Open Versus Endovascular AAA Repair in Patients Who Are Morphological Candidates for Endovascular Treatment

Endovascular therapies for noncoronary atherosclerosis in the elderly: supra-aortic vessels and thoracoabdominal aorta lesions

Due to the aging of the population and the fact that people are living longer, there are increasing numbers of older patients with noncoronary atherosclerosis. Carotid and subclavian arteries are often the first involved vessels in atherosclerosis, and thoracoabdominal aortic involvement is becoming even more frequent. New techniques, such as intra-arterial thrombolysis, protection and thrombo-aspiration devices, and new stent graft designs are becoming available for percutaneous treatment of atherosclerosis in such vessels. In this review, the authors offer geriatric cardiologists an overview and an update of the most recent advances in techniques and results in the field of interventional treatments of atherosclerosis of supra-aortic vessels and thoracoabdominal aorta in the elderly.

Infrarenal Abdominal Aortic Aneurysm Repair via Endovascular Versus Open Retroperitoneal Approach

The beneficial effects of open surgical abdominal aortic aneurysm (AAA) repair via a left retroperitoneal approach have been established. We compared the short-term outcome of infrarenal AAA repair via an endovascular approach with that of an open retroperitoneal approach. From October 2001 to April 2003, patients with infrarenal AAA >5 cm were offered repair via an endovascular approach (group I) with a variety of industry-made stent grafts or with an open retroperitoneal surgical approach (group II). Data were prospectively collected in the vascular registry and complications were analyzed. Data comparison between the two groups was done by using chi-squared analysis and two-tailed Students t-test. Statistical significance was identified at p < 0.05. Over an 18-month period, 492 patients underwent evaluation for AAA. Of these, 446 patients had infrarenal AAA and underwent either endovascular (group I: n = 175, male 85%, female 15%) or open surgical repair (group II: n = 232, male 74%, female 26%) via a left retroperitoneal approach. Group I patients had a higher incidence of coronary artery disease (66% vs. 35%, p < 0.05), hypertension (74% vs. 43%, p < 0.05), chronic obstructed pulmonary disease (29% vs. 12%, p < 0.05), and diabetes mellitus (20% vs. 7%, p < 0.05), a lower mean amount of intraoperative blood loss (277 cc vs. 1452 cc, p < 0.05), and shorter length of stay in the hospital (1.7 days vs., 7.3 days, p < 0.05). Group I also had fewer complications of myocardial infarction (1.7% vs. 5.2%, p = NS), renal failure (0% vs. 2.6%, p < 0.05), pulmonary failure (1.7% vs. 2.6%, p = NS), ischemic colitis requiring colectomy (0.6% vs. 2.6%, p < 0.05), multisystem organ failure (0% vs. 1.3%, p = NS), and death (0.6% vs. 1.3%, p < 0.05). Despite increased preexisting comorbidities, patients undergoing endovascular aneurysm repair had less morbidity, mortality, and blood loss and a shorter in-hospital length of stay than patients undergoing open surgical aneurysm repair via a left retroperitoneal approach.

Overview of success of EVAR: Progress to date

Endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms has been challenged by a number of groups, and the shortcomings of this procedure have been documented in the scientific literature. However, patients and physicians continue to pursue this procedure as a viable means of treating abdominal aortic aneurysms. Both device evolution and advancement of technical skills have led to dramatic improvements in the outcomes of EVAR within the last decade. These improvements and accomplishments have also been chronicled in the literature. This review looks at the successes of EVAR, based on both US Food and Drug Administration trials and independent studies comparing conventional open repair and endovascular repair.

Endovascular treatment of abdominal aortic aneurysms--6 years of experience with Ella stent-graft system

PURPOSE

Evaluation of 6-year results of abdominal aortic aneurysm (AAA) treatment by Ella stent-grafts with regard to safety and effectivity in relation to morphology of the aneurysm.

METHODS

From a group of 172 patients with AAA, in whom elective endovascular treatment was considered, 120 of them (69.8%) were found to be suitable for this type of therapy. The bifurcated type of stent-graft was implanted in 97 patients, uniiliacal type in 19 patients and only four patients were found to be suitable for tubular type of stent-graft. Additional necessary procedures (internal iliac artery occlusion or contralateral common iliac artery occlusion in a group of patients with uniiliacal type of stent-graft) were performed surgically during the stent-graft implantation. CT and US controls were performed at 3, 6 and 12 months after implantation, later every 12 months.

RESULTS

Primary technical success was achieved in 109 of the 120 patients (91%). Primary endoleak was recorded in 11 patients (primary endoleak type Ia in seven patients, type Ib in three patients and type IIIa in one patient). Assisted technical success after reintervention or spontaneous seal was 98.3%. Surgical conversion was indicated in two patients (1.7%). Perioperative mortality rate was 3.3%. Total average follow-up period was 20.7 months (range from 2 to 60 months). In nine patients (7.5%) secondary endoleak type II was found at control CT or US, in three patients partial thrombosis of the stent-graft was found. There was no aneurysm rupture during follow-up.

CONCLUSION

Treatment of AAA with Ella stent-graft system is effective and safe. Bifurcated stent-graft is the most frequently used type. Uniiliacal type of stent-graft is used by us only in cases of complicated morphology.

Endovascular Surgery and Pathology of the Thoracic Aorta

Although abdominal aortic aneurysms are the most common aortic pathology in the general population, the thoracic aorta is also a frequent site of aneurysms, chronic dissections, transections, and other potentially life-threatening pathologies. Not all of these lesions are amenable to endovascular repair; however, early evidence suggests that endovascular intervention in selected patients has a high rate of acute and midterm success. Indeed, the endovascular procedure reduces operating time and the need for blood transfusions and usually results in shorter intensive care unit and hospital stays compared with open surgery. In addition, overall rehabilitation is comparatively brief. Although these results are encouraging, no outcome data from randomized trials exists, and further study of the long-term efficacy and safety of endoluminal grafting is warranted.

Stent Grafts for the Treatment of Abdominal Aortic Aneurysms

Stent grafting for treatment of abdominal aortic aneurysms (AAAs) has been a major advance in endovascular surgery. Initial success with the original endoluminal stent graft encouraged worldwide study of the technology. In the United States, the Food and Drug Administration (FDA) insisted on considerable experience with the devices before approval because of early problems with device rupture, stent fracture, fabric perforation, graft migration, and modular separation. Complications associated with the endovascular graft technology led many to recommend its use only in patients who were considered at "high risk" for the standard, open procedure. Further study and device improvements have led to results that indicate the procedure has the potential to reduce operating time and blood loss and shorten intensive care unit and hospital stays compared with open surgical intervention. At present, there are three FDA-approved devices available for use, and a fourth is expected in 2003. The ultimate decision by the individual practitioner or the institutional team regarding which patients should be treated with endovascular technology is still not entirely straightforward. Patient selection should be based on vascular anatomy, the availability of a suitable device, the patient's desire for a minimally invasive procedure, and a commitment to what is likely to be a lifetime of device surveillance.