Endovascular graft repair of ruptured aortoiliac aneurysms

Complex endoleak treatment after failed endovascular aortic repair

BACKGROUND

Endovascular aneurysm repair (EVAR) has created new possibilities for patients with abdominal aortic aneurysms (AAAs), and in recent years it has become tremendously popular. Use of EVAR in selected groups of patients allows mortality and morbidity to be reduced in comparison to open repair. However, complications such as endoleaks (ELs) can be of great concern and warrant urgent therapy to prevent sac rupture.

CASE PRESENTATION

The case report presents urgent endovascular treatment of a high-risk type IA EL in a polymorbid 68-year-old patient 7 years after primary EVAR. The principle of treatment was parallel implantation of the proximal SG extension with the renal SG into the right renal artery (chimney technique). The subsequent type II collateral EL was treated by direct transabdominal AAA sac puncture and thrombin embolization.

CONCLUSION

EL can be a cause for urgent intervention, but specific anatomic features often require specialized SG types which are not readily available. The chimney technique allows the use of immediately available stent grafts to address endoleak in the setting of impending abdominal aneurysm rupture.

A Comparison of the Short-Term Outcomes After use of Aorto-Uni-Iliac Versus Bifurcated Endografts for Endovascular Repair of Ruptured Abdominal Aortic Aneurysms

BACKGROUND

To compare short-term outcomes of endovascular aneurysm repair (EVAR) with aorto-uni-iliac (AUI) versus bifurcated (BIFUR) endografts in ruptured abdominal aortic aneurysm (rAAA).

METHODS

A total of 26 rAAA patients receiving EVAR with AUI device (14 patients) or the BIFUR graft (12 patients) between January 2016 and December 2020 were enrolled and reviewed. All EVARs for rAAA were performed in an emergency basis. Graft implantation success, short-term survival rates, and major complications were analyzed.

RESULTS

Endograft implantation success was achieved in all patients. AUI group had shorter operative time than BIFUR group (121.77 ± 75.03 vs. 138.45 ± 143.34; P < 0.05). The 24-hr and 30-day survival rates were 85.7% (12/14) and 71.4% (10/14), respectively, whereas BIFUR group have 58.3% and 58.3%. None of the rAAA patients in both groups required reintervention. AUI group exhibited less incidence of compartment syndrome and endoleak compared with those of BIFUR ones.

CONCLUSIONS

The short-term results of EVAR with the AUI configuration graft in patients with rAAAs are encouraging.

Endovascular Aneurysm Repair-First Strategy for Ruptured Aneurysm Focuses on Fitzgerald Classification and Vein Thrombosis

BACKGROUND

Recent study have demonstrated the good results of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (RAAAs). We report on the results of our EVAR-first strategy for RAAAs focuses on Fitzgerald (F) classification and vein thrombosis.

MATERIALS AND METHODS

From 2011 to 2017, 31 patients with RAAA underwent EVAR at our hospital. We compared F-1 patients (group A) with F-2 to F-4 patients with obvious retroperitoneal hematoma (group B).

RESULTS

The baseline characteristics in group A (n = 9) and group B (n = 22) were similar. In group B, there were 8 cases of F-2, 10 cases of F-3, and 4 cases of F-4. Of the 22 cases in group B, 16 (73%) cases involved preoperative shock. Operation time was not significantly different (group A: 147 min and group B: 131 min, P = 0.48). The total mortality rate of group A and group B combined was 77.4%. The 30-day mortality was 0% for group A and 23.8% for group B, in which there were 2 F-4 cases and 3 F-3 cases. In group B, hematoma-related complications developed in 6 cases (deep vein thrombosis: 4 cases, abdominal compartment syndrome: 1 case, and hematoma infection: 1 case), and 1 case with deep vein thrombosis developed a pulmonary embolism that resulted in cardiac arrest. The 3-year survival rate was significantly higher for group A (100% vs. 52.3%, P = 0.016), but the freedom from aortic death rate was not significantly different (100% vs. 66.7%, P = 0.056).

CONCLUSIONS

Using EVAR for RAAA is a valid strategy. Certain complications that are associated with peritoneal hematoma, especially venous thrombosis, should receive particular attention.

Survival of Ruptured Abdominal Aortic Aneurysms in the West of Ireland: Do Prognostic Indicators of Outcome Exist?

Ruptured abdominal aortic aneurysm (RAAA) is a demanding vascular surgical problem and the cause of significant morbidity and mortality. The aim of this study was to identify prognostic factors that influence outcome. Over 6 years, 42 ruptured abdominal aortic aneurysms were operated on with a mean diameter of 7.2 cm. RAAA was defined as free intraperitoneal rupture. Data were collected retrospectively from hospital medical records. The male:female ratio was 8:1 and the mean age was 74 years (range 55–89). Fifteen were in hypovolemic shock and 27 patients were clinically stable. The perioperative mortality rate for the 15 shocked patients was 60% (9 patients) and the 1-year cumulative survival rate was 33%. The perioperative mortality rate for the 27 clinically stable patients was 40% (11 patients) and the 1-year cumulative survival rate was 56%. Survival curves were constructed for these groups to compare male versus female, age =70 versus age <70, shocked versus stable, and preoperative hemoglobin (Hb) =10 vs >10. No patient with preoperative cardiac arrest survived more than 24 hours. With VassarStats, the confidence interval for age, gender, hemodynamic status, and preoperative Hb were calculated. The standard weighted mean analysis by ANOVA gave a p value of <0.001. The overall 30-day mortality rate was 47% (20 of 42) and the 1-year mortality rate was 52% (22 of 42). Male patients over 70 years with RAAA in hypovolemic shock with low Hb have a higher 30-day mortality rate and few survive more than 1 year. The study suggests that each of these 4 parameters separately was not a strong prognostic indicator. Collectively, however, they strongly influence the prognosis of patients with RAAA. These findings strengthen the case for selective treatment for RAAA.

