Early complications of femorofemoral crossover bypass grafts after aorta uni-iliac endovascular repair of abdominal aortic aneurysms

Effectiveness of the Rotarex Excisional Atherectomy System in Both Subacute and Chronic Aortoiliac Endograft Thrombosis: An Innovative Option for the Modern Endovascular Surgeon Toolkit

PURPOSE

To report a successful revascularization case using the Rotarex™S atherothrombectomy system in a recent iliac limb thrombosis, and chronic hypogastric stent obstruction after previous aortoiliac aneurysm endovascular repair (EVAR).

CASE REPORT

A 72-year-old patient was treated for recent right iliac limb thrombosis and left iliac branch chronic hypogastric stent occlusion, 5 years after EVAR. A total endovascular approach, using both upper extremity and femoral vascular access, was settled with 2 Rotarex™S (6Fr and 10Fr) devices. The Rotarex™S catheters removed most of the intraluminal material, allowing additional endografts and bare metal stents to be deployed to support a new healthy lumen surface.

CONCLUSION

The total endovascular approach provided by the Rotarex™S device appears to be safe and effective in treating aortoiliac endografts occlusions, both in subacute and chronic phases. Larger studies could highlight differences and eventual advantages compared with more traditional solutions.

Double-Barrel Technique With Reversed Gore Excluder Stent Graft Limb for Common Iliac Aneurysm Exclusion in a Patient With Prior Aortic Surgical Repair

Surgical repair of a common iliac artery aneurysm (CIA) after previous open aortic reconstruction is associated with significant morbidity and mortality. Endovascular repair is considered less invasive than surgery. However, if preservation of the internal iliac artery (IIA) is required, the applicability of endovascular techniques may represent a challenge and a limitation to the use of standard aortic endografts or iliac branch devices. In these cases, the off-label use of endovascular devices may be an effective alternative. Herein, we report a successful hybrid approach to treat CIA using a reversed iliac limb endograft coupled with a double-barrel technique with femoro-femoral crossover bypass in a patient who had previously undergone open aortic reconstruction.

Femorofemoral Crossover Bypass Graft Has Excellent Patency When Performed with EVAR for AAA with UIOD

OBJECTIVES

To compare the durability of the crossover femorofemoral bypass graft (CFFBG) in combination with aorto-uni-iliac stent graft (AUIS) for abdominal aortic aneurysm with the durability of CFFBG used in the treatment of unilateral iliac occlusive disease (UIOD).

METHODS

We analyzed the clinical records of 69 patients who underwent CFFBG from 1992 until 2010. Group I consisted of 34 patients who received CFFBGs in combination with AUIS. Group II consisted of 35 patients treated with CFFBG for UIOD. The mean period of follow up was 2.7 years. Outcomes analyzed included primary graft patency, secondary graft patency, and postoperative morbidity and mortality.

RESULTS

There was one death in each group. Wound infection complicated 11.4% of CFFBGs performed as a sole procedure for UIOD and 5.8% of cases in combination with AUIS (P = 0.673). Primary graft patency was 96.5% and 96.5% at 2 and 5 years in group I, compared with 76.6% and 53.7% in group II (P = 0.046, 0.009). Secondary graft patency at 5 years was 100% and 92.9% for groups I and II, respectively. No variables independently influenced primary graft patency. Patients in group I experienced complications that could be linked to the bypass graft in 20.5% of cases, after long-term follow-up.

CONCLUSIONS

The CFFBG possesses superior long-term durability and patency when implemented in combination with aorto-uni-iliac stent grafts and does not seem to compromise the endpoint success of endovascular treatment.

Two cases of recurrent uterine cervical cancer with arterio-enteric fistula treated by femoro-femoral artery bypass in hybrid operation room

Little has been reported regarding aortic-enteric fistula (AEF) as a complication of gynecologic cancers because of its rarity. However, since it is lethal if left untreated, medical practitioners involved with gynecologic diseases should be aware of this deadly condition. In our hospital, we encountered two cases of cervical cancer complicated by AEF. In both cases, contrast computed tomography (CT) revealed leakage of the contrast material from an artery into the small intestine, indicating AEF. Endovascular procedures with complete embolization of the affected arteries and femoro-femoral artery bypass (f-f bypass) were performed in the hybrid operation room. The activities of daily living improved dramatically for both patients, and they survived for 3 months before dying from cervical cancer. While embolization by endovascular methods and f-f bypass performed in a hybrid operation room is, therefore, an available option for treating AEF, literature is lacking and more research is required to improve long-term outcomes for this disease.

Delayed Type IIIb endoleak secondary to graft fabric tear 7 years following implantation of a Medtronic Talent endovascular aortic device: A case report and review of the literature

Objectives:

To report a rare case of delayed Type IIIb endoleak secondary to fabric tear following implantation of a Medtronic Talent endovascular device.

Methods:

A 83-year old gentleman underwent elective endovascular aneurysm repair for infrarenal abdominal aortic aneurysm with a Medtronic bifurcated stent graft in 2008.

Results:

Seven years after the initial repair, imaging surveillance revealed significant endoleak and brisk aneurysm sac expansion due to Type IIIb endoleak secondary to endograft limb fabric tear.

Conclusions:

This case illustrates the imperative role of imaging surveillance in detection of long-term endovascular aneurysm repair complications. Furthermore, we discuss exclusion of the graft tear with aortouniiliac stent grafting as the treatment for this complication.

