Endoluminal stent grafts in the management of infrarenal abdominal aortic aneurysms: a realistic assessment.

OBJECTIVES:transfemoral endoluminal aortic management (TEAM) is technically feasible in the treatment of infrarenal abdominal aortic aneurysms but its advantage over conventional repair is unproved. We report our initial experience, learning curve and technical difficulties encountered during the process of establishing this novel technique in our institute. MATERIAL AND METHODS:over a 3-year period 400 cases of abdominal aortic aneurysms were reviewed; only 58 cases (15%) were suitable for endovascular repair under our TEAM protocol and 36 (9%) were offered endovascular intervention. They were mainly high-risk patients (85% ASA III and IV) with a mean age of 72 years. Thirty-three bifurcated grafts, two straight tube grafts and one aorto mono-iliac graft were deployed. We oversized the graft by 15-20% to the diameter of the aortic neck and both common iliac arteries. RESULTS:two cases (6%-95% CI: 1-19%) had on-table conversion because of ruptured common iliac arteries. Peri-operatively there were two deaths from multi-organ failure. Transient renal failure occurred in two patients and three patients (9%) suffered a non-fatal myocardial infarction. Sixteen percent of patients had a groin wound problem. The mean hospital stay was 7 days. Five minor endoleaks (15%) were identified and sealed at 30 days. One secondary endoleak was identified at 18 months because of a patent juxta-renal lumbar artery. No secondary cuffs or extensions were used. Mean follow-up was 29 months and all grafts remained patent. The technical, clinical, continuous and secondary success rates were 78%, 91%, 89% and 91% respectively with TEAM. CONCLUSION:endovascular training, patient selection and learning curve impose an impact on the final outcome. Until a reliable hard point is reached so that endovascular repair could be exercised in routine practice, the use of TEAM must be questioned in high-risk patients, and should be performed under clinical trial conditions using strict selection criteria.

Sultan S ，Evoy D ，Nicholls S ，Colgan MP ，Moore D ，Shanik G ... -  《EUROPEAN JOURNAL OF VASCULAR AND ENDOVASCULAR SURGERY》

The Utrecht endovascular technologies (EVT) experience.

The aim of this report is to review the single center, clinical experience with the Endovascular Grafting System (EGS/Ancure Endovascular Technologies, Menlo Park, Calif, USA) in the Netherlands. The program was started in January 1994 and at the moment of writing consists of 35 patients on an intention-to-treat basis. From January 1994 through January 1995, 11 patients (Group I) were treated. In January 1995, hook breaks of the attachments system were reported and consequently the EVT program was discontinued from January 1995 through January 1996, pending renewal of FDA approval. From January 1996 through October 1997, another 24 patients were treated with the redesigned EGS-II (group II). Patient and aneurysm characteristics are summarized in the table I. All patients were ASA class I-III and were scheduled for elective repair of asymptomatic infrarenal AAA. No compassionate cases or high-risk patients were included in this study. All patients were entered into a prospective follow-up program, including the following studies postoperatively, at 6 weeks, 6 and 12 months, and yearly thereafter. Duplex, plain X-rays and CT-angiography (CTA) with cine-mode post-processing. In Group I, there were 10 tubes and 1 one bifurcated system. The bifurcated EGS was explanted on the 1st postoperative day due to a significant proximal leak and lower back pain. Of the 10 tube grafts, 3 have been explanted. In one case (day 2) due to a proximal endoleak, in another case (at 12 months) due to persistent aneurysm growth with a distal endoleak and in the third case (at 3 years) due to a recurrent endoleak with aneurysm growth after initial spontaneous closure and shrinkage. These conversions and their postoperative courses were uneventful. In two cases, proximal hook breaks were detected after 6 and 15 months, but in both patients the aneurysm diameter has decreased and follow-up exceeds 3 years. Another 2 patients are alive more than 3 years after the procedure without signs of endoleak, but in one the aneurysm failed to shrink, probably due to complete circular calcification. The other 3 patients have died during follow-up (6, 11, and 20 months) from diseases unrelated to the aneurysm: one pancreatic carcinoma that had been missed on CT angiography, one respiratory failure and one myocardia infarction. Overall, at three years 4 out of 11 Group I patients are alive and well, with an excluded aneurysm. In Group II, there were 17 bifurcated grafts, 5 tubes, and 2 patients in whom a tube graft could not be placed because the introduction sheath could not pass the iliac artery. In one case, this was complicated by a tear in the external iliac artery. At conversion, both patients needed a conventional bifurcated graft, one extending into the groin to bypass the damaged external iliac artery. In a third patient, a tear in the distal aortic neck was detected intraoperatively after tube endograft placement. Conversion was performed in the same session. Of the 21 endografts that left the operating room, 2 have been explanted. In one case (day 5) a tear of the proximal neck was detected. Conversion to conventional repair involved suprarenal clamping which led to multiple organ failure in this 82-y/o patient who ultimately died. In the other the bifurcated endograft showed a distal endoleak on one side, which was locally repaired by an iliac interposition graft. Three months later a proximal and left distal endoleak was diagnosed, his aneurysm had not decreased in size, and his iliac interposition graft had occluded. He was then successfully converted to a conventional bifurcated graft. In 9 of the remaining 15 bifurcated and 4 tube grafts, endoleak was detected on the postoperative CTA. Five appeared to have closed spontaneously at 6 weeks, conversion has been scheduled in one, and 3 small endoleaks are being observed (2 weeks, 6 and 12 months). In all 35 attempts, there were four cases of injury to the common femoral artery at the introduction site, wh