Endoluminal Repair of Ruptured Abdominal Aortic Aneurysms Under Local Anesthesia: Initial Experience

Open surgical repair is the standard treatment for a ruptured infrarenal abdominal aortic aneurysm (rAAA). This approach is associated with mortality rates of up to 70%, with significant surgery-related morbidity among survivors. In selected patients, endoluminal repair (ER) of an rAAA under local anesthesia may allow emergent aneurysm repair with reduced perioperative stress, ideally resulting in improved outcomes. The authors report their initial experience using a commercially available bifurcated endoluminal stent-graft to treat patients with rAAA under local anesthesia. Five of 8 patients (63%) with rAAA in a 1-year interval (June 2000–May 2001) were treated with ER. Criteria for ER were the following: (1) suitable aortic anatomy based on preoperative computed tomography (CT) imaging and (2) a hemodynamic state not requiring immediate aortic control. Mean size of ER rAAAs was 8 cm. Four of 5 patients underwent ER under local anesthesia. All 5 ER patients survived the initial surgery, and 4 patients survived to discharge. The expired patient was a Jehovah’s Witness who had a successful ER but was profoundly anemic postoperatively and refused transfusion. On postoperative CT imaging, no endoleaks were noted and no AAA enlargement had occurred. In a selected but significant subset of rAAA patients, emergent repair using a commercially available bifurcated endograft under local anesthesia is feasible, and clinical outcomes are acceptable. These promising initial results suggest that a further evaluation of the role of endoluminal repair in the treatment of ruptured infrarenal AAAs is warranted.

Transition from Open Surgery to Endovascular Treatment of Abdominal Aortic Aneurysm Rupture

BACKGROUND

To review the outcome before and after the implementation of protocol-based strategy for endovascular repair (EVAR) of abdominal aortic aneurysm rupture (rAAA).

METHODS

A retrospective analysis of prospectively collected data from a tertiary center during the period 2006-2011. Demographics, comorbidities, blood examinations, perioperative patients' status, and mortality rates were recorded. Univariate and multivariate analyses were used to assess the association of the type of the procedure with various factors.

RESULTS

A total of 58 (46 open surgical repair [OSR] and 12 EVAR) patients with mean age of 74 ± 17 years (91% males) were treated for rAAA. However, 39 (11 EVAR and 28 OSR) were operated with protocol-based strategy available. Total mortality rate was 52.6% (10 of 19) initially and 38.5% (15 of 39) after the implementation of a protocol-based strategy. During protocol-based treatment, the survival rate did not differ between the 2 procedures (7 of 11 EVAR and 17 of 28 OSR; P, ns). A 30-day mortality rate was associated with preoperative number of platelets (unadjusted P values, P = 0.013), age (odds ratio [OR] 0.796; 95% confidence interval [CI], 0.685-0.925; P = 0.003), and diastolic blood pressure (OR, 1.053; 95% CI, 1.016-1.093; P = 0.005). After mean follow-up of 48 ± 11 months, EVAR patients presented better outcome regarding mortality rate (36% OSR vs. 0% EVAR; P = 0.0464).

CONCLUSIONS

After the adoption of an available rEVAR protocol-based strategy, EVAR and OSR were equally effective during postoperative 30 days. The role of hypotension and age is important on poor outcomes during this period. However, after midterm follow-up, EVAR demonstrates better survival rates than OSR.

Salvage of an Acutely Ruptured Thoracic Aortic Aneurysm during CPR

Purpose:

To report the successful endovascular treatment of a ruptured thoracic aortic aneurysm during cardiopulmonary resuscitation.

Case Report:

A 72-year-old woman with a type B aortic dissection treated conservatively for 8 years was referred for rupture of a 16-cm aneurysm of the descending thoracic aorta. During transfer to the operating room, the patient suffered cardiac arrest; cardiopulmonary resuscitation (CPR) was initiated. A few minutes later during CPR, the surgical procedure began with a cutdown of the right femoral artery and insertion of a guidewire and an aortic occlusion balloon, which was inflated at the origin of the left subclavian artery (LSA). Blood pressure was immediately measurable. By only partially deflating the occluding balloon, a thoracic stent-graft was advanced above it and deployed at the origin of the LSA while rapidly deflating and retracting the occluding balloon. Three stent-grafts were required to cover 27 cm of the descending aorta. The patient was partly ventilator dependent for 3 months due to a massive pleural hematoma that was not evacuated. At the 10-month follow-up, the patient is fully recovered without any sign of respiratory dysfunction or any other sequela. CT scans reveal that the massive hematoma is almost completely resolved.

Conclusions:

This case illustrates that optimal collaboration between anesthesiologists, interventional radiologists, and vascular surgeons with appropriate resources can significantly expand the possibilities of emergent treatment in the face of aortic rupture.

Endovascular Repair of AAA Rupture 20 Months after Endoluminal Stent-Grafting

Purpose:

To demonstrate the feasibility of endovascular repair of a ruptured abdominal aortic aneurysm (AAA) previously treated with an endoluminal stent-graft.

Case Report:

An 84-year-old man with a 9.5-cm AAA underwent endoluminal repair with an Endologix stent-graft, but a type I endoleak was detected postprocedurally. The patient was discharged and lost to follow-up. Twenty months later, he suffered an aneurysm rupture, which was repaired using endovascular techniques. Although he had a postoperative course complicated by aspiration pneumonia and renal failure, he recovered fully and was discharged from the hospital with no evidence of endoleak on the postprocedural imaging studies.

Conclusions:

Late ruptures after endoluminal AAA stent-grafting can be successfully treated with endovascular techniques.

Endoleak after Endovascular Repair of Ruptured Abdominal Aortic Aneurysm: Is it a Problem?

Purpose:

To illustrate the clinical significance of type I and type II endoleaks following endovascular treatment of a ruptured abdominal aortic aneurysm (AAA).