Management of a Large Intraoperative Type IIIb Endoleak in a Bifurcated Endograft

The purpose of this paper is to describe the intraoperative management of a type IIIb endoleak after deployment of a bifurcated endograft in a patient with narrow iliac access vessels. A 62-year-old man underwent elective endovascular repair (EVAR) of a 53 mm abdominal aortic aneurysm. After device deployment, a large IIIb endoleak, arising from the main body of the device, was visualized. Narrow iliac vessels precluded deployment of a second bifurcated graft, and the endoleak was successfully excluded with an aortomonoiliac device, followed by contralateral iliac occlusion and subsequent creation of a femorofemoral bypass. At 1-year follow-up, the aneurysm remains excluded and is decreasing in size. Type III endoleaks are a known complication of EVAR, requiring immediate treatment through their association with aneurysm enlargement and rupture. If an additional bifurcated graft cannot be used, aortomonoiliac conversion represents a feasible endovascular alternative treatment for type III endoleaks, other than conversion to open surgical repair. Therefore, aortomonoiliac converters with appropriate occluder devices should be readily available during deployment of bifurcated devices.

Patency Rates of Femorofemoral Bypasses Associated with Endovascular Aneurysm Repair Surpass Those Performed for Occlusive Disease

Purpose:

To evaluate the patency rates of femorofemoral grafts performed in conjunction with aortomonoiliac or aortomonofemoral (AMI/F) endografts.

Methods:

Over the past 8 years, 110 patients (98 men; mean age 77 ± 7 years, range 57–90) underwent aortoiliac aneurysm repair with an AMI/F endograft. Follow-up data in these patients were prospectively collected for a mean 2.3 years (range 1–68 months).

Results:

There were 2 early (<7 days) AMI/F endograft thromboses with secondary femorofemoral graft occlusion. In both patients, patency of all grafts was restored by thrombectomy plus stenting of the endograft. Three late (4, 5, and 10 months) AMI/F endograft thromboses led to femorofemoral graft failure; 2 were successfully treated, but the third patient refused further intervention. No femorofemoral bypass failed in the absence of AMI/F endograft thrombosis. There were no femorofemoral graft infections. Four-year life-table primary and secondary patency rates were 95% and 99%, respectively.

Conclusions:

Femorofemoral bypasses with AMI/F endografts for aneurysmal disease are durable procedures and have better patency than femorofemoral grafts used to treat occlusive disease. Femorofemoral bypass patency rates alone are not a disadvantage of aortomonoiliac endografts.

Aorto-Uni-Iliac Stent Grafts with and without Crossover Femorofemoral Bypass for Treatment of Abdominal Aortic Aneurysms: A Parallel Observational Comparative Study

We investigated the safety and efficacy of primary aorto-uni-iliac (AUI) endovascular aortic repair (EVAR) without fem-fem crossover in patients with abdominal aortic aneurysm (AAA) and concomitant aortoiliac occlusive disease. 537 EVARs were implemented between 2002 and 2015 in University Hospital Galway, a tertiary referral center for aortic surgery and EVAR. We executed a parallel observational comparative study between 34 patients with AUI with femorofemoral crossover (group A) and six patients treated with AUI but without the crossover (group B). Group B patients presented with infrarenal AAAs with associated total occlusion of one iliac axis and high comorbidities. Technical success was 97% (n = 33) in group A and 85% (n = 5) in group B (P = 0.31). Primary and assisted clinical success at 24 months were 88% (n = 30) and 12% (n = 4), respectively, in group A, and 85% (n = 5) and 15% (n = 1), respectively, in group B (P = 0.125). Reintervention rate was 10% (n = 3) in group A and 0% in group B (P = 0.084). No incidence of postoperative critical lower limb ischemia or amputations occurred in the follow-up period. AUI without crossover bypass is a viable option in selected cases.

Secondary modification into aortouniiliac configuration to salvage failed endovascular aneurysm repair is safe and effective but not associated with higher intervention rates during long-term follow-up

BACKGROUND

Reports of secondary modifications into aortouniiliac configuration to salvage-failed endovascular aneurysm repair (EVAR) are limited. We evaluated long-term results after these procedures and compared them with those after primary aortouniiliac endografting (AUE).

METHODS

A retrospective review of all EVAR performed from March 1995 until July 2011 was conducted. Patients were included when primary AUE (group I) or modification into aortouniiliac configuration (group II) was done.

RESULTS

Data analysis obtained 27 group I and 23 group II patients. Salvage of failed EVAR could be achieved in 96% of group II patients, and mortality was zero. Frequency of adverse events and amount of interventions to maintain aneurysm exclusion were not increased after secondary AUE. Kaplan-Meier estimates for long-term survival between groups were comparable (P = .36).

CONCLUSIONS

Secondary AUE allows correction of graft-related endoleaks potentially leading to late aneurysm rupture. Complications and adverse events throughout long-term follow-up were not necessarily increased when compared with primary AUE.

Crossover ilio-iliac bypass and removal of femoro-femoral graft as first treatment for the infection of crossover bypass in aorto-uni-iliac endovascular aneurysm repair

The crossover femoro-femoral bypass, classically used for the treatment of unilateral iliac arterial obstruction, has recently become an integral part of aorto-uni-iliac endovascular aneurysm repair. We therefore, reconsider the therapeutic problems related to thrombosis and in particular to infection of the femoro-femoral prosthesis, when many attempts have been made to preserve the bypass and treat the infection. Showing a case treated and well eight months later, we put forward the old technique of crossover ilio-iliac bypass, followed by the removal of the infected femoro-femoral graft. In our opinion, this technique circumvents the need for autologous tissue and allows for the use of prosthetics in a new, sterile, uncontaminated field. As this approach for these cases has so far not been reported in the literature, further cases and long-term follow-up are needed.

