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.

Aortouni-iliac endografting as an alternative salvage procedure to open conversion in failed endovascular aneurysm repair.

PURPOSE: To present a single-center experience with failed EVAR requiring conversions comparing open surgery to a minimally invasive procedure modifying the existing stent-graft into an aortouni-iliac (AUI) configuration. METHODS: A prospectively maintained database at our tertiary care university hospital was interrogated to identify all patients with failed EVAR who had undergone either stent-graft modification into an AUI configuration or open conversion between March 1995 and January 2012. Patients with late aneurysm ruptures were excluded. The search found 30 patients (one had initial treatment elsewhere) who required conversion among the 688 patients who had undergone EVAR in that time period. Before conversion, 16 (53%) patients had prior endovascular corrections to maintain aneurysm exclusion. RESULTS: An average time of 52.2 months (median 46.9, IQR 0.0-92.5) elapsed between initial EVAR and conversion. There were 11 early conversions (including 7 on-table), while 19 procedures were done >30 days post EVAR. Twenty-two (73%) patients underwent AUI endografting, while open conversions were carried out in 8 (27%). Mean hospital stay after conversion was 19.5 days (median 13.0, IQR 8.0-17.0). Overall mortality after conversion was 3.3% (1 patient after on-table open conversion), but since the introduction of AUI endografting as an alternative treatment approach, 30-day mortality following conversions fell to zero. CONCLUSION: Modification of a failed stent-graft into an AUI configuration serves as a less invasive treatment option compared to open conversion and allows salvage of the failed device. With the implementation of this alternative approach, mortality after conversion parallels the mortality of elective abdominal aneurysm repair.

Endovascular treatment of delayed rupture following prior abdominal aortic aneurysm repair achieves better survival rates.

PURPOSE: To test the hypothesis that endovascular treatment of delayed aneurysm rupture achieves significantly better survival rates compared to surgical conversion. METHODS: All patients sustaining delayed rupture following prior exclusion of an abdominal aortic aneurysm (AAA) either by endovascular aneurysm repair (EVAR) or open graft replacement from March 1995 through December 2011 were retrieved from a prospectively maintained database at a tertiary care university hospital. During the study period, 35 patients (32 men; mean age 72.9 years) presented with delayed rupture at a median 2.4 years (interquartile range 1.3-4.3) after initial AAA repair by EVAR (n=22) or open surgery (n=13). Causes of post-EVAR rupture were graft-related endoleaks, while ruptures after open repair occurred at anastomotic suture sites. Patients were divided into groups regarding type of treatment for delayed rupture: 20/35 (57%) underwent successful EVAR (10 redo procedures), 13/35 (37%) had surgery (3 redo procedures), and 2/35 (6%) patients received comfort care only. The primary endpoint was 30-day mortality. RESULTS: The 30-day mortality after curative treatment was 25% (5/20) for endovascular treatment compared to 54% (7/13) for surgery (p=0.14). Including additional deaths beyond 30 days, the overall in-hospital mortality was 52% (17/33). The Kaplan-Meier survival estimate for patients undergoing endovascular treatment was significantly higher (p=0.011). CONCLUSION: Endovascular treatment of delayed rupture is feasible and helps to reduce mortality. Our data suggest that endovascular procedures are a superior treatment option for EVAR-suitable patients with delayed rupture compared with surgical conversion.

Complete ten-year follow-up after endovascular abdominal aortic aneurysm repair: survival and causes of death.

PURPOSE: To analyze the hazard and causes of death after endovascular aneurysm repair (EVAR) of abdominal aortic aneurysms during a complete ten year follow-up. METHODS: This is a retrospective clinical study of 130 consecutive patients undergoing EVAR between 1995 and 1998. One-hundred twenty-one patients (93.1%) were treated with first-generation stentgrafts and nine patients (6.9%) received second-generation devices. All patients completed a follow-up of at least 10 years, unless death occurred before then. Time and causes of death were provided by the Austrian central register of deaths. RESULTS: The median follow-up was 7.6 years, and the 130 patients had 968.5 person-years of follow-up. The ten-year mortality rate was 62.3%. Cardiovascular events were the most frequent causes of death, with a 3.9 incidence rate per 100 person-years. Cancer death and death due to other causes occurred in 2.1 and 1.8 cases per 100 person-years, respectively. Lethal late aneurysm rupture happened in 4.6% (n=6), which corresponds to an annual incidence rate of 0.6 per 100 person-years. All of those patients had been treated with first-generation devices. CONCLUSIONS: Cardiovascular events were the most frequent cause of death after EVAR, followed by malignancy and other diseases. The risk of dying from secondary rupture was clearly lower than that of death due to other reasons during ten years after EVAR, even in patients with first-generation stentgrafts.