Case Report:

An 81-year-old patient presented with a ruptured AAA that was urgently treated with an Ancure aortomonoiliac endograft. After the postoperative computed tomographic (CT) scan, a distal type I endoleak was suspected, but the follow-up angiogram demonstrated only lumbar backbleeding. As the patient was stable, conservative treatment was recommended. After 3 months, a distal as well as a proximal type I endoleak were demonstrated, strangely enough, in the presence of a shrinking aneurysm and clearance of the retroperitoneal hematoma. Both endoleaks were treated endoluminally, after which the CT scan still showed contrast in the aneurysm sac, presumably from lumbar backbleeding. Twelve months after the initial procedure, the patient continues to do well.

Conclusions:

Although not well understood, the presence of an endoleak after endovascular repair of a ruptured AAA may not always be a life-threatening situation.

Abdominal Aortic Aneurysm Repair in Octogenarians versus Younger Patients in a Tertiary Referral Center

Operative survival is as high as 96% for elective abdominal aortic aneursym (AAA) repair but as low as 10% for emergency repair. Our primary aim was to compare elective AAA repair in octogenarians with nonoperative management. Our secondary aim was to compare octogenarians with their younger counterparts.

From 1998 to 2003, 180 patients with AAA were treated operatively or nonoperatively. Factors determining treatment included American Society of Anesthesiologists grade ≥ 4, inoperable malignancy, New York Heart Association class III, forced expiratory volume in 1 second < 35%, creatinine > 6.0 mg/dL, and patient and family choice. A parallel-group observational study was performed to assess age and treatment effects on outcome.

Seventy (39%) patients were repaired electively, 68 (38%) were managed nonoperatively, and 42 (23%) underwent emergency repair. Fifty-nine (33%) were octogenarians.

The octogenarian 5-year survival rate was 20% following emergency repair, 42% if treated nonoperatively, and 83% following elective repair. Younger cohort rates were 55% (emergency), 44% (nonoperative), and 76% (elective).

The octogenarian mean expansion rate was 0.26 cm/yr in those treated nonoperatively and 1.04 cm/yr in confirmed rupture. Rupture rate was related to expansion rate (95% confidence interval [CI] 0.06–0.59, r = .35, p = .01). The rates in the younger subgroup were 0.32 cm/yr and 1.14 cm/yr (95% CI −0.021–0.672}, r = .37, p = .03).

The octogenarian survival rate was highest following elective repair. Rupture was closely correlated with aneurysm expansion. Screening should reduce the incidence of octogenarian rupture of AAA and identify those patients most suitable for nonoperative management.

A small case series of aortic balloon occlusion in trauma: lessons learned from its use in ruptured abdominal aortic aneurysms and a brief review

BACKGROUND

EndoVascular and Hybrid Trauma Management (EVTM) is an emerging concept for the early treatment of trauma patients using aortic balloon occlusion (ABO), embolization agents and stent grafts to stop ongoing traumatic bleeding. These techniques have previously been implemented successfully in the treatment of ruptured aortic aneurysm.

AIMS

We describe our very recent experience of EVTM using ABO in bleeding patients and lessons learned over the last 20 years from the endovascular treatment of ruptured abdominal aortic aneurysms (rAAA). We also briefly describe current knowledge of ABO usage in trauma.

METHODS

A small series of educational cases in our hospital is described, where endovascular techniques were used to gain temporary hemorrhage control. The methods used for rAAA and their applicability to EVTM with a multidisciplinary approach are presented.

RESULTS

Establishing femoral arterial access immediately on arrival at the emergency room and use of an angiography table in the surgical suite may facilitate EVTM at an early stage. ABO may be an effective method for the temporary stabilization of severely hemodynamically unstable patients with hemorrhagic shock, and may be useful as a bridge to definitive treatment of the bleeding patients.

CONCLUSION

EVTM, including the usage of ABO, can be initiated on patient arrival and is feasible. Further data need to be collected to investigate proper indications for ABO, best clinical usage, results and potential complications. Accordingly, the ABOTrauma Registry has recently been set up. Existing experiences of EVTM and lessons from the endovascular treatment of rAAA may be useful in trauma management.

Repair of ruptured abdominal aortic aneurysms with bifurcated endografts: a single-center study

OBJECTIVE

The aim of this study was to describe our early experience in the treatment of ruptured abdominal aortic aneurysms with bifurcated endografts. We report on our initial twelve-month experience using this approach.

METHODS

Clinical data on patients with ruptured abdominal aortic aneurysms treated at a single tertiary center in Brazil were prospectively recorded. The eligibility for endovascular treatment was evaluated by computed tomography scanning and anatomical features were determined based on the method of treatment.

RESULTS

From February 2012 to January 2013 (12 months), 28 consecutive patients (mean age 67.2 years, range 45-85 years) underwent treatment for ruptured abdominal aortic aneurysms at our hospital. Eighteen patients (64.3%) were suitable for and underwent endovascular treatment with bifurcated endografts (16 patients) or aortouniiliac endografts (two patients). Ten patients who were considered unsuitable for endograft repair underwent open repair. Seven patients were classified as hemodynamically unstable (Endovascular, 5; Open, 2), and 21 were classified as stable (Endovascular, 13; Open, 8). The overall 30-day mortality rate associated with endovascular treatment was 27.8% (stable, 18.7%; unstable, 40%) and the rate associated with open repair was 50% (stable, 37.5%; unstable, 100%).

CONCLUSIONS

In this study, the suitability of patients for endovascular repair of ruptured abdominal aortic aneurysms was high and the overall results of endovascular treatment remain encouraging. Indeed, bifurcated endografts are a feasible option for treating anatomically eligible ruptured abdominal aortic aneurysms.

Nontraumatic acute aortic emergencies: Part 2, Pre- and postsurgical complications related to aortic aneurysm in the emergency clinical setting

OBJECTIVE

The aim of this article is to illustrate the imaging findings and spectrum of disease entities affecting the aorta. The clinical presentation and assessment of acute aortic pathology can be elusive or deceptive, making the diagnosis challenging. The widespread availability of advanced cross-sectional imaging technology in the emergency setting puts the radiologist at the forefront of accurate and timely diagnosis.