Blankensteijn JD ，Mali WP ，Eikelboom BC 《journal des maladies vasculaires》

[Surgery of abdominal aorta with horseshoe kidney].

Seventy one surgical procedures on abdominal aorta in patients with horseshoe kidney have been reported in literature until 1980. Bergan reviewed 30 operations of abdominal aortic aneurysms (AAA) in these patients until 1974. Of them 3 AAA were ruptured. Gutowitz noticed 57 surgically treated AAA in patients with horseshoe kidney until 1984. Over the period from 1991 to 1996 thirty nine new cases were reported , including 2 ruptured AAA. The surgery of the abdominal aorta in patients with horseshoe kidney is associated with the following major problems: -reservation of anomalous (aberrant) renal arteries; reservation of the kidney excretory system; approach to the abdominal aorta (especially in patients with AAA) and graft placement The aim of the paper is the presentation of 5 new patients operated for abdominal aorta with horseshoe kidney. Over the last 12 years (January 1, 1984 to December 31, 1996) at the Centre of Vascular Surgery of the Institute of Cardiovascular Diseases of the Clinical Centre of Serbia, 5 patients with horseshoe kidney underwent surgery of the abdominal aorta. There were 4 male and one female patients whose average age was 57.8 years (50-70). Patient 1. A 50-year-old male patient was admitted to the hospital for disabling claudication discomforts (Fontan stadium IlI) and with significantly decreased Ankle-Brachial indexes (ABI). The translumbal aortography showed aorto-iliac occlusive disease and horseshoe kidney with two normal and one anomalous renal artery originating from infrarenal aorta (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. The aorto-bifemoral (AFF) bypass with Dacron graft was done with end-to-end (TT) proximal anastomosis just under the anomalous renal artery. The graft was placed behind the isthmus. During a 12-year follow-up renal failure, renovascular hypertension and graft occlusion were not observed. Patient 2. A 53-year-old male patient was admitted to the hospital for symptomatic AAA. Two years before admission the patient underwent coronary artery bypass grafting. The Duplex scan ultrasonography and translumbal aortography showed an infrarenal AAA, aneurysm of the right iliac artery and horseshoe kidney with two normal and one anomalous renal artery originating from the left iliac artery (Crawford type III). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy, the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the bifurcated graft was anastomosed with the common femoral artery and the left limb with left iliac artery just above the origin of the anomalous renal artery. The first day after operation thrombosis of the left common femoral artery with leg ischaemia was observed. (That artery was cannulated for ECC during coronary artery bypass grafting 2 years ago). The revascularisation of the left leg was done with femoro-femoral cross over bypass. During a 11-year follow-up period, the graft was patent and renal failure or revascular hypertension were not observed. Patient 3. A 66-year-old male patient was admitted to the hospital for rest pain (Fontan stadium III) and significantly decreased ABI. The patient had diabetes mellitus and myocardial infarction two months before admission. Translumbar aortography showed an aorto-iliac occlusive disease associated with horseshoe kidney with 5 anomalous renal arteries. (Crawford type III). Due to high risk, the axillo-bifemoral (AxFF) extra-anatomic bypass graft was performed. Five years after the operation the patient died due to new myocardial infarction. During the follow-up period the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 4. A 50-year old male patient was admitted to the hospital for high asymptomatic AAA. The diagnosis was established by Duplex scan and translumbal aortography. The large infrarenal AAA (transverse diameter 7 cm) associated with horseshoe kidney with two normal renal arteries (Crawford type I) were found. Intravenous pyelography and retrograde urogrpahy showed two separated ureters. After partial aneurysmectomy the tubular Dacron graft was placed behind the isthmus. During a 15-month follow-up the graft was patent and there were no signs of renal failure and renovascular hypertension. Patient 5. A 70-year-old female patient was admitted to the hospital for large asymptomatic AAA. The Duplex ultrasonography, CT scan, NMR and translumbal aortography showed an infrarenal AAA, aneurysms of the both common iliac arteries, aneurysm