Anastomotic pseudoaneurysms after surgical reconstruction: outcomes after endovascular repair of symptomatic versus asymptomatic patients.

PURPOSE: To compare perioperative and follow-up outcomes of symptomatic versus asymptomatic patients following endovascular repair of anastomotic pseudoaneurysms (APAs) of the abdominal aorta and iliac arteries. METHODS: We retrospectively evaluated 17 patients (two women), with a mean age of 66.2 years (range 30-83 years). Endovascular treatment was performed in ten symptomatic, and seven asymptomatic patients electively. Data included technical success, perioperative (within 30 days) mortality and morbidity, as well as stent graft-related complications, reinterventions, and survival in follow-up. RESULTS: Bifurcated (n = 13), aortomonoiliac (n = 3) endoprosthesis and one aortic cuff were implanted with a primary technical success rate of 100%. The overall in-hospital mortality and morbidity rate was 11.8% and 35.3%. The mean survival was 36.5 (range 0-111) months. There was a clear trend toward a lower overall survival within hospital and at one and three years for symptomatic patients compared to asymptomatic patients. (47.7 (CI: 0-138.8) versus 52.6 (CI: 28.5-76.8) months (p = 0.274)). During follow-up, late stent graft related complications were observed in six patients (35.3%) necessitating eight endovascular reinterventions. Additional three patients with primary fistulas between the APA and the intestine were treated by late surgical revision. CONCLUSION: Endovascular therapy of APAs represents a considerable alternative to open surgical repair. Short proximal anchoring zones still pose a risk for endoleaks and unintentional overstenting of side branches with commercially available devices, but this might be overcome by use of fenestrated and branched stent grafts in elective cases.

Improved survival after abdominal aortic aneurysm rupture by offering both open and endovascular repair.

BACKGROUND: In the treatment of ruptured abdominal aortic aneurysm (rAAA), the results of open graft replacement (OGR) have remained constant but discouraging for the last 4 decades. Provided suitable anatomy, elective endovascular abdominal aortic aneurysm repair (EVAR) is less invasive and leads to improved perioperative mortality. Thus, it is reasonable to assume that endovascular treatment should improve the results of rAAA therapy. OBJECTIVE: To determine whether the use of both endovascular and open repair of rAAA leads to improved results. DESIGN: A single-center, retrospective analysis of 89 patients suffering from rAAA treated either by EVAR or OGR. PATIENTS: From October 1999 until July 2006, a consecutive series of patients with rAAA were analyzed. Time was divided into 2 periods of 41 months. During the first period, 42 patients were treated by OGR exclusively. Period 2 started with the availability of an EVAR protocol to treat rAAA; 31 patients received open repair while 16 patients underwent EVAR. MAIN OUTCOME MEASURES: Kaplan-Meier survival estimates were calculated and compared. RESULTS: Survival estimates showed a statistically significant reduction in overall postoperative mortality following the introduction of EVAR (P < .03). The 90-day overall mortality rate was reduced from 54.8% to 27.7% during the second period (P < .01). Survival of patients older than 75.5 years was especially improved (75% vs 28.6%; P < .01). There was a parallel pattern of significant reduction of the mortality rate after OGR to 29% (P < .03). CONCLUSION: Offering both EVAR and OGR to patients with rAAA leads to significant improvements in postoperative survival.

Endovascular therapy of ruptured abdominal aortic aneurysm: mid- and long-term results.