CONCLUSION

Cross-sectional imaging plays a pivotal role in the diagnosis and delineation of aortic pathology. Awareness of the imaging findings and complications can help in swift and accurate diagnosis.

Endovascular vs open repair for ruptured abdominal aortic aneurysm

OBJECTIVE

Endovascular repair (EVAR) of ruptured abdominal aortic aneurysm (rAAA) has become first-line therapy at our institution and is performed under a standardized protocol. We compare perioperative mortality, midterm survival, and morbidity after EVAR and open surgical repair (OSR).

METHODS

Records were retrospectively reviewed from May 2000 to September 2010 for repair of infrarenal rAAAs. Primary end points included perioperative mortality and midterm survival. Secondary end points included acute limb ischemia, length of stay, ventilator-dependent respiratory failure, myocardial infarction, renal failure, abdominal compartment syndrome, and secondary intervention. Statistical analysis was performed using the t-test, χ(2) test, the Fisher exact test, and logistic regression calculations. Midterm survival was assessed with Kaplan-Meier analysis and Cox proportional hazard models.

RESULTS

Seventy-four infrarenal rAAAs were repaired, 19 by EVAR and 55 by OSR. Despite increased age and comorbidity in the EVAR patients, perioperative mortality was 15.7% for EVAR, which was significantly lower than the 49% for OSR (odds ratio, 0.19; 95% CI, 0.05-0.74; P = .008). Midterm survival also favored EVAR (hazard ratio, 0.40; 95% CI, 0.21-0.77; P = .028, adjusted for age and sex). Mean follow-up was 20 months, and 1-year survival was 60% for EVAR vs 45% for OSR. Mean length of stay for patients surviving >1 day was 10 days for EVAR and 21 days for OSR (P = .004). Ventilator-dependent respiratory failure was 5% in the EVAR group vs 42% for OSR (odds ratio, 0.08; 95% CI, 0.01-0.62; P = .001).

CONCLUSIONS

EVAR of rAAA has a superior perioperative survival advantage and decreased morbidity vs OSR. Although not statistically significant, overall survival favors EVAR. We recommend that EVAR be considered as the first-line treatment of rAAAs and practiced as the standard of care.

Conversion to Open Repair from Emergency EVAR in a Patient with Ruptured AAA: Report of a Case

A 77-year-old woman with a ruptured abdominal aortic aneurysm (AAA) was transferred to our hospital. Due to a severe comorbidity, endovascular aortic repair of the ruptured AAA was proposed. During the operation, although a Zenith(®) AAA endovascular graft was deployed, digital subtracted angiography revealed an enhancement of the endoleak, and the patient became hemodynamically unstable. Therefore, we decided to convert to graft replacement of the abdominal aorta through a median laparotomy. During the postoperative period, the patient suffered from ischemic colitis, which resolved with conservative therapy. She was discharged after 33 postoperative days.

Ruptured abdominal aortic aneurysms: role of endovascular therapy

Ruptured abdominal aortic aneurysms historically have high mortality rates. Despite improvements in many open surgical techniques and perioperative care, these mortality rates have not significantly changed. Some of the reasons for the high mortality rates include the excessive blood loss and hypothermia that occur during open operative repair. The blood loss and hypothermia, combined with resuscitative dilutional coagulopathy, can lead to an irreversible spiraling coagulopathy that ultimately ends in the patient's demise. The availability of endovascular approaches to treat abdominal aortic aneurysms in the early 1990s offered an opportunity to substantially alter the treatment outcomes of ruptured abdominal aortic aneurysms. Endovascular repair offers many advantages, including rapid aortic control under local anesthesia, as well as an opportunity to limit the hypothermia and blood loss that occur with an open abdomen. This article will review the endovascular management of ruptured abdominal aortic aneurysms and describe the endovascular techniques for safe and effective treatment. Mt Sinai J Med 77:250-255, 2010. (c) 2010 Mount Sinai School of Medicine.

Population-based outcomes following endovascular and open repair of ruptured abdominal aortic aneurysms

PURPOSE

To evaluate national outcomes after endovascular and open surgical repair of ruptured abdominal aortic aneurysms (rAAA).

METHODS

The Nationwide Inpatient Sample was interrogated to identify all repairs between 2000 and 2005 for rAAA based on ICD-9 codes. In the study period, 2323 patients (1794 men; median age 75 years, range 45-98) with rAAAs had endovascular repair, while 26,106 patients (20,311 men; median age 73 years, range 22-99) had an open procedure. Outcomes included in-hospital mortality, length of stay (LOS), complications, and hospitalization charge. A secondary analysis was performed to compare outcomes from low-, medium-, and high-volume institutions based on annual rAAA repair volume.

RESULTS

Patients in the endovascular group were significantly older (p<0.05). Mortality was 41% overall: 33% and 41% for endovascular versus open repair, respectively (p<0.001). Mortality after endovascular repair was lower than open surgery for patients >or=70 years (36% versus 47%, p<0.001), but not for those <70 years (24% versus 30%, p = 0.15). LOS was shorter after endovascular repair (7 versus 9 days, p<0.001). Respiratory complications (8% versus 4%, p<0.05) and acute renal failure were more common following open repair (30% versus 23%, p<0.01). Costs were similar (endo $73,590 versus open $67,287, p = 0.15). Mortality decreased as hospital surgical volume increased (low 44%, medium 39%, high 38%; p<0.001). Over time, endovascular repair utilization increased more rapidly at high-volume centers, and a lower mortality was seen with endovascular repair at high-volume compared to low-volume hospitals (22% versus 44%, p<0.001). Multivariate predictors of mortality were age, female gender, lower hospital surgical volume, open repair, and year of surgery.

CONCLUSION

This population-based study found that mortality associated with rAAAs may be improved by the performance of endovascular repair, especially in older patients. Mortality after rAAA for both endovascular and open repairs was also lower at high-volume institutions.