of the left hypergastric artery and horseshoe kidney with two normal and two anomalous renal arteries. One of the anomalous renal arteries originated from AAA, and the other from the left common iliac artery (Crawford type II). Intravenous pyelography and retrograde urography showed two separated ureters. After partial aneurysmectomy the flow was restaured using bifurcated Dacron graft placed behind the isthmus. The right limb of the graft was anastomosed (TT) with bifurcation of the common iliac artery and the left limb with the distal part of the common iliac artery (end-to-side) just above the origin of the second anomalous renal artery. The first anomalous renal artery that originated from AAA was removed from the aneurysm wall and anastomosed with graft using Carrel patch technique. During a 9-month follow-up the graft was patent and there were no signs of renovascular hypertension and renal failure. The horseshoe kidney is a rare anomaly of the urinary system. The incidence of this anomaly is from 1:1600 to 1:400 In 95% of cases the kidneys are connected with the lower poles, while in 5% with the upper poles In most cases, the isthmus structure is parenchimatous structure, and rarely it consists of the connective tissue. Usually the isthmus is located in front of the abdominal aorta and inferior vena cava, and very rarely behind them In two thirds of patients anomalous vascularization is present There are two classifications of anomalous vascularization: Papin's and Crawford's. According to Papin's classification, based on the number of renal arteries, there are three types of horseshoe kidney vascularization: Papin I (20%): There are two normal renal arteries only. (One of our 5 patients); Papin II (66%): There are 3-5 renal arteries. (Four of our 5 patients); Papin III (14%): There are more than 5 renal arteries. The Crawford's classification based on the origin of renal arteries, is of greater surgical importance than Papin's. According to it there are also three types of vascularization: Crawford I: There are two renal arteries with normal origin. (One of our 5 patients); Crawford II: Besides two normal, there are 1-3 anomalous renal arteries originating from the infrarenal aorta or iliac arteries (Three of our 5 patients); Crawford III: All renal arteries have an anomalous origin. (One of our 5 patients). The patients with horseshoe kidney can also have two separated, or one connected excretory urinary systems. All our 5 patients had two separated ureters. There is no specific clinical manifestation of the horseshoe kidney. Urinary infection or calculosis are very frequent as are in other urinary anomalies. The diagnosis of horseshoe kidney is established by Dupplex ultrasonography, CT scan, NMR, radionuclide scintigraphy and angiography. Very often the diagnosis is established occasionally during the examination of aneurysmal and occlusive diseases of the abdominal aorta. In cases of AAA or AIO associated with horseshoe kidney preoperative vascularization and condition of the excretory system should be established. Besides standard translumbar aortography selective renovasography is often neccessary. In some cases the intraoperative angiography or arterial identification, with metallic probe must be done. All renal arteries are "terminal" without significant anastomosis on the side of the kidney. Therefor its preservation is neccessary. There are three ways. The first is the location of anastomosis (3 of our patients). The second is an AxFF bypass, but only in patients with AIO (One of our patients and in the third reimplantation of the renal artery using Carrel patch technique was performed (One of our patients). The Isthmus of the kidney aggravates aortic preparation especially in patients with AAA. Sometimes isthmectomy is neccessary. In such cases there is danger of urinary fistula. Therefor many authors suggest the left extraperitoneal approach to abdominal aorta. In our patients, the transperitoneal approach was used, isthmectomy was not neccessary and graft was placed behind the isthmus. The operation of the abdominal aorta in patients with horseshoe kidney can be difficult due to anomalous renal arteries, anomalous excretory urinary system and is Ehmus. In these patients a more precise preoperative diagnosis is neccessary.

Lotina SL ，Davidović LB ，Kostić DM ，Velimirović DV ，Petrović PLj ，Perisić-Savić MV ，KovacevićN S ... -  《Srpski Arhiv za Celokupno Lekarstvo》

[Short to midterm results of endovascular for 105 case of infrarenal abdominal aortic aneurysms].