As an alternative to open aneurysm repair, emergency endovascular aortic repair (EVAR) has emerged as a promising technique for ruptured abdominal aortic aneurysm (rAAA) within the last decade. The aim of this retrospective study is to present early and late outcomes of patients treated with EVAR for rAAA. Twenty-two patients (5 women, 17 men; mean age, 74 years) underwent EVAR for rAAA between November 2000 and April 2006. Diagnostic multislice computed tomography angiography was performed prior to stent-graft repair to evaluate anatomical characteristics and for follow-up examinations. Periprocedural patient characteristics and technical settings were evaluated. Mortality rates, hospital stay, and early and late complications, within a mean follow-up time of 744 +/- 480 days, were also assessed. Eight of 22 patients were hemodynamically unstable at admission. Stent-graft insertion was successful in all patients. The total early complication rate was 54%, resulting in a 30-day mortality rate of 23%. The median intensive care unit stay was 2 days (range, 2-48 days), and the median hospital stay was 16 days (range, 9-210 days). During the follow-up period, three patients suffered from stent-graft-related complications. The overall mortality rate in our study group was 36%. EVAR is an acceptable, minimally invasive treatment option in patients with acute rAAA, independent of the patient's general condition. Short- and long-term outcomes are definitely comparable to those with open surgical repair procedures.

Management of iatrogenic common femoral artery injuries in pediatric patients using primary vein patch angioplasty.

BACKGROUND: Invasive therapeutic and diagnostic procedures remain the most frequent causes of pediatric vascular injuries. Ideal management, especially the indication for surgical treatment, remains controversial. This study evaluates the outcome of surgical repair for iatrogenic common femoral artery (CFA) injuries in pediatric patients using primary vein patch angioplasty. METHODS: From January 1996 through February 2006, 8 patients were identified in the vascular registry of the Vienna General Hospital in Austria. A retrospective office chart review was performed on this consecutive series of patients treated for iatrogenic CFA injuries using primary vein patch angioplasty. RESULTS: The mean age was 5.8 years (range, 0.3-10.9 years). Surgical repair was performed for 5 ischemic limbs and 3 pseudoaneurysms. Urgent repair was necessary in 5 children (62.5%). After a median follow-up of 9 months (range, 1.8-77.6 months), palpable pedal pulses were present in all patients. No aneurysmatic degeneration of vein patches occurred, and no patient sustained any additional sequelae related to the arterial reconstruction. CONCLUSION: Routine use of a vein patch eases CFA repair, especially in the very young.

Repair of abdominal aortic aneurysms: the benefits of offering both endovascular and open surgical techniques.

Two treatment options are available for abdominal aortic aneurysms (AAAs): open surgical technique with graft replacement and endovascular aortic aneurysm repair (EVAR) as a minimally invasive procedure. The intention of this review is to highlight the advantages of both procedures and to demonstrate that offering both procedures is beneficial for the patient when he or she makes the important decision regarding which treatment to select. A comparative evaluation of both treatment options is offered as well as a short description of the risk of rupture and its consequences. The authors discuss the latest literature as well as their own experiences. An innovative statistical approach-the propensity score-based Cox model-is presented to evaluate the 2 treatment options. The benefits of offering both EVAR and open surgery permit optimal management of AAA for the individual patient and tailor the treatment to his or her organ dysfunctions and impaired physical status. In addition, EVAR offers a treatment option for otherwise incurable high-risk patients.

Endovascular repair of inflammatory aortic aneurysms: long-term results.

OBJECTIVE: Our objective was to report the long-term follow-up results of endovascular aneurysm repair of inflammatory aortic aneurysms. CONCLUSION: Endovascular aneurysm repair of inflammatory aortic aneurysms excludes the aneurysm and seems to reduce the size of the aneurysmal sac and the extent of periaortic fibrosis with acceptable periinterventional and long-term morbidity.

Endovascular therapy of inflammatory aortic aneurysms: a meta-analysis.

