Endovascular stent graft repair for aneurysms on the descending thoracic aorta

BACKGROUND: The traditional treatment of aneurysms of the descending thoracic aorta includes posterolateral thoracotomy and aortic replacement with a prosthetic graft. In this study, we report our experiences and results in endovascular stent graft placement as an alternative to surgical repair. METHODS: Between January 1989 and July 1997, a total of 68 patients (24 women) underwent replacement of the thoracic aorta. Mean age at operation was 51 years. Fifty-eight patients underwent conventional surgical treatment. All of these patients were suitable candidates for endovascular stenting; however, no stent graft material was available at the time of operation. Ten patients (1 chronic dissection, 9 atherosclerotic aneurysm) received in the past 8 months the first commercially manufactured endovascular stent graft. The mean diameter of the aneurysms in this group was 7 cm (range, 6 to 8 cm). Two stent patients were operated on using only spinal cord analgesia. All stent grafts were custom designed for each of the 10 patients. RESULTS: The 30-day mortality in the conventional group was 31% versus 10% in the stent group. Mean length of intervention was 320 minutes in the conventional group versus 150 minutes in the endovascular group. Spinal cord injury occurred in 5 patients (12%) in the surgical group, whereas none of the stented patients developed any neurologic sequelae. Mean intensive care unit stay was 13 days, followed by a mean of 10 days on a ward in the first group compared to 4 days in the intensive care unit and 6 days on the ward in the stent group. One stent was required in 2 patients, two stents were required in 3 patients, and four stents were deployed in 5 patients of our series. Five patients required transposition of the left subclavian artery to achieve a sufficient neck for the proximal placement of the stent. There was complete thrombosis of the thoracic aortic aneurysm surrounding the stent graft in 8 patients (80%). Two patients required restenting as a result of leakage (20%). Stent graft placing was performed through the femoral artery in 8 patients, whereas access was only achieved through the abdominal aorta in 2 patients. CONCLUSIONS: These preliminary results demonstrate that endovascular stent graft replacement might be a promising, cheaper, and safe alternative method in selected patients with descending thoracic aneurysms.     

Clinical results of endovascular stent graft repair for fifty cases of thoracic aortic aneurysms

Between February 1995 and December 1997, 50 cases (55 lesions) of thoracic aortic aneurysms including 20 cases of aortic dissections were treated with an endovascular technique using the stent grafts. All patients were treated in the operating room under general anesthesia and the stent grafts were implanted through 18 Fr. or 20 Fr. sheaths via femoral arteries under fluoroscopic guidance. The stent graft was composed of several units of self-expanding stainless-steel Z stents covered with an ultra-thin polyester fabric. Stent graft deployment was technically successful in 53 of 55 lesions (delivery success rate: 96.4%). Exclusion of the aneurysms and entry closing without endoleak were achieved within two weeks after the operation in 43 of 53 lesions (initial success rate: 81.1%). Endoleak was found in 10 lesions (minor endoleak: 8 and major endoleak: 2 lesions). Two patients died in the periopertive period of delivery failures as injury to external iliac artery and damage to the delivery sheath caused by tortuous and narrow access routes. Endovascular stent graft repair of thoracic aortic aneurysms is minimally invasive operation in comparison with conventional surgical graft replacement with extracorporeal circulation. These early results suggest that the stent graft repair is possibly safe and useful treatment for the patients of thoracic aortic aneurysms especially in high risk patients. However, careful long-term follow-up is necessary to prove the value and the effects of this endovascular treatment and improvement of the stent graft system and technical training of endovascular surgery for operators are required to reduce the delivery failure and to determine the stent graft repair is reliable treatment.     

