of acute aortic dissections and ruptured abdominal aortic aneurysms. Several factors account for this: (1) the rapidly evolving knowledge (particularly in the pathogenesis and precursors of aortic dissection [AD]), (2) the lack of comfort caused by infrequent exposure, (3) the misconceptions about the work up and treatment, (4) the lack of emergent vascular surgery back up in the community, and finally (5) the high short-term mortality and missed rates. Finally, the media has publicized cases of celebrities and other patients who experienced fatal outcomes when their aortic catastrophes went undiagnosed. Practitioners of emergency care should, therefore, understand the challenges, be aware of the recent advances, and help limit the controversies in the evaluation and management of these patients.

Endovascular therapies for noncoronary atherosclerosis in the elderly: supra-aortic vessels and thoracoabdominal aorta lesions

Due to the aging of the population and the fact that people are living longer, there are increasing numbers of older patients with noncoronary atherosclerosis. Carotid and subclavian arteries are often the first involved vessels in atherosclerosis, and thoracoabdominal aortic involvement is becoming even more frequent. New techniques, such as intra-arterial thrombolysis, protection and thrombo-aspiration devices, and new stent graft designs are becoming available for percutaneous treatment of atherosclerosis in such vessels. In this review, the authors offer geriatric cardiologists an overview and an update of the most recent advances in techniques and results in the field of interventional treatments of atherosclerosis of supra-aortic vessels and thoracoabdominal aorta in the elderly.

Acute traumatic aortic rupture: A comparison of surgical and stent-graft repair

OBJECTIVE

The study's objective was to comparatively evaluate surgery and stent-graft repair of acute or subacute traumatic aortic rupture.

METHODS

A total of 76 patients (14-76 years old; mean, 37 years; male/female ratio, 63/11) with a traumatic aortic injury were admitted to our hospital between 1981 and 2003. Six patients died within 1 to 9 days of another associated severe traumatic lesion. The 70 remaining patients were divided according to the type of rupture repair. In group 1, 35 patients were treated surgically: 28 with immediate repair and 7 with delayed repair (average time interval 66 days, 5-257 days). In group 2, 29 patients were treated with stent grafting of the aortic isthmus. In group 3, 6 patients with minor aortic lesions were treated medically with a close follow-up.

RESULTS

In the 28 patients treated surgically in the emergency department, the mortality and paraplegia rates were 21% and 7%, respectively. No death or paraplegia was observed in the group with delayed surgical repair. With stent grafting, complete exclusion of the pseudoaneurysmal sac was observed in all patients. Except for 1 iliac rupture treated during the same procedure, there was no major morbidity or mortality during the mean follow-up of 46 months (13-90 months). No major complication was observed in group 3.

CONCLUSIONS

In stable rupture of the aorta, initial conservative treatment is safe and allows management of the major associated lesions. Stent grafting of the aortic isthmus is a valuable therapeutic alternative to surgical repair, especially in patients considered high risk for conventional thoracotomy.

Emergency endovascular interventions for acute thoracic aortic rupture: Four-year follow-up

OBJECTIVE

High mortality and paraplegia rates associated with the surgical management of acute thoracic aortic ruptures limit its success. It was our objective to evaluate whether emergency endovascular interventions would improve the outcomes of these patients.

METHODS

Sixty patients aged 28 to 83 years were admitted to our institution with an acute rupture of the thoracic aorta (27 ruptured aneurysms, 15 perforated type B dissections, 18 traumatic ruptures). Twenty-eight patients were treated surgically with cardiopulmonary bypass, and 32 patients were acutely treated with an endovascular stent graft. Medical records were reviewed for prehospital and emergency department data, operative findings, and outcomes. Patients were followed up at yearly intervals with high-resolution multidetector computed tomographic angiography.

RESULTS

Perioperatively, there were 1 death (3.1%) among the 32 patients in the endovascular group and 5 deaths (17.8%) among the 28 patients in the surgical group. There were 4 late deaths in the endovascular group and 1 in the surgical group. There were 2 access failures in the endovascular group. There were 1 stroke in the endovascular group and 1 case of paraplegia in the surgical group. Three patients in the endovascular group had endovascular leaks develop that required reintervention. Two patients in the endovascular group had late thrombosis of the left subclavian artery.

CONCLUSION

Despite encouraging early outcomes, midterm results suggest a trend toward increased reintervention and late complication rates in the endovascular group. Therefore continued surveillance of patients treated with stent grafts is necessary.