PURPOSE: To report a meta-analysis of results from endovascular aneurysm repair (EVAR) of inflammatory aortic aneurysms (IAA). METHODS: A comprehensive literature review was performed to identify all studies reporting the results of EVAR in patients with IAA. To be included in the analysis, an article had to provide a minimum follow-up of 6 months, information about primary technical success, details of immediate and long-term complications, and evaluation of at least one of the basic outcome criteria: changes in aneurysm sac diameter, periaortic fibrosis (PAF), and/ or renal impairment. All studies were reviewed by 2 independent observers for the inclusion criteria. Data were retrieved on the technical and clinical success, outcome criteria, mortality in follow-up, and reinterventions from 14 articles selected from among 701 initially identified. RESULTS: The 14 articles encompassed 46 patients (45 men [97.8%]; mean age 65 years, range 59-75) with a mean follow-up of 18 months after endovascular repair of IAAs located in the abdominal aorta. The primary technical success rate was 95.6% (44/46) and the 30-day clinical success rate was 93.4% (43/46). The median aneurysm sac diameter regression was 11 mm. Of 43 patients with PAF prior to the intervention, 22 (51.2%) patients showed complete regression, 18 (41.8%) remained unchanged, and 3 (7.0%) showed progression after EVAR. Renal impairment disappeared in 11 (45.8%) of 24 patients. Reinterventions were reported in 8 patients. The procedure-related and follow-up mortality rates were 0% and 13.0%, respectively. CONCLUSIONS: EVAR of IAA is feasible, excludes the aneurysm effectively, and reduces PAF and renal impairment in most patients with very low periprocedural and midterm mortality and an acceptable reintervention rate.

Abdominal aortic aneurysms and concomitant diseases requiring surgical intervention: simultaneous operation vs staged treatment using endoluminal stent grafting.

HYPOTHESIS: To investigate whether staged or synchronous treatment of infrarenal abdominal aortic aneurysms (AAAs) and concomitant diseases (CDs) requiring surgical repair plays a clinical role. We considered endovascular aneurysm repair (EVAR) in particular. DESIGN: Review of a prospectively gathered database. SETTING: Tertiary care university teaching hospital. PATIENTS: We reviewed a total of 946 patients receiving elective AAA exclusion from 1980 through 2002. We divided the period into 2 observation intervals: 1980-1994, when only open graft replacement was available (n = 331), and 1995-2002, with 615 patients (326 who had open graft replacement and 289 who had EVAR). With regard to the physical status, expressed by the score from the American Society of Anesthesiologists (Park Ridge, Ill), we recorded in-hospital mortality rates and checked possible differences. MAIN OUTCOME MEASURES: Indications for therapy and mortality rates before and after the availability of EVAR. RESULTS: During the first interval, 14 simultaneous operations were carried out. During the second period, 19 patients received simultaneous operations while 49 underwent staged treatment using EVAR. The overall mortality rate was 3.7%. Irrespective of the American Society of Anesthesiologists classification, the mortality rate for patients who had EVAR was 0% in comparison with 13.6% for patients in American Society of Anesthesiologists class 3 or 4 after open graft replacement (P<.03). CONCLUSIONS: The coincidence of a patient having both an AAA and a CD is rare but should not be neglected. Staged treatment of AAAs using EVAR followed by surgical therapy for CDs can be an effective causal therapy with an acceptable mortality rate provided that suitable aneurysm anatomy exists.

Endografting increases total volume of AAA repairs but not at the expense of open surgery: experience in more than 1000 patients.

PURPOSE: To compare the volume of open graft replacements (OGR) for abdominal aortic aneurysm (AAA) versus endovascular aneurysm repairs (EVAR) over time and after modifying selection criteria. METHODS: A review was conducted of 1021 consecutive patients who underwent AAA repair from 1989 through 2002: 496 elective OGRs for infrarenal AAAs (STANDARD), 289 elective EVARs for infrarenal AAAs, 59 complex OGRs for suprarenal AAAs, and 177 emergent OGRs for ruptured AAAs. Patients from 1995 to 2002 were divided into 2 groups based on shifting treatment strategies; 454 patients were treated by STANDARD or EVAR at the surgeon's discretion between 1995 and 2000 (post EVAR). The second group comprised 161 patients treated in 2001-2002 after the introduction of "high-risk" screening criteria (age > or = 72 years, diabetes mellitus, renal dysfunction, impaired pulmonary function, or ASA class IV) that dictated EVAR whenever anatomically feasible. For comparison, 170 STANDARD repairs performed in the 6 years prior to EVAR served as a control. RESULTS: While surgery for ruptured AAAs remained fairly stable over the 14-year period, the number of patients undergoing elective repair increased due to the implementation of EVAR. During the 6 years after its introduction, EVAR averaged 34.3 patients per year; after 2001, the annual frequency of EVAR increased to 41.5 (p > 0.05). In like fashion, the rate of STANDARD repairs increased to 41.3 patients per year versus 28.3 before EVAR (p = 0.032). ASA class IV patients increased by almost 9 fold in the recent period versus pre EVAR (p = 0.006). The overall mortality after elective infrarenal AAA repair decreased between the pre and post EVAR periods (6.5% versus 3.7%, p > 0.05) and fell still further to 1.2% in the most recent period (p = 0.021 versus pre EVAR). CONCLUSIONS: The implementation of an EVAR program increases the total volume of AAA repairs but does not reduce open surgical procedures. By allocating patients to EVAR or open repair based their risk factors, mortality was markedly reduced.