AneuRx stent graft versus open surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial

The results of a prospective, nonrandomized, multicenter clinical trial that compared endovascular stent graft exclusion of abdominal aortic aneurysms with open surgical repair are presented. During an 18-month period, 250 patients with infrarenal aneurysms underwent treatment at 12 study sites-190 patients underwent endovascular repair using the Medtronic AneuRx stent graft (Sunnyvale, Calif), and 60 underwent open surgical repair. There was no significant difference in operative mortality rates between the groups. The patients who underwent stent grafting had significant reductions in blood loss, time to extubation, and days in the intensive care unit and in the hospital, with an earlier return to function. The major morbidity rate was reduced from 23% in the surgery group to 12% (P <. 05) in the stent graft group. There was no difference in the combined morbidity/mortality rates between the two groups. Primary technical success at the time of discharge for the patients with stent grafts was 77%, largely as a result of a 21% endoleak rate. At 1 month, the endoleak rate had decreased to 9%. There was no difference in the primary or secondary procedure success rates at 30 days between the surgery and stent graft groups. The primary graft patency rate at 6 months was 98% in the surgery group and 97% in the stent graft group. The aneurysm exclusion rate at 1 month and 6 months was 100% in patients who underwent surgery and 91% in patients who underwent stent grafting. Stent graft migration occurred in three patients and resulted in late endoleaks; each endoleak was corrected by means of endovascular placement of a stent graft extender cuff. There have been no aneurysm ruptures and no surgical conversions to open repair in the stent graft group. Stent graft repair compares favorably with open surgical repair, with a reduced morbidity rate, shortened hospital stays, and satisfactory short term outcomes.     

A pseudoaneurysm after repair of thoraco-abdominal aortic aneurysm

We report a 63-year-old female patient developing a pseudoaneurysm three years after patch-plasty of an aneurysm located at the distal thoracic aorta. Redo-operation was performed including total replacement of the descending thoracic aorta with reimplantation of distal intercostal arteries using small-caliber interposition grafts. This case presentation underlines the ineffectiveness of patch repair for the treatment of aortic aneurysms. Furthermore, the surgical technique of reimplantation of intercostal arteries using a separate graft is discussed.     

Experience of reoperations followed by repairs of abdominal aortic aneurysms

We experienced 8 cases who required reoperations, including 2 re-redo operations, after repairs of infrarenal abdominal aortic aneurysms. Of 8 patients, one patient developed a new aneurysm due to atherosclerosis in thoraco-abdominal aorta involving all visceral arteries and other 7 patients had aneurysmal formations at proximal anastomotic sites, including 3 suprarenal, 2 juxtarenal and 2 infrarenal aortic lesions. Etiology at initial operation in patients who subsequently developed anastomotic aneurysms included vasculo-Beh?et disease in 4, atherosclerosis in 2 and dissecting aortic aneurysms type III due to Marfan syndrome in 1. At reoperation, all who had vasculo-Beh?et disease had ruptures of anastomotic sites and 2 patients underwent repairs of dehiscent patch, 1 extra-anatomic bypass between ascending and abdominal aorta and 1 interposition of graft. One patient who had graft infection after repair of abdominal aortic aneurysm required axillo-femoral bypass with removal of infected graft. A patient who had dehiscence of proximal anastomosis after repair of aortoiliac occlusive disease required interposition of graft. Two patients, Marfan syndrome and aneurysm in thoraco-abdominal aorta, underwent graft replacement of thoraco-abdominal aorta concomitant with reconstruction of all visceral arteries. There were 8 patients who required reoperations for aneurysms at distal anastomotic sites after repairs of abdominal aortic aneurysms. Five patients underwent repairs of new aneurysms, including replacement of total arch in 3, descending aorta in 1 and iliac artery in 1. In all cases, no hospital death was noted, however, late deaths were occurred in vasculo-Beh?et disease, Marfan syndrome and graft infection. Thus, late result depends on etiology of disease. Although patients who requires reoperation after repair of abdominal aortic aneurysms have higher operative risk factors, early and late results are satisfactory compared to initial operations.     

The potential of various HIV-1 mutants to inhibit the replication of wild-type virus

Transluminal placement of a stent graft in patients with an abdominal aortic aneurysm is a new endovascular technique that offers a potentially less invasive and less risky alternative to open surgery. Complications after stent graft placement are not infrequent, but in most cases secondary endovascular intervention is successful. We describe a late major leak in the aneurysmal sac caused by a distal migration of the iliac limb of a bifurcated graft. This late complication was successfully treated by covered stent placement, excluding and thrombosing completely the reformed aneurysm.     