Modification of a bifurcated stent graft for aortouniiliac endovascular aneurysm repair in a renal transplant patient

INTRODUCTION

We describe a case of aortouniiliac (AUI) endovascular aortic aneurysm repair (EVAR) using combined iliac limb and bifurcated body stent graft modular system.

CASE REPORT

This technique is demonstrated in a 58-year-old man with a 6-cm abdominal aortic aneurysm suitable for EVAR. The patient has a functioning cadaveric renal transplant anastamosed to the mid right external iliac artery, an occluded left iliac system and stenosed right iliac system. The renal allograft was protected with minimal passage across the transplant artery origin using this modified approach. The patient was successfully treated with a bifurcated main body deployed within a contralateral limb endoprosthesis. Subsequent scans confirmed no endoleaks or stent migration.

CONCLUSIONS

The AUI conversion from existing Gore excluder stent graft system is safe and should be considered when faced with challenging anatomy of a pelvic renal transplant, slender access, and contralateral iliac occlusion.

Long-term Results of Femoro-Femoral Crossover Bypass After Endovascular Aortouniiliac Repair of Abdominal Aortic and Aortoiliac Aneurysms

Aortouniiliac stent grafts allow the endovascular treatment of complex anatomy aortoiliac aneurysms. The main drawback is the need for femoro-femoral crossover bypass, with its complications and its patency limitations. However, some authors have shown good results of femoro-femoral crossover bypass in aneurysmal disease. In this article, initial and long-term results of our experience in femoro-femoral crossover bypass revascularization after endovascular aortouniiliac stent grafts repair of aortoiliac aneurysms is reported. Prospective collection, intention-to-treat, and retrospective analysis maintained database. Femoro-femoral crossover bypass patency assessment of all patients treated between January 1999 and September 2002, compared patients with or without associated occlusive arterial disease. Urgent indications were excluded. In total of 52 patients, with a mean age 72.6 years, 30.8% of patients were identified with associated occlusive arterial disease. Initial systemic and local, access site, complications were 7.7% and 7.7%, respectively, no early thrombosis or death is reported. Primary patency was 90.9% at 54 months, 66 months assisted primary and secondary patency were 97.7% and 100%, respectively. The 48-month survival rate was 84.2%. No significant differences between patients with or without associated occlusive arterial disease were found. Femoro-femoral crossover bypass after aortouniiliac stent grafts treatment of aortoiliac aneurysms shows excellent initial and long-term patency and low complication rate.

Iliac Conduit for Renal and Visceral Artery Access During Endovascular Repair of a Pararenal Aneurysm with a Fenestrated Stent-Graft

PURPOSE

To report a technique for fenestrated stent-graft repair involving a conduit implanted at the origin of a patent aneurysmal common iliac artery (CIA) in a patient with a pararenal aortic aneurysm and iliac artery occlusion.

CASE REPORT

A 60-year-old man with multiple comorbidities presented with an 8-cm abdominal aortic aneurysm (AAA) with no infrarenal neck according to computed tomography (CT). Both CIAs were aneurysmal; the left was occluded, as were the left internal and external iliac arteries and the inferior mesenteric artery. Two patent accessory renal arteries were depicted. Because an infrarenal neck was absent, treatment with a fenestrated endograft was performed under general anesthesia. The right CIA was approached via an oblique retroperitoneal incision. A 10-mm polytetrafluoroethylene tube graft was implanted on the origin of the right CIA aneurysm in an end-to-side fashion to facilitate delivery of a Zenith endograft constructed with 2 small fenestrations for the renal arteries, 1 large strut-free fenestration for the superior mesenteric artery, and a scallop for the celiac trunk. The proximal fenestrated body of the Zenith device was introduced via the right iliac artery by direct puncture of the common femoral artery. The conduit was used to cannulate the 3 fenestrations for subsequent deployment and for delivery of the distal Zenith aortomonoiliac device. The procedure was completed successfully, but 12 hours after surgery, the patient developed a significant right retroperitoneal hematoma, which was treated surgically. CT confirmed patency of all visceral arteries and no endoleak. One month after the initial procedure, he had recovered totally and was discharged.

CONCLUSION

Iliac conduits could widen the feasibility of fenestrated endografting in patients unfit for open surgery with pararenal aneurysms and challenging iliac anatomy. However, this adjunctive procedure has its own morbidity.

Endograft treatment of ruptured abdominal aortic aneurysms using the Talent aortouniiliac system: An international multicenter study

OBJECTIVE

To understand the potential of endovascular aneurysm repair (EVAR) in patients presenting with a ruptured abdominal aortic aneurysm (rAAA), the proportion in whom this procedure was applicable was assessed. Mortality and morbidity was also determined in patients treated with emergency EVAR (eEVAR) when anatomic and hemodynamic conditions allowed (ie, in the entire cohort with patients receiving endovascular and open repair combined). In addition, a comparison was made between the treatment group with eEVAR and open repair.