[Ruptured abdominal aortic aneurysms: status quo after a quarter century of treatment experience]. / Rupturierte abdominelle Aortenaneurysmen: Status quo nach einem Vierteljahrhundert Behandlungserfahrung.

BACKGROUND: Postoperative mortality rates between 40% and 50% have been invariably reported for the treatment of ruptured abdominal aortic aneurysms (rAAA) over the last 50 years. The aim of this analysis was to investigate which patient subgroups benefit from open surgery and in which subgroups a change of treatment strategies should be considered due to lack of improvement despite optimal patient management. PATIENTS AND METHODS: From 1980 to 2002 a total of 230 patients underwent surgery because of a ruptured AAA. The observation period was divided into 3 intervals to achieve an approximately equal distribution of patients. The effect of the observation period and of baseline parameters on mortality rates were investigated. RESULTS: Between 1980 and 1990, 72 patients were operated with a mortality rate of 38.9% (n = 28). During the second period (1991-1996) surgery was performed in 72 patients with a mortality rate of 40.3% (n = 29). In the third observation interval (1997-2002) 86 patients underwent surgery with an unvaried high mortality rate of 40.7% (n = 35). By applying a logistic regression model including age, gender, modality of rupture, location of cross-clamping and type of operation, only the modality of rupture and the patient's age, which are uncontrollable by the surgeon, could be shown to have a significant impact. CONCLUSION: Summing up these findings, open surgical repair of rAAA only leads to acceptable results when performed in younger patients without supposed comorbidities. Survival appears to be accidental in patients with advanced age and increased prevalence of relevant comorbidities/underlying diseases. Minimally invasive techniques may offer promising treatment options to those patients, as they do in elective interventions.

Elective endovascular stent-graft repair of atherosclerotic thoracic aortic aneurysms: clinical results and midterm follow-up.

OBJECTIVE: The purpose of this study was to evaluate the clinical and midterm results after endovascular treatment of atherosclerotic thoracic aortic aneurysms. MATERIALS AND METHODS: Twenty-eight consecutive patients who were 53-82 years old (mean age, 71.6 years) were treated with a commercially available endoprosthesis. Subclavian transposition or bypass surgery was performed before the procedure in eight patients. Size dynamics of the aneurysms were analyzed on the basis of diameter and thrombus volume measurements obtained on three-dimensional CT reconstructions before hospital discharge (n = 22) and at the 1-year (n = 22), 2-year (n = 12), and 3-year (n = 5) follow-ups. RESULTS: The technical success rate was 100%. There was no 30-day mortality. None of the patients had symptoms due to spinal cord ischemia. The survival rate at 1, 2, and 3 years was 96.1%, 90.9%, and 80.2%, respectively. During the perioperative period, patients presented with leukocytosis (37%), fever (36%), elevated C-reactive protein value (92%), pleural effusion (50%), and periaortic atelectasis (41%). Three early type I endoleaks sealed spontaneously. Three early type II endoleaks persisted over time, and one late type II endoleak was detected. In patients with type II endoleaks, thrombus volume of the aneurysms was constant (n = 2) or increased (n = 2). In patients without endoleaks, mean thrombus volume decreased (-53.2 +/- 56.8 mL, -40%) significantly (p = 0.001) during the first year. There was no significant interval decrease between the 1- and 2-year follow-ups (mean, -2.4 mL, p = 0.92) and between the 2- and 3-year follow-ups (mean, -0.4 mL, p = 0.68). CONCLUSION: Endovascular treatment of atherosclerotic thoracic aortic aneurysms may result in a substantial reduction of the aneurysm sac in patients without endoleaks.