Endovascular management of traumatic infrarenal abdominal aortic dissection

Dissection is a recognized finding after blunt trauma to the abdominal aorta. Immediate and long-term prognosis is poor without surgical treatment especially since most patients present severe associated injuries. On the basis of encouraging results using endovascular techniques to treat experimental dissection of the descending thoracic aorta, we treated three patients with traumatic infrarenal abdominal aortic dissection by percutaneous stent placement. There were two men 34 and 41 years of age and one 89-year-old woman. In all patients, dissection began in the infrarenal portion of the aorta and extended into the iliac arteries. All patients had multiple associated injuries. The main symptoms were acute abdominal pain (two patients) and ischemia of the lower extremities (two patients). Diagnosis was missed in one patient despite exploratory laparotomy for an associated injury. Two patients were treated in the acute phase by placement of a self-expanding endovascular prosthesis at the aortoiliac level. The third patient was treated in the chronic phase by placement of a balloon-expandable endovascular stent. All procedures were performed uneventfully by femoral route. Success of treatment was confirmed by arteriography and computed tomography (CT) scan demonstrating obliteration of the dissection. Upon late follow-up examination, all patients were in satisfactory condition, with normal Doppler ultrasound findings. These findings confirm experimental studies using endovascular treatment for dissection of the descending thoracic aorta and are promising for future clinical management.     

Preoperative diagnosis of the thoracic aortic aneurysm by three-dimensional CT angiography

Serial eight patients with thoracic aortic aneurysms were evaluated by a newly developed three-dimensional CT angiography (3D-CT) from December 1992 to January 1993. The patients include 3 aortic dissections, 3 aortic arch aneurysms, one descending aortic aneurysm and one thoracoabdominal aortic aneurysm. The surgical treatment was performed after the evaluation of 3D-CT, and the operative findings were compared to the three-dimensional images reconstructed by 3D-CT in all patients. Three-dimensional displays were achieved using the unique method of data collection of the helical (spiral) scanner with continuous tube rotation and continuous table feed. A intravenous contrast material was used to image the thoracic aorta and major aortic branches with the single-breath-hold technique. Two and three-dimensional images reconstructed by 3D-CT were displayed within 10-20 minutes after the scanning. These three-dimensional images of the aortic lesions could be displayed in any angle we chose. Three-dimensional structures of the thoracic aorta and major aortic branches were clearly visualized and easily recognized by 3D-CT. These images were similar to the intraoperative findings and were quite useful to determine the operative procedure. The successful repair of thoracic aortic aneurysm was achieved in all cases. 3D-CT is a new and attractive modality to assess the vascular system. Although our experience is limited, 3D-CT may be a useful and powerful diagnostic method for the surgical treatment of thoracic aortic aneurysm.     

Endovascular stent graft placement for patients with aortic aneurysm and end-organ dysfunction

Endovascular stent grafts (ESGs) for the treatment of aortic aneurysm is becoming popular because it is less invasiveness for the patient. This new modality seems to be especially useful for treating high risk patients, such as those with end-organ dysfunction. In this study we retrospectively analyzed the results of ESG placement for patients with renal or hepatic dysfunction. From January 1996 to December 1997, six patients with end-organ dysfunction (two with descending thoracic aneurysm and four with abdominal aneurysm) underwent ESG placement. Five of these patients had renal dysfunction, with serum creatinine levels of 2.0 mg/dl or greater, and the remaining patient had hepatic dysfunction with a prothrombin time less than 60%. One of the patients also had severe atherosclerotic disease with a history of multiple brain infarctions. All the patients received custom made endovascular spiral Z stents covered with a woven Dacron (DuPont Co., Wilmington, DE) graft, which was delivered via a femoral artery under local anesthesia. None of the patients showed significant changes in renal or hepatic function after the procedure. None of the five patients with renal dysfunction needed hemodialysis after ESG placement, although the mean preoperative level of serum creatinine and blood urea nitrogen was 3.4 mg/dl and 42.0 mg/ dl, respectively. All the patients left the recovery room on postoperative day 1. These results indicated that endovascular stent graft placement is extremely useful in the treatment of aortic aneurysm patients with end-organ dysfunction.     