METHODS

Between February 2003 and September 2004, 10 participating institutions enrolled a representative sample of 100 consecutive patients in whom eEVAR was considered. Patients in the New Endograft treatment in Ruptured abdominal aortic Aneurysm (ERA) trial were offered eEVAR or open repair in accordance with their clinical condition or anatomic configuration. Written informed consent was obtained from all patients or their legal representatives. The study included patients who were treated by stent-graft technique or by open surgery in the case of adverse anatomy for endoluminal stent-grafting or severe hemodynamic instability, or both. Data were collated in a centralized database for analysis. The study was sponsored and supported by Medtronic, and eEVAR was uniquely performed with a Talent aortouniiliac (AUI) system in all patients. Crude and adjusted 30-day or in-hospital and 3-month mortality rates were assessed for the entire group as a whole and the EVAR and open repair category separately. Complication rates were also assessed.

RESULTS

Stent-graft repair was performed in 49 patients and open surgery in 51. No significant differences were observed between these treatment groups with regard to comorbidity at presentation, hemodynamic instability, and the proportion of patients who could be assessed by preoperative computed tomography scanning. Patients with eEVAR more frequently demonstrated a suitable infrarenal neck for endovascular repair, a longer infrarenal neck, and suitable iliac arteries for access than patients with open repair. The primary reason to perform open aneurysm repair was an unfavorable configuration of the neck in 80% of the patients. In patients undergoing eEVAR, operative blood loss was less, intensive care admission time was shorter, and the duration of mechanical ventilation was shorter (P < or = .02, all comparisons). The 30-day or in-hospital mortality was 35% in the eEVAR category, 39% in patients with open repair, and 37% overall. There was no statistically significant difference between the treatment groups with regard to crude mortality rates or rates adjusted for age, gender, hemodynamic shock, and pre-existent pulmonary disease. The cumulative 3-month all-cause mortality was 40% in the eEVAR group and 42% in the open repair group (no significant differences at crude and adjusted comparisons). The 3-month primary complication rate in the two treatment groups was similar at 59%.

CONCLUSIONS

In approximately half the rAAA patients, eEVAR appeared viable. An unsuitable infrarenal neck was the most frequent cause to select open repair. In dedicated centers using a Talent AUI system, eEVAR appeared to be a feasible method for treatment of a rAAA. The overall first-month mortality did not differ across treatment groups (patients with endovascular and open repair combined), yet was somewhat lower than observed in a recent meta-analysis reporting on open repair.

Endovascular AAA Repair With the Aortomonoiliac EndoFit Stent-Graft: Two Years' Experience

PURPOSE

To evaluate the feasibility and efficacy of a specific aortomonoiliac endograft and the durability of the femorofemoral bypass for treatment of abdominal aortic aneurysm (AAA).

METHODS

From 2002 to 2004, 39 high-risk (ASA III/IV) patients (36 men; median age 74 years, range 63-84) with AAA (n = 33) or AAA and common iliac artery aneurysm (n = 6) were treated with an EndoFit aortomonoiliac endograft and femorofemoral crossover bypass. The contralateral iliac axis was obstructed with an endoluminal occluder. Patients were followed with contrast-enhanced computed tomography at 1, 6, 12, and 24 months.

RESULTS

EndoFit AMI stent-grafts were implanted successfully in all patients. Perioperative mortality was zero. Endoleak occurred in 3 (7.7%) cases. A proximal type I endoleak was identified at 1 month and was treated with a proximal cuff. Two type II endoleaks are under surveillance because the aneurysm sac shows no enlargement. Thrombosis of the femorofemoral graft occurred in 1 case during the immediate postoperative period due to insufficient inflow from a residual stenosis of the endograft (primary patency 97.5%). The deficit was treated successfully (secondary patency 100%). Two (5.1%) tunnel hematomas were treated conventionally. Median follow-up was 14 months (range 6-30). All patients are alive. None of the aneurysms has ruptured or been converted to an open procedure. Graft migration, serious infection, paraplegia, distal embolization, or any other serious complication has not been observed.

CONCLUSIONS

In high surgical risk patients with complex iliac anatomy, aortomonoiliac endograft with femorofemoral crossover bypass is feasible and efficacious. Moreover, the midterm patency of the extra-anatomic bypass appears quite satisfactory.

A temporary hemostatic valve in the short limb of a bifurcated stent-graft to facilitate endovascular repair of ruptured aortic aneurysm: experimental findings

PURPOSE

To evaluate a homemade tricuspid valve placed in the short limb of a bifurcated aortic stent-graft to facilitate endovascular treatment of ruptured abdominal aortic aneurysms (AAA).

METHODS

A valve consisting of 3 polytetrafluoroethylene cusps was constructed in the short limb of a bifurcated stent-graft. The endoprosthesis was placed into an in vitro circulation model with pulsatile flow. Angiography was performed before and after insertion of the second graft limb.

RESULTS

Angiographically, there was complete occlusion of the short limb before and normal patency after deployment of the second graft limb. Cannulation of the short limb with a guidewire was performed without technical difficulty.

CONCLUSIONS

Addition of a temporary hemostatic valve in the short limb of a bifurcated stent-graft can potentially reduce blood loss during endovascular treatment of ruptured AAAs.

Oblique Groin Incision for Endovascular Repair of Abdominal Aortic Aneurysms

PURPOSE

Groin incision for access to the femoral artery is necessary for stent graft repair of abdominal aortic aneurysm (AAA). However, lymphatic and infectious complications can occur during wound healing after surgery. A vertical incision traditionally is used, but a new oblique incision technique has the potential to reduce complications. We report our results from AAA stent repairs performed via oblique incisions at our center for a 33-month period.

