Secondary endovascular and conversion procedures for failed endovascular abdominal aortic aneurysm repair: can we still be optimistic?

The purpose of this study was to evaluate the incidence, etiology, and outcome of secondary endovascular and "open" conversion procedures after failed endovascular abdominal aortic aneurysm repair (EVAR). From January 1997 until December 2005, 625 patients with an infrarenal abdominal aortic aneurysm were treated by elective EVAR, with 98.7% (n = 617) primary EVAR success. The mean follow-up of the 617 patients was 46.7 +/- 11.2 months. One hundred of these patients (16.2%) required secondary endovascular or peripheral procedures, and 39 (6.3%) patients underwent a secondary abdominal conversion. There were 5 acute conversions (0.8%) and 34 elective conversions (5.5%). The pre-EVAR anatomic suitability data, the main cause of the secondary procedure, and stent graft type were compared between patients with primary EVAR success, patients in need of a secondary endovascular or peripheral procedure, and patients with abdominal conversion. The overall main causes for reinterventions were proximal migration (n = 60; 9.7%), progressive kinking of the stent graft (n = 59; 9.6%), and late type III endoleak (n = 12; 1.9%). Multivariate logistic regression analysis showed that factors significantly correlated with secondary procedures were the abdominal aortic aneurysm's maximum diameter, the proximal neck's width and length, and particularly the commercial withdrawal of the stent graft (p < .001). The morbidity and mortality rates of secondary endovascular or peripheral interventions were 0%. The mortality rate of acute secondary conversions was 20% (n = 1) and of elective secondary conversions was 8.8% (n = 3). The morbidity rates for acute and elective conversions were 0% and 65%, respectively. The aneurysm-related mortality rate in our series was below 1%. Abdominal conversion surgery still carries a high mortality rate, but the overall EVAR-related mortality rate remains low. Early pitfall detection and proper reintervention are crucial to long-term EVAR success.

Surgical outcome of degenerative versus postreconstructive extracranial carotid artery aneurysms.

OBJECTIVES: Extracranial carotid artery aneurysms (ECAAs) are rare vascular lesions, and large series with short-term and long-term outcomes are seldom reported. This study compared the clinical presentation and conventional treatment outcomes of different ECAA types according to their etiology. METHODS: We retrospectively reviewed the data of 55 consecutive patients (47 men, 8 women) with 61 ECAAs who were treated from January 1986 to December 2007 by conventional surgical techniques. The patients were a mean age of 65 +/- 11 years (range, 30-92 years). Thirty-two ECAAs (52.5%) occurred postoperatively after previous carotid endarterectomy, of which 26 patients had 29 degenerative aneurysms (47.5%). Clinical presentation included cerebral stroke in three patients (4.9%) and transient ischemic attack in 26 (42.7%). Mean follow-up was 42.7 +/- 22.0 months. Statistical analysis was performed within and between degenerative and post-reconstructive ECAA subgroups of patients. RESULTS: Open aneurysm resection included 27 extended polytetrafluoroethylene interposition grafts, 12 venous grafts, and 22 closures using synthetic patch. Cumulative 1-year primary patency rates were 86.9% for the degenerative ECAAs and 96% for the postoperative ECAAs, with respective secondary patency rate at 5 years of 80% and 93.3%. The 5-year patency rate was 88.9% for synthetic grafts compared with 66.7% for vein grafts and 86.4% for synthetic patches. These differences were not statistically significant (P > .05). Complications for the degenerative ECAAs included two reconstruction thromboses <30 days, two cerebral strokes, and one myocardial infarction. The patients with postoperative ECAAs experienced one early thrombosis and two strokes postoperatively. Two patients (3.6%) from the degenerative ECAA subgroup died of cardiac decompensation (n = 1) and cerebral ischemic event (n = 1). CONCLUSIONS: Despite the different trends, no significant differences were found between degenerative ECAA and postoperative ECAA patients in clinical presentation, localization, and surgery outcomes. The good middle-term and long-term patency rates of synthetic graft reconstruction justify its use in the treatment of ECAAs, and it is less time consuming and technically demanding compared with vein interposition graft.

Endovascular treatment of iatrogenic and traumatic carotid artery dissection.