Reoperations after operation on the thoracic aorta: etiology, surgical techniques, and prevention

Recurrent aortic aneurysms, persistent or new dissection, new onset of valvular and coronary artery disease, graft infection, and prosthetic endocarditis are not rare after thoracic aortic operations; they can be difficult to diagnose and represent a formidable surgical challenge. Between 1977 and 1991, 876 operations were performed on the thoracic aorta in our institution: 340 in dissections, 299 in true aneurysms, 150 for aortic remodeling and external wall support during aortic valve replacement, and 87 for miscellaneous causes. During the same period, there were 193 additional reoperations. Vascular reoperations on abdominal aorta and peripheral arteries accounted for 73 cases and are not further discussed in this study. The reasons for reoperation (n = 130) in 120 patients were: failure of biologic valves (n = 23); aneurysm recurrence in a proximal or distal aortic segment (n = 21); pseudoaneurysm formation at suture lines (n = 13); new dissection or dilatation involving ascending aorta (n = 11), aortic arch (n = 13), and descending aorta (n = 10); aneurysm after aortic remodeling (n = 13); new onset of valvular disease (n = 5); and new onset of coronary disease (n = 5). Infected aortic graft and prosthetic endocarditis accounted for 10 reoperations, and a planned two-staged procedure was performed in 6 patients. Omitting the failed biologic valves, reoperations were performed on the aortic segment previously operated on in 69.3% of the cases and on other thoracic segments in 30.7%. Overall hospital mortality rate after reoperation was 5.8%. A significant decrease in operative mortality was observed in the most recent period (3.0% between 1989 and 1991). Reoperations are technically demanding, and some of them are preventable; therefore (1) graft inclusion technique should be abandoned in ascending aortic operation due to formation of false aneurysms; (2) in patients with Marfan syndrome, complete repair of the diseased aorta should be attempted during the initial operation; (3) aortic arch dissection should be repaired definitively during the first operation in low-risk patients; (4) biological valves should be avoided in aneurysm operations; and (5) homograft replacement is the treatment of choice in prosthetic endocarditis or in infected composite graft after an aortic valve or ascending aortic operation.     

Stent-graft placement procedures for descending thoracic aortic aneurysms

Descending thoracic aortic aneurysms most often are caused by arteriosclerosis and appear most frequently in elderly males. These patients often are asymptomatic, but they may experience symptoms related to compression of adjacent thoracic structures, or they may present for treatment when their-aneurysms rupture. Open surgical resections and repairs of descending thoracic aortic aneurysms are associated with bleeding, paraplegia, strokes, renal insufficiency, and the need for prolonged ventilatory support in the postoperative period. At Stanford (Calif) University Hospital, surgeons are placing endovascular stent-grafts in patients with descending thoracic aortic aneurysms who meet specific anatomic selection criteria. This new treatment modality provides patients with a less invasive, less hazardous, and potentially less expensive alternative to open surgical resection and repair procedures. Preoperative teaching and skilled perioperative nursing care are essential for positive patient outcomes with stent-graft treatment of descending thoracic aortic aneurysms.     

The "first generation" of endovascular stent-grafts for patients with aneurysms of the descending thoracic aorta

OBJECTIVE: Our goal was to determine whether endovascular stent-grafting is feasible and effective for patients with aneurysms of the descending thoracic aorta. METHODS: Starting in July 1992, we conducted a prospective, uncontrolled clinical trial in 103 patients (mean age 69 years [range 34-89 years]) who underwent endovascular treatment of aneurysms of the descending thoracic aorta using a custom-fabricated, self-expanding stent-graft device. Follow-up was 100% complete and averaged 22 months. Sixty-two patients (60%) were judged not to be reasonable candidates for a conventional "open" surgical procedure. RESULTS: Complete thrombosis of the aneurysm was ultimately achieved in 86 (83%) patients. The early mortality rate was 9% +/- 3% (+/- 70% CL). Multivariable analysis revealed that myocardial infarction or stroke was linked with a higher likelihood of early death (P = .001). Early serious complications included paraplegia in 3% +/- 2% and stroke in 7% +/- 3%. Actuarial survival estimates at 1 year and 2 years were 81% +/- 4% and 73% +/- 5% (+/- 1 SE), respectively; being judged not to be a surgical candidate portended a higher probability of death (P = .003). According to the intent-to-treat principle, "treatment failure" (including all late sudden unexplained deaths) occurred in 38 patients; 53% +/- 10% of patients were free from treatment failure at 3.7 years. Stent-graft related complications occurred commonly and were linked with several anatomic, technical, and patient-related risk factors. CONCLUSIONS: This 5-year clinical trial involving use of a "first generation" device indicates that endovascular stent-grafting of descending thoracic aortic aneurysms is feasible with acceptable medium-term results. More refined, commercially developed devices available today offer less traumatic and more precise stent-graft deployment; these major technical advantages, coupled with important lessons we have learned over time and better patient selection, should be associated with more salutary clinical results in the future.     