To assess short to midterm outcome of endovascular aneurysm repair (EVAR) of infrarenal abdominal aortic aneurysms (AAA) in 105 cases. Stent-grafts were placed into 105 patients with infrarenal AAA between January 2001 and February 2007. The clinical data of those cases were retrospectively analyzed. Primary technical success rate was 100%. Eighty-two cases (78.09%) were followed-up for 1 to 73 months (mean, 8.9 +/- 5.8 months). Three cases (2.86%) died during peri-operative period, from acute cardiac infarction, multi-organ failure and significant upper gastrointestinal bleeding, respectively. Another one died from hepatic cancer 30 months after EVAR. Twenty-one cases experienced primary endoleak. Eighteen were type I, among which 10 underwent secondary intervention in the form of balloon dilatation (n = 9) and stent-graft placement (n = 1), 8 sealed spontaneously. Two cases were type II and sealed spontaneously. One type III was treated by placing a stent-graft. An emergent femorofemoral crossover was performed for one graft limb thrombosis 2 weeks after EVAR. Four late type I endoleaks occurred. One stent-graft migration without endoleak was cured conservatively. Two stent-graft infections occurred 1 month and 3 months after EVAR respectively, and were cured with debridement, drainage and antibiotics. Nine femorofemoral or iliofemoral bypass and three internal iliac bypasses were all patent during the follow-up period. Endovascular repair is a safe and effective method for infrarenal AAA with perfect short to midterm outcomes.

Shi DB ，Fu WG ，Wang YQ ，Shen S ，Guo DQ ，Chen B ，Xu X ，Jiang JH ，Yang J ，Shi ZY ，Dong ZH ，Zhu T ... -  《-》

[Endovascular therapy of abdominal aortic aneurysm: results of a mid-term follow-up].

Prospective study to evaluate clinical results and complications of endovascular abdominal aortic aneurysm treatment in a mid-term follow-up. A total of 122 patients (9 females, 113 males, average age 70.9 +/- 7.9 years) with abdominal aortic aneurysms were treated with stent grafts (53 Vanguard or Stentor endografts, 69 Talent endografts). Group I consisted of 40 patients who had all aortic tributaries of the aneurysm sac occluded prior to endovascular grafting, either spontaneously by parietal thrombosis or by selective coil embolization of the respective ostia preserving collateral circulation distal to the vessel occlusion. Group II consisted of 82 patients and included all cases without or with incomplete coil embolization with at least one patent vessel. Stent grafting was performed in general anesthesia in the first 21 patients, followed by peridural anesthesia in 15 cases, and local anesthesia with conscious sedation in 86 cases. The results were evaluated with Spiral-CT, MRI and radiographs of the endovascular graft, with follow-up examinations obtained at 3, 6, 12 months, and every year. Implantation was successfully completed in all cases without primary conversion surgery, laparotomy, or any significant complication. Mean follow-up was 29 +/- 21 months (maximum 84 months). The 30-day mortality was 0.8 % due to a myocardial infarction 3 days after discharge from the hospital. A total of 47 re-interventions were performed in 29 patients (23.8 %), with 35 re-interventions in 18 cases with Vanguard or Stentor endografts and 12 re-interventions in 11 patients with Talent endografts. 23 percutaneous re-interventions included distal graft extension (n = 11), Wallstents for kinking and limb stenosis (n = 3), and secondary coil embolization of collateral vessels (n = 9). 24 surgical re-interventions included proximal graft extension (n = 6), new endovascular grafts (n = 3), surgical clipping of lumbar and mesenteric artery branches for type-II endoleaks following ineffective secondary coil embolization (n = 1), and femorofemoral crossover bypasses (n = 4). A total of 10 secondary conversion operations were performed because of damage to the membrane (n = 4; 3 Vanguard endografts, 1 Talent endograft), significant caudal migrations (n = 5; 4 Vanguard endografts, 1 Talent endograft) associated with type-I endoleaks (n = 2), limb occlusion (n = 1), disconnection of graft components (n = 1), and significant endoluminal thrombus deposits (n = 1). One patient, who was followed for 82 months, suffered from a significant endoleak for 10 months with increasing aneurysm diameter but he refused surgery. He was admitted with aneurysm perforation and was successfully operated with aortic graft replacement. Compared to group II, the incidence and size of endoleaks was reduced in group I (incidence 19.2 % versus 29.9 %, p < 0.05). Group I demonstrated significantly better aneurysm shrinkage at 36 months follow-up (Delta sagittal diameter - 11.1 +/- 8.4 mm versus - 4.9 +/- 6.2 mm, p < 0.05). In selected patients, endovascular aneurysm treatment is an effective alternative to open surgery. It is safely performed in local anesthesia with low mortality rate and a low number of acute complications. Intermediate follow-up revealed re-interventions in around one quarer of all patients, especially when Vanguard or Stentor endografts were implanted. Primary coil embolization of all aortic branches prior to endovascular grafting improves clinical outcome. Insufficient proximal fixation and its consecutive complications remains a major problem of this method.

Pitton MB ，Schweitzer H ，Herber S ，Schmiedt W ，Neufang A ，Düber C ，Thelen M ... -  《-》