METHODS

Data for 134 consecutive patients undergoing elective stent repair of asymptomatic infrarenal AAA performed by 2 cardiovascular surgeons at a single center from July 1, 2000, to March 31, 2003, were gathered for analysis. Wound complication percentages for infections, paresthesias, sepsis, and seroma were calculated.

RESULTS

In 134 patients, a total of 278 incisions were made. Reasons for extra incisions included improving catheter entry angle (5 cases), tunneling for vascular tapes (3 cases), and initial approach too low (2 cases). The percentages were, however, calculated on a per-patient basis. Thirty day analysis revealed a 0% infection rate, 4.7% incidence of paresthesias, 2.38% rate of wound seroma, and 0% wound sepsis rate.

CONCLUSION

Because of the nonexistent infection rate and low wound complication rate, our data supports the use of oblique groin incisions for stent repair of asymptomatic infrarenal AAA.

Is cross-femoral bypass grafting a disadvantage of aortomonoiliac endovascular aortic aneurysm repair?

PURPOSE

The need for cross-femoral bypass grafting (CFBG) is considered by some to be a major disadvantage of endovascular aneurysm repair (EVAR) with the aortomonoiliac technique. To determine the durability of CFBG in this setting, we examined data from 148 consecutive high-risk patients in a clinical trial of EVAR with a custom-made aortomonoiliac endovascular stent graft.

METHODS

All data were collected prospectively. After hospital discharge, patients were evaluated at 1, 3, and 6 months and annually thereafter. All CFBG was constructed of expandable polytetrafluoroethylene.

RESULTS

During follow-up averaging 23.6 +/- 16.2 months, nine CFBG complications developed in 8 patients (5.4%), including disruption (n = 2), infection (n = 3), thrombosis (n = 2), and pseudoaneurysm (n = 3). Four patients with CFBG complications died, of consequences of infection (n = 2), intracranial hemorrhage during attempted CFBG thrombolysis (n = 1), and intracranial hemorrhage during anticoagulation (n = 1). There were no amputations. At life table analysis, freedom from CFBG complication was 96.3% +/- 1.6% at 12 months, 94.1% +/- 2.2% at 24, 36, and 48 months, and 86.2% +/- 7.8% at 60 months. Overall survival for this high-risk patient group was 83.4% +/- 3.1% at 12 months, 70.4% +/- 4.1% at 24 months, 56.5% +/- 5.3% at 36 months, and 44.8% +/- 6.4% at 48 months.

CONCLUSION

CFBG is durable, with a low rate of complications in patients undergoing aortomonoiliac EVAR. Need for CFBG should not discourage use of aortomonoiliac devices in patients with anatomy unfavorable for other EVAR approaches.

Durability of femorofemoral bypass grafting after aortouniiliac endovascular aneurysm repair

INTRODUCTION

Endovascular aneurysm repair (EVAR) with aortouniiliac prostheses extends the morphologic range of aneurysms that can be treated and is potentially a more rapid and simple operation than bifurcated endovascular repair. It may, however, be limited by durability of the femorofemoral extra-anatomic bypass graft required to revascularize the contralateral lower limb. Previous studies of femorofemoral bypass grafts were performed almost exclusively in patients with occlusive disease. An 8-year single center experience with use of the femorofemoral bypass graft in aneurysmal disease is reported.

METHODS

All patients undergoing EVAR with an aortouniiliac endovascular stent graft over eight years (1994-2002) at a single institution were included in a retrospective study. Patient data were collected from a prospectively maintained local endovascular database. All patients gave informed consent and were part of an endovascular program approved by the local ethics committee.

RESULTS

Over the 8 years, 231 patients underwent EVAR with an aortouniiliac endovascular stent-graft. Median follow-up was 22 months. Localized wound complications were observed in 25 patients (11%). Cumulative 3-year patency rate for the femorofemoral bypass graft was 91%. At the end of 5 years 83% of grafts remained patent.

CONCLUSIONS

The femorofemoral bypass graft used during EVAR with aortouniliac stent grafts offers encouraging medium and long-term patency. When graft occlusion occurs, it is usually directly attributable to inadequate inflow from the endovascular stent graft itself or to endoluminal damage of the external iliac artery. Awareness and early detection of stent-graft distortion or complications in the external iliac artery may result in improved patency rates.

Treatment of type III endoleak with an aortouniiliac stent graft

The purpose of this study was to present a novel treatment method for repair of a type III endoleak due to separation of modular components of an AneuRx (Medtronic AVE, Sunnyvalle, CA) stent graft as a result of graft kinking. A 73-year-old male had undergone endovascular repair of a 8.2-cm abdominal aortic aneurysm (AAA) 2 years previously. An aortic extender cuff was required to secure the proximal graft. Computed tomographic (CT) follow-up revealed a type III endoleak at 6-month follow-up. Plain radiographs showed separation between the main graft body and the aortic extender cuff. A second custom-made 28 mm x 5.5 cm aortic extender cuff was placed to seal the type III endoleak. Follow-up CT showed a persistent endoleak with an increase in AAA size to 10.5 cm. The patient underwent remedial AAA repair with an aortouniiliac endograft placed within the previous stent graft and a femorofemoral bypass. At 3-month follow-up there was no detectable endoleak. This constitutes an alternative endovascular therapy for modular device separation (type-III endoleak) after endoluminal AAA repair in patients who cannot undergo repair with a second bifurcated graft.