Anterior patch aortic aneurysm model for the study of endoluminal grafts

Endovascular graft repair for aortic aneurysms has led to concerns regarding the healing characteristics of the graft within a thrombus-lined aneurysm and the effect that collateral flow may have on the endoluminal prosthesis and the aneurysm. An anterior aortic patch aneurysm model that preserved collateral arteries was examined and modified to address these issues. In canines (n = 30) a Dacron knitted patch (n = 27) or a rectus fascia patch (n = 3) was sutured into a 3.5-cm anterior aorotomy. Dacron patch aneurysm diameter was an average of 21.8 +/- 2.2 mm (mean canine normal aortic diameter 9.06 +/- 0.79 mm). Canines underwent angiogram, computed tomography, and/or intravascular ultrasound from 1 to 11 weeks later, at which time an endoluminal prosthesis was deployed and followed 30 to 60 days until harvest. Aneurysms accumulated minimal thrombus through the initial 11 weeks. Significant stenosis (mean 21.2% +/- 19%) occurred at aneurysm necks in association with a patch imbrication suture technique (n = 11). Following modification (n = 16), this decreased to a mean of 3.6 +/- 9.7%. Collateral lumbar artery patency was 95% at the time of imaging prior to graft placement. Following successful graft implantation, 16 of 18 aneurysms were filled with thrombus and in most cases the collateral circulation occluded. One of three fascial patch aneurysms ruptured 21 days after creation. This model more accurately depicts abdominal aortic aneurysms with the inherent thrombus and collateral flow that is important when studying aspects of endovascular aortic graft repair.     

Clinical decision making and operative approaches to thoracic aortic aneurysms

The care of the patient with thoracic aneurysms is quite complicated. The decision to treat an aneurysm must be based on the risk of rupture and the patient's life expectancy. The preoperative evaluation must include detailed imaging to allow proper preoperative planning. This is especially important to determine the need for hypothermic circulatory arrest or the potential to treat a descending aneurysm with an endovascular approach. Thorough preoperative preparation and intraoperative care are as important as surgical decision making and meticulous technique. Although significant advances have been made in operative approaches, cerebral and myocardial preservation, and postoperative care, the management of complicated aneurysms of the thoracic aorta is frequently a humbling experience.     

Anatomical suitability of abdominal aortic aneurysms for endovascular repair

BACKGROUND: Aortic aneurysm anatomy is crucial when considering patients for endovascular repair. The aim of this study was to determine the proportion of patients with aortic aneurysm suitable for endovascular repair with three different graft-stent systems. METHODS: Spiral computed tomographic angiography was used to assess the anatomy of 154 abdominal aortic aneurysms. Measurements were made of aneurysm neck length and diameter, renal artery to aortic bifurcation length, common iliac artery diameter and length, and external iliac artery diameter. Aneurysms were assessed for anatomical suitability for currently available aortoaortic, aortobi-iliac and aortouni-iliac devices. RESULTS: Six patients (4 per cent) had a distal aortic neck suitable for implantation of a straight aortic graft. Fifteen patients (10 per cent) had arterial anatomy suitable for implantation of a bifurcated graft and 85 (55 per cent) patients were suitable for endovascular repair with an aortouni-iliac graft. The primary reasons for unsuitability were: proximal neck length less than 1.5 cm (44 patients), proximal neck diameter greater than 3.0 cm (12), and angulation of the proximal neck (three). A further ten patients were considered unsuitable for an aortouni-iliac graft because of bilateral common iliac artery aneurysms (four), tortuous iliac arteries (four) and narrow external iliac arteries (two). CONCLUSION: The aortouni-iliac device has the widest applicability of the currently available endovascular systems but open repair remains the only option for a large proportion of patients.     