Open repair for ruptured abdominal aortic aneurysm: is it possible to predict survival?

The aim of the study was to determine variables that could be used to predict survival in patients with ruptured abdominal aortic aneurysm (RAAA) and to assess the accuracy of the Glasgow Aneurysm Score (GAS) and the Acute Physiology Chronic Health Evaluation II (APACHE-II). From January 1998 to July 2006, 103 patients underwent operations for RAAA. For each patient, 44 variables were retrospectively recorded in a database. Data were analyzed with univariate and multivariate methods. In the univariate analysis significant predictors of death were hypotension (p=0.001), preexisting peripheral vascular disease (p<0.001), renal insufficiency (p=0.037), chronic obstructive pulmonary disease (p=0.028), level of HCO(3)(-) (p<0.001), intraperitoneal rupture (p=0.001), blood transfused (p<0.001), cardiac complications (p<0.001), and APACHE-II score (p=0.001). Multivariate analysis confirmed statistical significance for coexisting peripheral vascular disease (p<0.001), diastolic blood pressure at admission <60 mm Hg (p=0.039), APACHE-II score >18.5 (p=0.025), HCO(3)(-) <21 mg/dL (p<0.001), and intraperitoneal rupture of the aneurysm (p=0.011) as predictors of death. Results of the study suggested that different factors can be helpful in identifying those patients whose operative risk is prohibitive. APACHE-II, contrary to GAS, is an accurate system to predict postoperative death after repair for RAAA.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: Systematic Literature Review

Endovascular repair is increasingly used for ruptured abdominal aortic aneurysms (RAAAs). This study estimated the mortality rate for this approach. A review of 307 publications in English was performed. Thirty-four publications representing 1,200 patients with RAAA were deemed appropriate for analysis by weighted least squares regression. Of the 1,200 patients, 531 (44.3%) underwent endovascular aneurysm repair (EVAR). The average age was 74 years, and 13% were female. Aortouni-iliac grafts were used in 49.4% of patients, and 50.6% received bifurcated grafts. The technical success rate was 94.9%, with a mortality rate of 30.2%. The ratio of endovascular cases to the total number of cases strongly predicted the mortality rate (weighted coefficient −0.378, p < .0003). The mortality rate following EVAR of RAAA is 30%. A 3.8% reduction in mortality was found for each 10% increase in the percentage of ruptures repaired endovascularly at each center. These results are suggestive of a learning curve.

Endovascular aneurysm repair: current and future status

Endovascular aneurysm repair has rapidly expanded since its introduction in the early 1990s. Early experiences were associated with high rates of complications including conversion to open repair. Perioperative morbidity and mortality results have improved but these concerns have been replaced by questions about long-term durability. Gradually, too, these problems have been addressed. Challenges of today include the ability to roll out the endovascular technique to patients with adverse aneurysm morphology. Fenestrated and branch stent-graft technology is in its infancy. Only now are we beginning to fully understand the advantages, limitations, and complications of such technology. This paper outlines some of the concepts and discusses the controversies and challenges facing clinicians involved in endovascular aneurysm surgery today and in the future.

Emergent treatment of an Iatrogenic arterial injury at femoral puncture site With Symbiot self-expanding PTFE-covered coronary stent-graft

We report an intracranial stenting procedure complicated by active bleeding from the femoral puncture site because of high arterial puncture. The patient was treated by placement of two PTFE-covered self-expanding coronary stent-grafts. To our knowledge, there have been very few reports on stent-grafting of femoral artery in the literature. The low profile and flexibility of the coronary stent-graft enabled treatment via a six French sheath and 12th month patency is demonstrated with CT angiography.

Early and mid-term results of ruptured abdominal aortic aneurysms in the endovascular era in a community hospital

OBJECTIVE

Endovascular repair (EVAR) has been increasingly used for ruptured abdominal aortic aneurysms (rAAAs), especially in major academic centers. The goal of this article is to report our results with an EVAR-first approach for rAAA which we adopted in 2001 in our community hospital.

METHODS

All consecutive patients who underwent attempted repair for rAAA between February 2001 and July 2006 were analyzed. Only patients with computed tomographic or visual verification of extraluminal blood were included.

RESULTS

A total of 40 patients (30 men; mean age, 76.4 +/- 7.2 years; range, 57-89 years) presented with rAAA. Thirty patients underwent attempted EVAR for rAAA, constituting 4.1% of all EVAR cases (n = 738), and 10 patients had attempted open repair. Twenty-one (53%) were transferred from another institution. Computed tomography was performed in 97.5%. On arrival to the emergency department, 43%% were hypotensive (systolic blood pressure <80 mm Hg). Transfemoral balloon occlusion was used in 12 cases (30%; 10 in the EVAR group and 2 in the open group). The length of operation was 128 +/- 35 minutes (range, 77-210 minutes) in EVAR cases. EVAR was completed in 93.3% (iliac anatomy and proximal endoleak caused open conversion in two cases). Out of the 10 open treated cases, 1 was converted to EVAR and survived. The grafts used for EVAR were AneuRx (n = 21), Zenith (n = 5), and Ancure (n = 4), and 97% were bifurcated. Five patients (16.6%) in the EVAR group died within 30 days (four required balloon occlusion). The mean length of stay was 9.1 +/- 6.2 days (range, 4-30 days) in survivors of EVAR. In the EVAR-treated group, two patients died (7 and 9 months; unrelated), and six of the surviving patients (23%) required secondary procedures (five femorofemoral bypasses for limb occlusions and one proximal cuff for a type I endoleak that caused repeat rupture) during a mean follow-up of 13.8 +/- 10.4 months (range, 3-39 months). The mortality rate was 40% (4/10) in patients who underwent open procedures during this period, with an overall mortality rate of 22.5% for all ruptures treated. The difference in 30-day mortality in the EVAR and open groups did not reach statistical significance (17% vs 40%; P = .19). In the entire cohort, hypotension (systolic blood pressure <80 mm Hg) on arrival and loss of consciousness were associated with 30-day mortality. Balloon occlusion was correlated with mortality in the EVAR-treated group (44% vs 4%; P = .019). The multivariate analysis using logistic regression showed that hypotension (odds ratio [OR], 7.4; 95% confidence interval [CI], 1.3-42.0; P = .025), loss of consciousness (OR, 37.5; 95% CI, 3.4-40.8; P = .003), and the need for balloon occlusion (OR, 5.2; 95% CI, 1.8-25.5; P = .042) were correlated with higher perioperative mortality, whereas age greater than 76 years, coronary artery disease, chronic obstructive pulmonary disease, hypertension, diabetes, renal insufficiency, and type of procedure did not.