This paper reports on the early and midterm results of endovascular treatment of acute carotid artery dissections, its specific problems, and its limitations. We encountered seven patients with symptomatic extracranial carotid artery dissection, three cases of which occurred after carotid endarterectomy, two after carotid angioplasty and stenting, and two after trauma. Balloon-expandable and self-expanding stents were placed using a transfemoral approach. Success in restoring the carotid lumen was achieved in all patients. No procedure-related complications occurred. All patients experienced significant clinical improvement while in the hospital and achieved complete long-term recovery. At follow-up (mean, 22.4 months), good luminal patency of the stented segments was observed. In conclusion, in this small series, primary stent-supported angioplasty seems to be a safe and effective strategy in the treatment of selected patients having acute traumatic extracranial carotid artery dissection, with excellent early and midterm results. Larger series and longer-term follow-up are required before definitive recommendations can be made.

Isolated iliac artery aneurysms: endovascular versus open elective repair.

OBJECTIVE: To compare endovascular and open repair of isolated or solitary iliac artery aneurysms (SIAAs). METHODS: We present the results of 55 patients with 58 SIAAs that were treated between January 1998 and December 2005 in two European university hospitals. In one center, the standard procedure, if not contraindicated, was endovascular repair, and 32 (58.2%) consecutive patients with 33 SIAAs were treated by using only endovascular techniques (endovascular iliac aneurysm repair; EVIAR). In the second center, 23 (41.8%) consecutive patients with 25 SIAAs were treated by conventional surgical techniques because advanced endovascular skills were not available before late 2005. EVIAR included coil embolization of the hypogastric artery in 13 of the 33 cases with aneurysmal involvement of the internal iliac artery. In the "open" group of patients, midline laparotomy and a transperitoneal approach with bifurcated aortoiliac graft replacement was performed in 4 cases, and a lower lateral abdominal incision with a retroperitoneal approach and iliac replacement was performed in 19 cases. RESULTS: The mean follow-up period was similar in both groups (EVIAR, 35.3 +/- 21.3 months; open, 31.3 +/- 19.9 months). The two groups of patients had similar demographic and clinical characteristics compared with previous reported series, and data analysis revealed a statistically significant difference between the two groups only in hypertension. The early and mid-term outcomes and especially the 3-year primary patency rates were also similar between the two groups (EVIAR, 97%; open, 100%). In the EVIAR group, there was no evidence of endoleaks, kinking, or graft migration, and 26 aneurysms remained stable, whereas in 7 aneurysms a slight decrease in size (>10% in diameter) was observed. Comparison of operative time, intraoperative blood loss, and postoperative hospital stay revealed significant differences (P < .001) in favor of the endovascular group. Secondary intervention was not necessary in any patient in either group during the entire follow-up period. CONCLUSIONS: Elective management with endovascular or open techniques of isolated iliac aneurysms can be accomplished with very low morbidity and mortality rates. Better intraoperative and early postoperative outcomes, as well as the durable mid-term results in our EVIAR-treated patients, indicate that endovascular techniques could be offered as first-line therapy of SIAAs.

Long-term outcome after Talent endograft implantation for aneurysms of the abdominal aorta: a multicenter retrospective study.