Three-year experience with the White-Yu Endovascular GAD Graft for transluminal repair of aortic and iliac aneurysms

PURPOSE: To report a > 3-year experience with a modular, balloon-expandable endovascular graft used for aneurysm exclusion in the aorta and other arteries. METHODS: The customized White-Yu Endovascular GAD Graft, a woven polyester prosthesis with an intrinsic Elgiloy wire graft attachment system along the body of the graft, is a flexible endograft design available in straight, tapered, and bifurcated versions that can be delivered transluminally through 18F to 24F sheaths. RESULTS: Since July 1993, 93 patients have received the White-Yu endograft for treatment of 76 abdominal aortic, 3 thoracic aortic, 13 iliac, and 1 popliteal aneurysms. Of the 79 aortic procedures, 39 involved straight tube grafts, 20 were tapered aortoiliac models, and 20 were bifurcated devices. Success rates for tube grafts were 81% in the abdominal aorta and 100% for the thoracic aorta; 5 primary endoleaks (14%) and 2 conversions to surgery (5.6%) occurred with this graft type. Aortoiliac grafts were deployed successfully in 95% (19/20) of cases with 1 conversion (5%) due to thrombosis. Seventy-five percent of the bifurcated endograft procedures were successful, with 4 conversions (20%) for technical failures and 1 graft thrombosis. Four additional endografts were deployed to treat two primary and two secondary endoleaks in tube graft patients. Two access-related arterial injuries were treated surgically. There was one case of embolus to the distal femoral artery but no microembolization. Overall perioperative (30-day) mortality was 3.1%. Over a mean 18-month follow-up (range 2 to 39), no late graft thrombosis, stenosis, or graft migration has been seen on CT scans or X ray. Endoleak has not been detected in any aortoiliac or bifurcated graft. Aneurysm size has diminished consistently in successfully treated cases. CONCLUSIONS: The White-Yu endograft appears to offer a safe, efficacious, and minimally invasive means of excluding aneurysms from the circulation. Improvements in patient selection, surgical techniques, and equipment have reduced the incidence of endoleak and conversion to open repair over the course of the evaluation.     

Reoperation after repair of type A and B dissecting aneurysm

BACKGROUND: In the late postoperative period after repair of an aortic dissection or dissecting aneurysm, reoperations may be required. The interval to reoperation, size and location of intimal tear, and results of reoperation were evaluated. METHODS: Between January 1982 and April 1997, 138 patients underwent surgery for Stanford type A (90 patients) or type B (48 patients) dissections of the aorta. The entire aorta was evaluated in postoperative follow-up by computed tomography and magnetic resonance imaging for 6 months to 15 years. Reoperations were performed in 14 (10.1%) patients with changes in the aneurysms at the site of the initial repair or in the distal aorta. Selective cerebral perfusion or retrograde cerebral perfusion with deep hypothermia was used in the repair of the ascending, arch, and distal arch aneurysms. Reoperations included aortic root reconstruction (n=3), resection of a pseudoaneurysm (n=1), and replacement of the ascending aorta (n=1), arch (n=5), descending aorta (n=2), thoracoabdominal aorta (n=1), or abdominal aorta (n=1). Secondary reoperations were performed in four patients (replacement of the arch [n=2], thoracoabdominal aorta and abdominal aorta). Consequently two patients had subtotal aortic replacements. The aneurysms were caused by an anastomotic leak, a new intimal tear following aortic cross-clamping, a second intimal tear in the distal arch or abdominal aorta, and Marfan syndrome. RESULTS: Two patients (2/18 11.1%) died of bleeding or low output syndrome. Two patients died of graft infection or prosthetic valve infection 3 months after surgery respectively. CONCLUSIONS: 1) The surgical results of reoperation for type A and B dissections were good. 2) Close postoperative follow-up of the patent false lumen in the entire aorta was necessary. 3) At the initial operation, total resection of the intimal tear in the aortic arch in low-risk patients reduced the risk of reoperation.     

Fertility in anovulatory patients after primary cesarean section

We report a successful surgical treatment of an infective thoracic aortic aneurysm ruptured to the left lung. A 63-year-old man who had been suffering from fever and cough showed twice of hemoptysis. Chest CT revealed a descending thoracic aortic aneurysm ruptured to the left lung. A semiemergent operation was performed. At operation, aneurysm of descending thoracic aorta was found adherent to the left lung. Aneurysmectomy with left pneumonectomy was carried out. The postoperative course of the patient was uneventful. Conceivably, in order to avoid massive intraoperative bleeding during division of dense adhesion and postoperative graft infection, concomitant lung resection is necessary.     