CONCLUSIONS

Our results show that EVAR is feasible with favorable outcomes in patients presenting with rAAA in a busy community hospital. There is a high secondary intervention rate, which can potentially be decreased by ensuring good iliac limb anatomy at the end of the procedure and by a closer follow-up.

Endovascular Ruptured Abdominal Aortic Aneurysm Repair (EVRAR): A Systematic Review

BACKGROUND

To review evidence supporting the use of endovascular ruptured aneurysm repair (EVRAR) for treatment of ruptured abdominal aortic aneurysm (RAAA).

METHODS

A systematic review of the medical literature was performed for relevant studies. We searched a number of electronic databases and hand-searched relevant journals until November 2006 to identify studies for inclusion. We considered studies in which patients with a confirmed ruptured abdominal aortic aneurysm were treated with EVRAR, which reported endpoints of mortality and major complications.

RESULTS

There was 1 randomised controlled trial (RCT), 33 non-randomised case series (24 retrospective and 9 prospective) reports were identified comparing EVRAR (n=891) with conventional open surgical repair for the treatment of RAAA. Whilst no benefit in the primary outcome of mortality was noted in the only RCT, evidence from non-randomised studies suggest that EVRAR is feasible in selected patients, where it may be associated with a trend towards reductions in blood loss, duration of intensive care treatment, early complications, and mortality.

CONCLUSIONS

For the treatment of symptomatic or ruptured abdominal aortic aneurysm, emergency endovascular repair (EVRAR) is feasible in selected patients, with early outcomes comparable to best conventional open surgical repair for the treatment of RAAA.

Repair of ruptured abdominal aortic aneurysms by endovascular techniques

Emergency EVR for ruptured AAA is now technically feasible, and several reports with small numbers have appeared in the literature from major centers suggesting that the results may be the same as or better than seen with open repair. The immediate priority is avoidance of over-resuscitation together with the rapid transfer of the patient to CT and then to the operating theater. Because of the learning curve involved, these cases should be attempted only by major centers that have extensive elective endovascular experience. The requirement for 24-hour availability of surgeons and radiologists trained in endovascular techniques places an enormous strain on vascular and radiologic staff and is achievable only in major centers with large teams of doctors. These issues raise important questions about the delivery of vascular services and whether all cases of ruptured aortic aneurysm should be transferred to major vascular centers. The operating theater staff and other support persons need training in endovascular techniques and in rapid deployment of an aortic occlusion balloon. A wide selection of devices, guidewires, and catheters must be immediately available in the operating theater. The ideal way to establish the role of EVR for ruptured AAA would be a randomized trial, but there might be logistic difficulties in recruiting sufficient numbers in major vascular centers, particularly as screening for AAA becomes more common and reduces the number of cases. There also are ethical issues as to whether these patients can give informed consent for involvement in such a trial. The alternative is for major centers to continue to develop their endovascular programs, to do more cases, and to compare the results with historical controls undergoing open repair.

Endovascular Repair of Ruptured Abdominal Aortic Aneurysms: Experience in a Community Hospital

The endovascular technique has been recently used as an alternative procedure for selected patients with ruptured abdominal aortic aneurysm (RAAA) as a result of the potential for decreasing morbidity, mortality, and recovery time. We examined our institution's results with endovascular repair of RAAA. Between July 2005 and April 2006, four patients underwent endovascular repair of infrarenal RAAA. We performed a retrospective analysis of our comorbidities, operation time, length of intensive care unit and hospital stay, morbidity and mortality, blood transfusions, and secondary interventions on these patients at our institution. The median age was 73.2 years (range, 66–82 years); 75 per cent were male and 25 per cent were female. Mean operating time was 90 minutes. We had no operative or postoperative mortalities. Five complications occurred in three patients. These included acute renal failure, common femoral artery intimal dissection, graft thrombosis of the iliac limb, ischemic colitis, and chronic obstructive pulmonary disease exacerbation. Endovascular repair of RAAA by an endovascular team is feasible in the community hospital setting. Our limited number of patients in this study does not allow us to compare it directly with results from the standard open procedure. A larger, multi-center study may eventually show this method to be helpful in patients who require repair of RAAA.

Surgery Insight: advances in endovascular repair of abdominal aortic aneurysms

Despite improvements in diagnostic and therapeutic methods and an increased awareness of their clinical significance, abdominal aortic aneurysms (AAAs) continue to be a major source of morbidity and mortality. Endovascular repair of AAAs, initially described in 1990, offers a less-invasive alternative to conventional open repair. The technology and devices used for endovascular repair of AAAs have progressed rapidly and the approach has proven to be safe and effective in short to midterm investigations. Furthermore, several large trials have demonstrated that elective endovascular repair is associated with lower perioperative morbidity and mortality than open repair. The long-term benefits of endovascular repair relative to open repair, however, continue to be studied. In addition to elective repair, the use of endovascular repair for ruptured AAAs has been increasing, and has been shown to be associated with reduced perioperative morbidity and mortality. Advances in endovascular repair of AAAs, including the development of branched and fenestrated grafts and the use of implantable devices to measure aneurysm-sac pressures following stent-graft deployment, have further broadened the application of the technique and have enhanced postoperative monitoring. Despite these advances, endovascular repair of AAAs remains a relatively novel technique, and further long-term data need to be collected.