Ruptured abdominal aortic aneurysm: endovascular treatment

BACKGROUND

This report describes our preliminary experience in endovascular management of 25 ruptured abdominal aortic aneurysms (rAAAs).

METHODS

In the past 3 years we treated 46 patients who had rAAA, and 25 (54.3%) were treated with an endovascular approach. Patients' mean age was 76 +/- 9 years. The diagnosis was confirmed by computed tomographic angiography in 23 patients (92%). Mean aneurysm diameter was 73 +/- 17 mm. We used an infrarenal bifurcated device in 17 patients (68%), a suprarenal bifurcated in four patients (16%), and an aortomonoiliac graft in four patients (16%). Overall, nine patients (36%) required intensive care. Every patient underwent radiologic follow-up according to the Eurostar register, with concomitant evaluation of the D-dimer level (cut-off <200 microg/L) as a biological marker for endoleaks.

RESULTS

The primary technical success rate was 100%. Overall in-hospital mortality rate was 20%. Mean hospitalization was 7 days (range, 3-30), and mean follow-up was 7 months. One occlusion (4%) of the iliac limb and two type II endoleaks (8%) occurred. The mean D-dimer level in type I endoleak was 1045 microg/L (range, 459-2021).

CONCLUSIONS

In our experience, endovascular management of rAAA is feasible and safe and produces better results than conventional surgery, provided the morphology is suitable and the procedure is carried out by an experienced endovascular team.

Endovascular repair of ruptured abdominal aortic aneurysms: logistics and short-term results

PURPOSE

To report our experience in establishing a treatment protocol for endovascular aneurysm repair (EVAR) of ruptured abdominal aortic aneurysms (rAAA), including an investigation of the reasons for patient exclusion and a report of our short-term results.

METHODS

Between 1997 and July 2002, 21 patients with rAAA underwent endovascular repair according to our protocol and were followed prospectively. A retrospective analysis was also conducted of 23 rAAA patients treated with open repair from January 2001 through June 2002. Procedural and clinical data from this sample were compared to 14 contemporaneous emergent EVAR cases and analyzed to determine why the open repair patients were not treated with an endovascular approach.

RESULTS

Among the 21 patients treated with emergent EVAR since the beginning of this protocol, 6 (29%) procedures were performed under local anesthesia and 6 were performed percutaneously. Thirty-day mortality was 19%. In the comparison of 14 emergent EVAR cases to 23 open rAAA repairs, the mean duration of symptoms prior to intervention was 12 hours for the EVAR patients and <1 hour for OR patients. No significant difference was found in operating time, but the EVAR group had significantly less blood loss (p=0.0001) and transfusion needs (p=0.02); duration of intensive care unit stay was significantly shorter in the EVAR group (p=0.02). Thirty-day mortality was 29% (4/14) for EVAR and 35% for OR (8/23) (p>0.05). Reasons for not performing EVAR were unavailability of adequate equipment (n=11) or trained staff (n=7), hemodynamically unstable patient (n=2), mycotic aneurysm (n=2), and unfavorable anatomy in a 60-year old patient with a <5-mm-long, sharply angled infrarenal neck.

CONCLUSIONS

Endovascular repair of ruptured aortic aneurysms is feasible, and short-term results are promising. Good logistics, adequate training of physicians and staff in an elective setting, and versatile endografts are prerequisites for this type of treatment program.

Ruptured AAA in a patient with a horseshoe kidney: emergent treatment using the talent acute endovascular aneurysm repair kit

PURPOSE

To report emergent endovascular repair of a ruptured abdominal aortic aneurysm (AAA) in a patient with a horseshoe kidney.

CASE REPORT

A 78-year-old man with a horseshoe kidney presented with a contained rupture of a 72-mm AAA. After urgent computed tomographic angiography (CTA) documented the blood supply to the kidney and the suitability of the aneurysm for endovascular repair, the patient was given a local anesthetic. An aortomonoiliac stent-graft constructed from components provided in a Talent Acute Endovascular Aneurysm Repair Kit was inserted successfully. The procedure was completed with placement of a contralateral common iliac artery occluder and a femorofemoral bypass graft. No complications were encountered, and the patient was discharged with an excluded aneurysm on the fourth postoperative day. At 3 months, aneurysm exclusion was confirmed by CTA, and no endoleak was present; the retroperitoneal hematoma had disappeared. The patient remains in good general condition 8 months after treatment.

CONCLUSIONS

The advantages of endovascular aneurysm repair in the emergency setting can facilitate rapid recovery in patients with symptomatic or ruptured aneurysms, especially those having a horseshoe kidney.