Echolaparoscopic-guided alcohol injection of liver metastases

At Nuremberg Southern Hospital we have been using endovascular therapy for aortic aneurysms for the past 3 years. Between August 1994 and August 1997, 193 patients with infrarenal aortic aneurysms were treated with endovascular stent grafts. Besides using commercially available modular systems of the Stentor type (MinTec/Vanguard*, Boston Scientific) we also participated in a multicenter study implanting EGS devices (EVT in 65 patients). Follow-up examinations must strive to detect thrombotic complications as well as endoleaks with high sensitivity and specificity. To avoid aneurysm rupture significant increase in aneurysm diameter must be detected in a timely fashion to select patients for additional corrective endovascular procedures or conversion to open surgical therapy. A close follow-up regimen therefore is absolutely mandatory for all patients undergoing endovascular aortic grafting, particularly when new prosthetic devices are being introduced. Prosthetic devices that have been adequately tested using controlled study designs and are commercially available may be followed-up using a standardized follow up scheme as delineated. Particularly during the first postoperative year color duplex with use of an intravenous ultrasound enhancing agent has been used successfully to detect even minor endoleaks originating from retrograde perfusion via aortic side branches (lumbar or inferior mesenteric artery). Only patients with documented endoleaks or suspected outflow obstruction requiring further intervention need to undergo diagnostic arteriography. After conventional aneurysm repair yearly duplex scans are usually sufficient to follow the normal patient. Patients who have undergone endovascular therapy, however need to be followed much closer using duplex as well as abdominal CT scans. This will logically result in significantly higher follow up costs. Periinterventional costs of endovascular aortic reconstruction currently exceed those of conventional aortic repair by approximately 50%. Given the current health care finance situation it is questionable whether endovascular therapy of abdominal aneurysm will become standard practice in Germany.     

Contemporary management of isolated iliac aneurysms

OBJECTIVE: Because isolated common iliac artery aneurysms are infrequent, are difficult to detect and treat, and have traditionally been associated with high operative mortality rates in reported series, we analyzed the outcomes of operative repair of 31 isolated common iliac artery aneurysms in 21 patients to ascertain morbidity and mortality rates with contemporary techniques of repair. METHODS: A retrospective review study was conducted in a university teaching hospital and a Department of Veterans Affairs Medical Center. Perioperative mortality and operative morbidity rates were examined in 17 men and four women with isolated common iliac artery aneurysms between 1984 and 1997. Ages ranged from 38 to 87 years (mean 69 +/- 8 years). Slightly more than half of the cases were symptomatic, with abdominal pain, neurologic, claudicative, genitourinary, or hemodynamic symptoms. One aneurysm had ruptured and one was infected. There was one iliac artery-iliac vein fistula. All aneurysms involved the common iliac artery. Coexistent unilateral or bilateral external iliac aneurysms were present in four patients; there were three accompanying internal iliac aneurysms. Overall, 52% of patients had unilateral aneurysms and 48% had bilateral aneurysms. Aneurysms ranged in maximal diameter from 2.5 to 12 cm (mean 5.6 +/- 2 cm). No patients were unavailable for follow-up, which averaged 5.5 years. RESULTS: Nineteen patients underwent direct operative repair of isolated iliac aneurysms. One patient had placement of an endoluminal covered stent graft; another patient at high risk had percutaneous placement of coils within the aneurysm to occlude it in conjunction with a femorofemoral bypass graft. Patients with bilateral aneurysms underwent aortoiliac or aortofemoral interposition grafts, whereas unilateral aneurysms were managed with local interposition grafts. There were no deaths in the perioperative period. Only one elective operation (5%) resulted in a significant complication, compartment syndrome requiring fasciotomy. The patient treated with the covered stent required femorofemoral bypass when the stent occluded 1 week after the operation. The patient treated with coil occlusion of a large common iliac aneurysm died 2 years later when the aneurysm ruptured. CONCLUSIONS: Isolated iliac artery aneurysms can be managed with much lower mortality and morbidity rates than aneurysm previously been reported by using a systematic operative approach. Percutaneous techniques may be less durable and effective than direct surgical repair.