Tratamento endovascular de aneurisma de ilíaca roto: relato de caso

A taxa de mortalidade cirúrgica do aneurisma de ilíaca roto é similar à do aneurisma de aorta abdominal roto, devido à sua localização profunda na pelve, dificuldade de exposição distal da ilíaca decorrente do hematoma, bridas devido a laparotomia prévia e proximidade com ureter e estruturas venosas. O objetivo do presente estudo é enfatizar o procedimento endovascular como mais uma opção na correção dessas lesões. Relata-se o caso de um paciente de 60 anos de idade, submetido a derivação com enxerto aorto-biilíaco prévio com prótese há 5 anos, por aneurisma de aorta abdominal infra-renal, apresentando rotura de aneurisma em segmento remanescente da ilíaca comum esquerda. Estava hemodinamicamente estável após ressuscitação com fluidos e foi submetido ao tratamento endovascular de urgência, com a exclusão do aneurisma e ausência de vazamentos.

Epidemiology of aortic aneurysm repair in the United States from 1993 to 2003

The epidemiology of abdominal aortic aneurysm (AAA) disease has been well described over the preceding 50 years. This disease primarily affects elderly males with smoking, hypertension, and a positive family history contributing to an increased risk of aneurysm formation. The aging population as well as increased screening in high-risk populations has led some to suggest that the incidence of AAAs is increasing. The National Inpatient Sample (1993-2003), a national representative database, was used in this study to determine trends in mortality following AAA repair in the United States. In addition, the impact of the introduction of less invasive endovascular AAA repair was assessed. Overall rates of treated unruptured and ruptured AAAs remained stable (unruptured 12 to 15/100,000; ruptured 1 to 3/100,000). In 2003, 42.7% of unruptured and 8.8% of ruptured AAAs were repaired through an endovascular approach. Inhospital mortality following unruptured AAA repair continues to decline for open repair (5.3% to 4.7%, P = 0.007). Mortality after elective endovascular AAA repair also has statistically decreased (2.1% to 1.0%, P = 0.024) and remains lower than open repair. Mortality rates for ruptured AAAs following repair remain high (open: 46.5% to 40.7%, P = 0.01; endovascular: 40.0% to 35.3%, P = 0.823). These data suggest that the numbers of patients undergoing elective AAA repair have remained relatively stable despite the introduction of less invasive technology. A shift in the treatment paradigm is occurring with a higher percentage of patients subjected to elective endovascular AAA repair compared to open repair. This shift, at least in the short term, appears justified as the mortality in patients undergoing elective endovascular AAA repair is significantly reduced compared to patients undergoing open AAA repair.

Endovascular treatment for ruptured abdominal aortic aneurysm

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Contemporary management of the infra-renal abdominal aortic aneurysm

Abdominal aortic aneurysms (AAAs) principally affect men over 60 years of age. Aneurysms are usually asymptomatic and detected coincidentally or following the onset of symptoms. Elective repair of an AAA is considered when the diameter reaches 5.5cm or annual expansion exceeds 1 cm. Rupture represents a catastrophic event and carries an unacceptably high mortality. The advent of endovascular repair heralds an improvement in operative outcome for this disease process. In this review we provide an overview of the recent trials investigating the management of non-ruptured and ruptured aneurysms and the strategies that may be invoked to lower the mortality of this disease process

A single-center experience in open and endovascular treatment of hemodynamically unstable and stable patients with ruptured abdominal aortic aneurysms

OBJECTIVE

To retrospectively compare a single center's immediate and mid-term outcomes of ruptured abdominal aortic aneurysm open and endovascular repair (EVAR) for two patient groups-hemodynamically stable and unstable patients-in the same time period.

METHODS

Patients presenting at our center with confirmed rupture of an abdominal aortic aneurysm between December 1999 and April 2006 were considered according to an intention-to-treat model with EVAR. Patients with symptomatic or acute (but not ruptured) AAAs were not included in this study. Thirty-three patients underwent EVAR, and 91 underwent open repair. Seventy-two patients (EVAR, 45%; open, 63%) were classified as hemodynamically unstable at arrival, and 52 were classified as stable (EVAR, 55%; open, 37%). Ninety-seven percent of EVAR procedures commenced under local anesthesia, and 100% of open repairs occurred with general anesthesia. Overall successful graft deployment, 30-day mortality, overall reintervention rate, and complications were the study primary end points.

RESULTS

Overall successful graft deployment for EVAR was 91%; for open repair, it was 96%. Overall 30-day mortality for EVAR was 30% (unstable, 53%; stable, 11%), and the rate was 46% for open repair (unstable, 61%; stable, 21%). The EVAR postoperative reintervention rate (within 30 days) was 15% (unstable, 20%; stable, 11%), and for open repair it was 10% (unstable, 9%; stable, 15%). We recorded a 27% severe complication rate for EVAR patients (unstable, 40%; stable, 17%), and for patients treated with open repair, it was 33% (unstable, 35%; stable, 29%). Our overall EVAR eligibility rate was 52%, and our overall EVAR treatment rate was 27%.

CONCLUSIONS

Our study's overall results for EVAR remain encouraging when compared with those of conventional repair, but large randomized trials are required to confirm the efficacy of the procedure.

A Randomised Trial of Endovascular and Open Surgery for Ruptured Abdominal Aortic Aneurysm – Results of a Pilot Study and Lessons Learned for Future Studies

INTRODUCTION

EVAR has the potential to improve outcome after ruptured abdominal aortic aneurysm (AAA). Published series have been based upon selected populations.

METHODS

An interim analysis of a single centre prospective randomised controlled trial comparing endovascular aneurysm repair (EVAR) with open aneurysm repair (OAR) in patients with ruptured AAA was performed. Patients who had a ruptured AAA and who were considered fit for open repair were randomised to EVAR or OAR after consent had been obtained. Those in the EVAR group had pre-operative spiral computed tomographic angiography (CTA). The primary endpoint was operative (30-day) mortality and secondary endpoints were moderate or severe operative complications, hospital stay and time between diagnosis and operation. A power study calculation required 100 patients to be recruited.