Femoral incision morbidity following endovascular aortic aneurysm repair

Currently available aortic stent-grafts require bilateral femoral incisions for device deployment. The incidence of morbidity (infection, lymphatic complications, breakdown) of vertical, infrainguinal incisions used in endovascular aneurysm repair (EVAR) for abdominal aortic aneurysms (AAAs) was assessed, and the natural history of asymptomatic groin fluid collections following such procedures was determined. Between June 1999 and February 2001, 77 consecutive patients underwent EVAR for AAAs utilizing bilateral vertical femoral incisions. Fifty-nine (77%) bifurcated stent-grafts (BSGs), and 18 (23%) aortouniiliac (AUI) devices, with femorofemoral bypass were performed. Patients returned at 2 weeks, 1 month, and 6 months for physical examination, and 1 month and 6 months for abdominal and pelvic computed tomography (CT) scans. The presence of fluid collections was determined from the dictation report of the attending radiologist. Data are reported as (n) mean +/-SE. Patient characteristics were compared using Fisher's exact test; p<0.05 considered significant. There were 72 males and 5 females, age 75 +/-6.4 years and aneurysm size (77) 5.6 +/-0.8 cm. There were no cases of wound breakdown or lymph fistula. Wound infections occurred in 3/150 incisions (2%), 2/34 AUI incisions (6%), and 1/116 BSG incisions (0.86%). There was no statistical difference (p=0.13) between graft types (BSG vs AUI). All infections were diagnosed clinically before the 1-month CT scan, treated without operative intervention or hospitalization, and resolved. There was a significant decrease in the BSG group and overall in asymptomatic wound fluid collections from 1 to 6 months postoperatively. At 1 and 6 months, respectively, the BSG group had 17 (14.6%) and 3 (2.6%) fluid collections out of 116 incisions (p=0.003); the AUI group had 6 (17.6%) and 1 (2.9%) fluid collection(s) out of 34 incisions (p=0.13); and overall 23 (15.3%) and 4 (2.6%) out of 150 incisions (p=0.004). The present study demonstrates that bilateral vertical femoral incisions used in EVAR have a wound infection rate of 2.0%. Infections are usually detected and treated clinically and empirically without the need for hospitalization or surgery. Asymptomatic groin wound fluid collections resolve significantly within 6 months without intervention. Therefore, surgical femoral artery exposure adds little morbidity to the endovascular repair of abdominal aortic aneurysms.

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

PURPOSE

To analyze the outcome of endovascular exclusion of abdominal aortic aneurysm (AAA) using aortomonoiliac stent-grafts.

METHODS

Fifty-seven consecutive patients (49 men; median age 70, range 56-89) with AAA >5 cm were treated in a 6-year period with the conical ELLA stent-graft. Forty-two (73.9%) patients were classified ASA (American Society of Anesthesiologists) IV and 6 as ASA V. In the majority of cases, the implantation procedure featured device delivery through the external iliac artery, transrenal placement of a bare stent in selected cases, and an iliofemoral crossover graft through a prevesical tunnel.

RESULTS

Successful deployment was achieved in 56 (98.2%) patients. Mean time to discharge was 8.7 days (range 2-125). Two patients died in the 30-day period. Nine endoleaks occurred in 8 (14%) patients; 4 required further intervention. Mean follow-up was 35.3 months (range 1-66), during which 5 patients died from unrelated causes. No late endoleak, graft occlusion, device twisting/migration, or aneurysm rupture was observed. No correlation between type I endoleaks and unfavorable proximal neck or iliac artery anatomical characteristics could be found. Primary technical and clinical success rates were 86.0% and 94.7%, respectively.

CONCLUSIONS

In this approach, the crossover graft remains in a retropubic space and consequently does not have all the disadvantages of a subcutaneously placed prosthesis. The results achieved in this group of high-risk patients support recommendation of this technique as a simple and safe alternative to bifurcated systems.

Risk stratification and outcomes of transluminal endografting for abdominal aortic aneurysm: 7-year experience and long-term follow-up

PURPOSE

To determine early and late outcomes of transluminal endografting (TE) in patients with abdominal aortic aneurysm (AAA), stratified by predicted risk of procedure-related mortality with conventional operation.

MATERIALS AND METHODS

A retrospective study was conducted in consecutive risk-stratified AAA patients undergoing TE at a not-for-profit cardiovascular referral center from March 1994 through November 2000 with follow-up through February 2001. With use of conventional risk strata (0 = low, 1 = minimal, 2 = moderate, and 3 = high), predicted procedure-related mortalities were 0%-1% in stratum 0 (n = 40), 1%-3% in stratum 1 (n = 118), 3%-8% in stratum 2 (n = 116), and 8%-30% in stratum 3 (n = 31). Main outcome measures were: (i) TE procedural success, (ii) procedure-related mortality, (iii) major nonfatal complications, (iv) composite adverse outcome (ii + iii), (v) length of stay (LOS), (vi) freedom from AAA rupture, (vii) late survival, (viii) late complications, and (ix) endoleaks and their classification and management.

