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

A novel hybrid approach to the treatment of common iliac aneurysms: antegrade endovascular hypogastric stent grafting and femorofemoral bypass grafting

A progressively enlarging left common iliac artery aneurysm developed in a 72-year-old man 7 years after open abdominal aortic aneurysm repair with a bifurcated Dacron graft. Because both the right hypogastric and inferior mesenteric arteries had been ligated at the initial operation, preservation of left hypogastric flow was critical to avoid pelvic or intestinal ischemia. He was a poor open surgical candidate owing to obesity, a hostile abdomen, and multiple medical comorbidities. Therefore, a novel hybrid approach was used consisting of left transbrachial selective left hypogastric artery catheterization, followed by deployment of two, overlapping, antegrade, covered stent grafts extending from the proximal left graft limb into the left hypogastric artery. A right-to-left femorofemoral crossover bypass was added to perfuse the left lower extremity and was performed in end-to-end fashion to the left common femoral artery to exclude and prevent retrograde flow into the iliac aneurysm. Also presented are potential procedural pitfalls and a detailed review of open, endovascular and hybrid options to preserve hypogastric flow when treating iliac aneurysms in complex, high-risk patients.

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.

Long-term results of endovascular aneurysm repair with aortouni-iliac custom-made stent grafts

The purpose of this study was to review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using custom-made aortouni-iliac (AUI) devices with femorofemoral bypass. Between June 1999 and March 2001, 23 consecutive patients (1 female, 22 male) at high risk of open aortic aneurysm repair underwent EVAR with custom devices in an AUI configuration. The mean follow-up was 37 months (range 2-72 months), and the mean age was 76.8 years (range 67.5-88.7 years). Increased surgical risk was evidenced by 92% and 69% of patients with significant pulmonary or cardiac disease, respectively. The preoperative mean aneurysm diameter (n = 23) 62 +/- 8.2 mm was significantly greater than the postoperative diameter, (n = 23) 54 +/- 16.4 mm. Ten endoleaks occurred. Migration of the stent graft occurred in 9% (n = 2). Secondary interventions were necessary in 23%, whereas tertiary interventions were required in 9%. Patients at high risk of open aneurysm repair received sufficient protection from aneurysm rupture with custom-made AUI devices.

Intraoperative Monitoring of Penile and Buttock Blood Flow During Endovascular Abdominal Aortic Aneurysm Repair

OBJECTIVE

The purpose of this study was to assess the pelvic circulation during endovascular abdominal aortic aneurysm repair (EVAR) with a new monitoring system measuring penile and buttock blood flow.

METHODS

We measured penile brachial pressure index (PBI) during EVAR by pulse-volume-plethysmography (form PWV/ABItrade mark). We also measured bilateral gluteal tissue oxygen metabolism with near-infrared spectroscopy to provide a gluteal tissue oxygenation index (TOI). Twenty-two men who underwent aortouni-iliac stentgraft with crossover bypass for exclusion of abdominal aortic aneurysm were studied. Twelve patients underwent aorto-uni-common iliac artery stentgraft (CIA) and ten underwent aorto-uni-external iliac artery stentgraft (EIA).

RESULTS

In all patients, there was an immediate reduction in PBI during the EVAR procedure. After revascularization of the ipsilateral limb of the stent graft, the recovery of PBI was significantly less in EIA group. After the completion of crossover bypass, PBI in both groups recovered to the baseline values. In both groups there was a bilateral reduction in gluteal TOI during malperfusion of the internal iliac artery. After revascularization of ipsilateral limb of the stent graft, the ipsilateral TOI recovered to the baseline level in CIA patients, but recovery was incomplete in EIA patients. In contrast, contra-lateral TOI remained low in both groups after revascularization of ipsilateral limb of the stent graft. Only after completion of crossover bypass did the contra-lateral TOI recover to baseline level in both groups.

CONCLUSIONS

Both TOI at the buttocks and PBI are a sensitive reflection of pelvic haemodynamics. Penile blood flow and bilateral gluteal blood flow are supplied via different circulations and both should be monitored for full assessment of the pelvic circulation.

Midterm Survival After Endovascular Versus Open Repair of Infrarenal Aortic Aneurysms

PURPOSE

To report the midterm survival after endovascular repair (ER) of infrarenal aortic aneurysms and to compare the outcomes to contemporaneous patients treated with open repair (OR).

METHODS

Between January 1995 and December 2001, 498 patients were treated for abdominal aortic aneurysm: 289 (52%) underwent OR and 209 (48%) underwent ER at a single center. Preoperative risk factors were graded according to the SVS/AAVS risk stratification. A computerized database was used to record demographic, clinical, and follow-up data.

RESULTS

Significant benefits (p<0.0001) were observed in the ER group in terms of mean procedural time (163+/-66 versus 132+/-61 minutes), mean blood loss (1268+/-923 versus 122.5+/-284 mL), and mean hospital length of stay (16.24+/-13.3 versus 9.3+/-11.6 days). The perioperative mortality for OR and ER patients were, respectively, 5.1% and 1.5% (p=0.04). The mean follow-up was 40 months in the OR group (range 0-85) and 19 months in the ER group (range 2-80). Contact was lost with 31 (6%) patients during the study. No overall survival advantage was observed for OR over ER, and comparison of OR and ER according the risk classifications did not yield any significant differences. No patients died of aneurysm rupture, but 7 ER patients had to be converted to open surgery. The cumulative freedoms from reinterventions at 4 years for the OR and ER groups, respectively, were 87% and 63% (p=0.001). Patients treated by OR had better clinical success (p=0.001). Patients in the ER group without iliac artery aneurysm showed a significant improvement (p=0.035) over patients with aneurysmal iliac arteries.

CONCLUSIONS

Over the 7 years of this study, ER realized its goal: prevention of aneurysm rupture. Despite a greater number of reinterventions for ER patients, no overall survival difference was observed.