RESULTS

Between September 2002 and December 2004, 103 patients were admitted with suspected ruptured AAA. Only 32 patients were recruited to the study. Of these, four patients died before receiving surgical treatment. On an intention to treat basis the 30-day mortality rate was 53% in the EVAR group and 53% in the OAR group. Moderate or severe operative complications occurred in 77% in the EVAR group and in 80% in the OAR group. Median total hospital stay in the EVAR group was 10 days (inter-quartile range 6-28) and 12 days (4-52) in the OAR group. Median time between diagnosis and operation was 75 minutes (64-126) in the EVAR group and 100 minutes (48-138) in the OAR group.

CONCLUSIONS

Despite the relative high operative mortality in the EVAR group, these preliminary results show that it is possible to recruit patients to a randomised trial of OAR and EVAR in patients with ruptured AAA. CT scanning does not delay treatment.

An intention-to-treat by endovascular repair policy may reduce overall mortality in ruptured abdominal aortic aneurysm

OBJECTIVE

The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysm (AAA) has been restricted to a small number of specialized units on a selected group of patients. The aim of this study is to assess if the overall mortality in these patients with ruptured AAA may be reduced in a unit where all patients with ruptured AAA are considered first for EVAR.

METHODS

During a 24-month period beginning in July 2002, 51 patients admitted with ruptured AAA were considered for EVAR as the treatment of choice and comprised the study group. EVAR was performed in 17 patients. Open repair was performed in 34 patients: 13 patients had hemodynamic instability and 16 patients had an unsuitable aortic neck anatomy. The study group was compared with a historical control group of 41 patients with ruptured AAA who were treated by open repair from July 2000 to June 2002.

RESULTS

Mortality rate was 39% in the study group compared with 59% in the control group (P = .065). The duration of stay in the intensive care unit was significantly lower in the study group than in the control group (P = .01), although the total in-hospital stay was similar (17 days vs 14 days, P = .83). Within the study group, EVAR patients had a mortality rate of 24% compared with 47% in the open group (P = .14).

CONCLUSION

Although the number of patients was small, offering EVAR to as many patients as possible with ruptured AAA has resulted in a 20% reduction in mortality, albeit statistically insignificant. However, it is in the unstable patients that EVAR will need to improve survival before it may be hailed to supersede the conventional approach.

Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms

INTRODUCTION

The successful application of endovascular techniques for the elective repair of abdominal aortic aneurysms (AAAs) has stimulated a strong interest in their possible use in dealing with a long-standing surgical challenge: the ruptured abdominal aortic aneurysm (RAAA). The use of a conventional open procedure to repair ruptured aneurysms is associated with a high operative mortality of 45% to 50%. In this study, we evaluated the current frequency of endovascular repair of RAAAs in four large states and the impact of this technique on patient outcome.

METHODS

We examined discharge data sets from 2000 through 2003 from the four states of California, Florida, New Jersey, and New York, whose combined population represents almost a third of the United States population. Proportions and trends were analyzed by chi2 analysis and continuous variables by the Student's t test.

RESULTS

We found that since the year 2000, endovascular repair has begun to emerge as a viable treatment option for RAAAs, accounting for the repair of 6.2% of cases in 2003. During the same period, the use of open procedures for RAAAs declined. The overall mortality rate for the 4-year period was significantly lower for endovascular vs open repair (39.3% vs. 47.7%, P = .005). Moreover, compared with open repair, endovascular repair resulted in a significantly lower rate of pulmonary, renal, and bleeding complications. Survival after endovascular repair correlated with hospital experience, as assessed by the overall volume of elective and nonelective endovascular procedures. For endovascular repairs, mortality ranged from 45.9% for small volume hospitals to 26% for large volume hospitals (P = .0011). Volume was also a determinant of mortality for open repairs, albeit to a much lesser extent (51.5% for small volume hospitals, 44.3% for large volume hospitals; P < .0001).

CONCLUSION

We observed a benefit to using endovascular procedures for RAAAs in institutions with significant endovascular experience; however, the analysis of administrative data cannot rule out selection bias as an explanation of better outcomes. These data strongly endorse the need for prospective studies to clarify to what extent the improved survival in RAAA patients is to be attributed to the endovascular approach rather than the selection of low-risk patients.

Endovascular treatment of ruptured and symptomatic abdominal aortic aneurysms

OBJECTIVE

To report the experience of endovascular repair (ER) in patients with ruptured and symptomatic abdominal aortic aneurysms (rAAA and sAAA), comparing results with a cohort of controls who underwent open repair (OR) of sAAA or rAAA.

DESIGN

A historically controlled cohort study.

MATERIALS

Retrospective data from 21 patients who underwent ER and prospective data from 23 patients who underwent OR.

METHODS

Results were compared using the Mann-Whitney U-test.

RESULTS

Eleven ER patients had sAAAs and 10 had rAAAs. Nine OR patients had rAAAs and 13 had sAAAs. Thirty-day mortality was 11% in patients with rAAA in the ER group, and 54% in the OR group (p=0.03). There were no post-operative deaths in the patients who had an sAAA in the ER group, and one death in the patients who had sAAA in the OR group. Results as expressed as mean ER value versus mean OR value and p-value. ER was associated with significant reductions in the length of operation (2.6 versus 3.1h, p=0.03), blood transfusion requirements (0.86 versus 10.7 units p<0.01), time in critical care (1.5 versus 6.1 days, p=0.02), and total hospital stay (8.5 versus 17.5 days, p=0.01) compared with OR. There was no difference in time from admission to arrival in theatre between the two groups (3.4 versus 5.0h, p=0.35).

CONCLUSIONS

In patients with rAAA and sAAA that are suitable for stenting, ER has reduced mortality compared with open repair. Assessment for ER does not cause a pre-operative delay, operating time is reduced, blood transfusion requirements are reduced and there is a faster recovery.