RESULTS

Women were significantly less likely than men to qualify for and undergo endografting: 24 of 91 (26.4%) women underwent TE, compared to 281 of 684 (41.1%) men. Of 305 attempted TE procedures, 291 (95.4%) were successful, four (1.3%) were urgently converted to open repair, and 10 (3.3%) were aborted. Procedure-related mortalities occurred in eight cases (2.6%) overall and one of 40 (2.5%), one of 118 (0.8%), four of 116 (3.4%), and two of 31 (6.5%) cases for risk strata 0-3, respectively. Perioperative survivors were significantly younger than nonsurvivors (74.3 y +/- 9 vs 81.6 y +/- 5.1; P =.0087). Forty-six patients (15.1%) had major complications. Composite adverse outcome was worse for patients in stratum 3 than those in stratum 1 (P =.0296) and those in strata 0, 1, and 2 combined (P =.026). Procedure-related mortality declined with institutional experience, from 4% among the first 100 patients undergoing TE to 1% among the last 105. For strata 0-3, median LOS were 2, 3, 3, and 4 days, respectively. Seventy patients (22.9%) had 75 endoleaks, of which 30 necessitated additional procedures, 17 self-resolved, and 22 were untreated as of March 1, 2001. Five patients with endoleak died of unrelated causes. One late-onset type IA endoleak (26 mo) resulted in the only AAA rupture and death in the follow-up period among the 291 patients who underwent successful transluminal endograft implantation. Actuarial survival rates at 1 year after TE were 90.3% +/- 1.9% for the overall study group and 97.5% +/- 2.5%, 94% +/- 2.5%, 86.9% +/- 3.3%, and 81.3% +/- 7.7% for risk strata 0-3, respectively. At 5 years, overall actuarial survival was 69.6% +/- 6.1%. Thirty-eight late deaths were attributable to post-TE AAA rupture (n = 1), AAA rupture late after failed TE with no further treatment (n = 1), other cardiovascular disorders (n = 7), cancer (n = 15), other causes (n = 10), and unknown causes (n = 4). Late deaths occurred in risk strata 0-3 at the following rates: two of 40 (5%), 10 of 118 (8.5%), 16 of 116 (13.8%), and 10 of 31 (32.3%), respectively (stratum 0 vs stratum 3, P =.0017; stratum 1 vs stratum 3, P =.003).

CONCLUSIONS

TE is safe and confers durable protection against AAA rupture in treated populations. Still, protection is not absolute in patients with endoleaks, because late AAA enlargement and even rupture can occur. Given current knowledge, technology, and practice, careful patient selection and close surveillance of patients after implantation of transluminal endografts is essential.

Endovascular stent-graft repair of primary aortocaval fistula with an abdominal aortoiliac aneurysm

A primary aortocaval fistula is present in less than 1% of all abdominal aortic aneurysms. Until recently, surgical repair was the only method of treatment and was associated with a high incidence of morbidity and mortality. With the rapid development of aortic stent-graft technique, endovascular stent-graft repair may offer an alternative to the management of this often fatal condition. We report a case of an aortoiliac aneurysm with an aortocaval fistula successfully treated with endovascular stent-grafting. The unique hemodynamic changes, technical problems, and complications associated with this case are discussed, and the literature is reviewed.

Failure of endovascular abdominal aortic aneurysm graft limbs

OBJECTIVE

Endovascular abdominal aortic aneurysm (AAA) grafts are subject to subsequent failure of endograft limbs. We sought to determine what device-related factors could be identified that might contribute to limb failure.

METHODS

We reviewed the records of patients who had undergone endovascular AAA repair and femorofemoral bypass grafting at a single institution.

RESULTS

Endovascular AAA repair was performed in 173 patients. There were 137 bifurcated endografts and 36 aortomonoiliac grafts combined with femorofemoral bypass grafts, yielding a total population of 310 aortic graft limbs and 36 femorofemoral grafts. Thirty-nine additional patients underwent femorofemoral bypass grafting for occlusive disease. The cumulative primary patency of all endografts performed for AAA was 92% at 21 months. Secondary patency was achieved for all failed endograft limbs. There were 24 aortic graft limb "failures" that required intervention: seven limbs underwent thrombosis requiring revision; kinked limbs requiring stenting either at the time of graft placement (17) or subsequently (7) were identified. Fully supported endograft limbs had better primary patency (97% at 18 months) than unsupported limbs (69% at 18 months, P <.001). The aortomonoiliac grafts with femorofemoral bypass grafts tended to have better patency (97% at 18 months) than bifurcated endografts (90% at 18 months), but this did not reach statistical significance (P =.28, not significant). Femorofemoral grafts performed for occlusive disease were found to have somewhat lower patency than those performed for AAA (83% vs 92% at 18 months of follow-up, P =.37, not significant).

CONCLUSIONS

Fully supported AAA endografts provide superior endograft limb patency compared with unsupported designs. Consideration should be given to routine stenting of all unsupported endograft limbs. Aortomonoiliac grafts and bifurcated grafts provide similar results for endograft limb patency. Femorofemoral bypass grafts performed in conjunction with aortomonoiliac grafts for AAA disease provide excellent short-term patency.

Relationship between preoperative patency of the inferior mesenteric artery and subsequent occurrence of type II endoleak in patients undergoing endovascular repair of abdominal aortic aneurysms

OBJECTIVES

The purpose of this study was (1) to find out whether preoperative inferior mesenteric artery (IMA) patency (on radiographic imaging) predicts IMA-related endoleaks after endovascular repair of infrarenal abdominal aortic aneurysms, (2) to determine feasibility of measuring aneurysm sac pressures in patients with endoleaks, and (3) to report early evidence of effective endovascular obliteration of IMA endoleaks.