BACKGROUND: The development of newer-generation endografts for the endovascular treatment of abdominal aortic aneurysms has resulted in considerable improvements in clinical performance. However, long-term outcome data are still scarce. To assess long-term clinical and radiographic outcomes after use of the Talent stent graft, a retrospective analysis was performed that was based on 165 patients treated with this endograft in Germany between October 1996 and December 1998. METHODS: Data were collected according to the recommendation of the ad hoc committee for standardized reporting practices in vascular surgery and were evaluated statistically by using univariate and multivariate analyses. RESULTS: A total of 165 patients were treated with a Talent endograft in 9 German centers before December 31, 1998. Most were asymptomatic (94.5%), male (97.6%), and treated with a bifurcated graft (86.7%). Two patients (1.2%) died within 30 days, and 28 (17%) died during the follow-up period. The cause of death was aneurysm rupture in one case. Survival was 95.4% +/- 1.7% at 1 year, 89% +/- 2.6% at 2 years, 78.1% +/- 3.6% at 5 years, and 76.2% +/- 4.1% at 7 years. Patients classified as American Society of Anesthesiologists grade IV had a significantly lower survival rate (24.9%) than those classified as American Society of Anesthesiologists grade II and III (91.9% and 77.3%). During a mean follow-up period of 53.2 +/- 20.1 months (range, 1-84 months), 47 secondary procedures were performed in 31 patients (18.8%). Kaplan-Meier estimates showed a freedom from secondary intervention of 94.7% +/- 1.8%, 81.7% +/- 3.3%, and 77.4% +/- 3.6% at 1, 3, and 7 years, respectively. The reason for secondary treatment was endograft thrombosis in 10 patients (6.1%), persisting primary endoleak in 9 (5.5%), late secondary endoleak in 6 (3.6%), graft migration in 3 (1.8%), aneurysm rupture in 2 (1.2%), and graft infection in 1 (0.6%). Device migration (> or =10 mm) occurred in seven patients (4.2%). Other graft changes, such as graft kinking (n = 4; 2.4%), fracture of metallic stents (n = 2; 1.2%), erosion of the longitudinal bar (n = 2; 1.2%), or modular component separation (n = 1; 0.6%), were rare. Follow-up computed tomographic imaging revealed a decrease of the maximum aneurysm sac diameter (>5 mm) in 106 (64.2%) patients and an increase in 14 (8.5%) patients. The mean aneurysm diameter significantly decreased (P < .001). Of the factors recorded at baseline, only endoleaks showed a significant correlation with the risk of aneurysm increase during follow-up (P < .001). Adverse anatomy (neck diameter >28 mm, neck length <15 mm, and '5 patent aortic branches) did not adversely influence the aneurysm shrinkage rate, the risk for a secondary procedure, or the clinical success rate. A significantly higher rate of clinical success (P < .05) was observed in patients older than 65 years of age. CONCLUSIONS: Implantation of the Talent endograft device is a safe and effective alternative to open surgery for exclusion of abdominal aortic aneurysm. In comparison with first-generation grafts, the device showed superior durability for as long as 5 to 7 years after implantation. Even if prototypes of the Talent device were implanted in this study, the graft was also successfully used in most patients, even in those with adverse anatomy. Because improvements of the endograft have been made to address connecting bar breaks, a lower incidence of graft limb occlusion can be expected in the future.

The role of epidural spinal cord stimulation in the treatment of Buerger's disease.

PURPOSE: This clinical, retrospective study is evaluated the effect of epidural spinal cord stimulation (SCS) in the treatment of Buerger's disease. METHODS: The clinical criteria of Shionoya were used to diagnose 29 patients (22 men, 7 women; mean age 33.7 years) with Buerger's disease. The patients underwent SCS. Complete physical examination and vascular laboratory data were available and recorded for all patients. Questions regarding the improvement of symptoms, in lifestyle, and in physical activities were asked direct interview or by telephone during mean follow-up of 4 years. RESULTS: The regional perfusion index (RPI), the ratio between the foot and chest transcutaneous oxygen pressure at baseline (before SCS treatment) was 0.27 +/- 0.25. Three months after SCS implantation the RPI increased to 0.41 +/- 0.22. During the follow-up period, a sustained improvement in microcirculation was recorded: the RPI at 1-year follow-up was 0.49 +/- 0.34 and at 3-year follow-up was 0.52 +/- 0.21. The most pronounced improvement in the RPI values was found in the subgroup of 13 patients with trophic lesions. In this group, the RPI increased significantly from 0.17 +/- 0.21 to 0.4 +/- 0.18 (P < .023) after a mean follow-up of 5.7 years. Two patients underwent major amputation of the lower target limb. The limb survival rate was 93.1%. During the follow-up period of 4 years, 21 of the 29 patients continued to smoke, and only five patients stopped nicotine exposure. CONCLUSIONS: We recorded a significant benefit in the microcirculation, a good limb survival rate, and the absence of new trophic lesions. During the follow-up period, no severe complications related to the implanted devices occurred. Because of the diffuse, distal, segmental nature of the disease, SCS should be considered as an alternative treatment modality in patients with Buerger's disease.

Spinal cord stimulation in the treatment of peripheral vascular disease: results of a single-center study of 258 patients.

This report is of a retrospective study of data from 258 patients who received spinal cord stimulation (SCS) for the treatment of peripheral vascular disease as a result of arteriosclerosis. The patients' clinical outcomes were monitored over a period of 18 months. In patients with a low baseline transcutaneous oxygen pressure (TcPO(2)) value of <10 mm Hg, limb survival at 18 months of follow-up (estimated by use of Kaplan-Meier survival analysis) was 77.8%, and this was even higher, at 89.5%, in patients with a medium baseline TcPO(2) value of 10-30 mm Hg. This successful treatment was accompanied by a sustained increase in TcPO(2) values to approximately 30 mm Hg in both of these groups. In looking at diabetic and nondiabetic patients, there is no difference in limb survival as a result of the treatment. It is concluded that SCS is an effective therapy in improving limb survival in patients with peripheral vascular disease. In addition, TcPO(2) values at baseline may be a useful predictor of treatment outcome.