METHODS

We studied 76 consecutive cases of infrarenal aortic aneurysms that were repaired with an endovascular approach (March 1998-April 1999).

RESULTS

There were 13 (17%) endoleaks persistent 30 days after the procedure. Eleven (85%) of these 13 were IMA-related endoleaks, which were documented with selective superior mesenteric artery angiography. The preoperative finding (on computed tomographic scan) of a patent IMA does not always predict an IMA-related endoleak, but results in a statistically and clinically significant higher ratio of patients with IMA-related endoleaks in the immediate postoperative period (24% versus 3%, P <.035). In eight of the 11 patients with persistent IMA-related endoleaks, measurement of intra-aneurysm sac pressures was possible, and six of these patients had systemic pressures within the excluded aneurysm sac. Nine (82%) of 11 IMA-related endoleaks were successfully obliterated by means of selective IMA embolization.

CONCLUSIONS

Many endoleaks are caused by a patent IMA, and this can result in persistence of systemic pressure within the aneurysm sac. The preoperative finding (on computed tomographic scan) of a patent IMA is a predictor of increased rates of IMA endoleaks, and IMA endoleaks can be successfully obliterated through endovascular procedures, after endovascular abdominal aortic aneurysm repair.

Complications of endovascular repair for thoracic and abdominal aortic aneurysm: an imaging spectrum

Endovascular stent-graft implantation is an alternative to conventional open surgery for the treatment of aortic aneurysm. Forty-nine consecutive patients with aortic aneurysm (thoracic, n = 17; infrarenal, n = 32) were treated with endovascular stent-graft implantation. Complications occurred in 25 patients (two patients had two complications): endoleak (n = 13), graft thrombosis (n = 5), graft kinking (n = 2), pseudoaneurysm caused by graft infection (n = 1), graft occlusion (n = 1), shower embolism (n = 1), perforation of mural thrombus by means of inadvertent penetration of delivery system (n = 1), colon necrosis (n = 1), aortic dissection (n = 1), and hematoma at the arteriotomy site (n = 1). Imaging findings were analyzed for spiral computed tomography, plain abdominal radiography, transesophageal echocardiography, and digital subtraction angiography. Since some of these complications are fatal, radiologists need to instantly and accurately recognize them. Awareness and understanding of possible complications should help ensure a safe, successful procedure.

Utility and reliability of endovascular aortouniiliac with femorofemoral crossover graft for aortoiliac aneurysmal disease

OBJECTIVE

The purpose of this study was to determine the early efficacy of endovascular aortouniiliac stent grafts with femorofemoral bypass graft in the treatment of aortoiliac aneurysmal disease.

METHODS

We analyzed 51 consecutive patients from January 1997 to March 1999 with a mean follow-up of 15.8 months. Patients ranged in age from 44 to 93 years (mean, 75 years) with a mean aortic aneurysm diameter of 6.2 cm. Technical success was achieved in 50 patients; one patient required conversion to open repair intraoperatively. We placed 28 custom-made and 22 commercial devices. The mean operative time was 223 minutes. The endograft was extended to the external iliac artery in 42% of cases. The contralateral common iliac artery was occluded using either a closed covered stent or intraluminal coils.

RESULTS

The median hospital stay was 4 days with an average intensive care unit stay of 0.25 days. There were no operative mortalities. Two patients died during follow-up from unrelated conditions. Endoleaks occurred in 11 patients (22%); seven patients (14%) required intervention (four catheter based, three operative). Other complications occurred in 38% of patients but were largely remote or wound related. One femorofemoral bypass graft occluded immediately postoperatively as a result of an intraprocedural external iliac dissection yielding a 98% primary patency and 100% secondary patency. Clinical success was achieved in 88% of patients.

CONCLUSIONS

These data suggest that this strategy represents a reliable method of repair of aortoiliac aneurysmal disease and extends the capability of an endoluminal approach to patients with complex iliac anatomy.

The value of the oblique groin incision for femoral artery access during endovascular procedures

Groin incisions for access to femoral vessels are typically made in a vertical fashion extending across the groin crease. Significant morbidity can be associated with these incisions, including lymphoceles, lymph fistulae and infections, as documented in the infrainguinal revascularization literature. We have adopted an oblique groin incision for femoral artery access during endovascular graft reconstruction of the aorta because of the potential for reduced wound morbidity. In this study we report our experience with this technique and compare it with the existing literature to determine its usefulness. From June 1998 to May 1999, 98 consecutive patients received endovascular exclusion of aortic aneurysms at The Mount Sinai Medical Center, New York. Patients were treated with aortoaortic (24), aortouniiliac with femorofemoral crossover bypass (41), or bifurcated endografts (33) and were prospectively studied for wound complications. Aortoaortic procedures required one inguinal incision whereas aortouniiliac with femorofemoral crossover bypass and bifurcated procedures employed bilateral inguinal wounds. Wound complications were defined as cellulitis, subcutaneous purulence, femorofemoral graft infection, lymphocele, or lymphocutaneous fistulae. The oblique groin incision allows adequate exposure to the femoral arteries and is associated with low wound morbidity. We suggest that this approach may be the preferred technique for access to femoral arteries during endovascular procedures, and should be considered for infrainguinal arterial reconstructions.