MR angiography vs CT angiography in the follow-up of nitinol stent grafts in endoluminally treated aortic aneurysms.

Our objective was to evaluate the accuracy of contrast-enhanced 3D MR angiography (MRA) in the follow-up of patients with endoluminally treated aortic aneurysms and correlate these findings with uni- or biphasic CT angiography (CTA). Forty MR angiograms in 32 patients with implanted aortic nitinol stent grafts were compared to CTA. Twenty-two MR examinations were correlated with arterial-phase CTA (uniphasic), and 18 MR examinations were correlated with biphasic CTA. Uniphasic CTA demonstrated three type-1/type-3 endoleaks and four reperfusion (type-2) endoleaks. In addition, MRA depicted two type-2 reperfusion endoleaks that were missed by CTA. Using biphasic CTA, two type-1/type-3 endoleaks and three reperfusion (type-2) endoleaks were detected; of those, delayed scanning detected three reperfusion (type-2) endoleaks missed during arterial-phase CTA. In addition to the findings by CTA, MRA depicted another type-2 reperfusion endoleak. Magnetic resonance angiography is at least as sensitive as uni- or biphasic CTA for detecting endoleaks and may consequently offer advantages in patients with contraindications to iodinated contrast agents.

Endovascular stent grafting versus open surgical operation in patients with infrarenal aortic aneurysms: a propensity score-adjusted analysis.

BACKGROUND: Although transfemoral endovascular aneurysm management (TEAM) of infrarenal abdominal aortic aneurysms (AAA) is widely performed, open graft replacement is still considered the standard of care. The aim of this study was to investigate whether clear indications for TEAM can be established in patients with significant comorbidities without investigating differences in relative procedure efficacy or durability. METHODS AND RESULTS: A propensity score-based analysis of 454 consecutive patients treated electively for AAA from January 1995 through December 2000 was performed. Of those 454 patients, 248 received open surgery and 206 received TEAM. In-hospital mortality rates (MRs) were compared. After adjusting for propensity scores, a Cox proportional hazard model (COX) was employed to test the influence of the respective treatment on postoperative 900-day survival estimates (SEs). Several potential preoperative risk factors were used as covariates. The MR of all patients was 3.7%. Explorative analysis demonstrated that patients treated by TEAM presented with significantly more risk factors. In American Society of Anesthesiologists class IV patients, a significant difference in MR was detected (4.7% for TEAM versus 19.2% for open surgery; P<0.02). After adjusting for the propensity to receive TEAM or open surgery, a regression analysis of survival based on COX revealed predictive influences of impaired kidney (P<0.047) or pulmonary function (P<0.001), increased age (P<0.05), and selection of treatment modality (P<0.002) on SE. CONCLUSIONS: TEAM represents a less invasive procedure for AAA therapy in patients with significant preoperative risk factors. Especially in geriatric patients with multiple morbidities, TEAM offers a method of therapy with acceptable MRs and SEs, making active treatment possible in otherwise incurable patients.

Endovascular placement of a nitinol-ePTFE stent-graft for abdominal aortic aneurysms: initial and midterm results.

PURPOSE: Because first-generation stent-grafts did not meet initial expectations, a recently designed nitinol-expanded polytetrafluoroethylene (ePTFE) stent-graft was tested for treatment of abdominal aortic aneurysms (AAAs) in a prospective clinical study. The primary study endpoints were technical success and safety. MATERIALS AND METHODS: A nitinol-ePTFE self-expandable stent-graft (Excluder) was used to treat 72 patients with AAAs. The median follow-up period was 21.5 months +/- 13 (range, 1-46 mo). RESULTS: Primary technical success in accurate placement of the device was achieved in 70 of 72 patients (97%). Complete exclusion of the aneurysm from arterial flow was achieved in 57 of 72 patients (79.2%). Three type I leaks were observed during implantation and were immediately corrected with a proximal cuff prosthesis in two patients. Fourteen of 72 patients (19.4%) had a type II leak. Major complications were observed in three patients (4.1%), including one death in the early postinterventional period (one of 72, 1.4%). At 3 months, aneurysms were excluded in 70 of 71 patients (98.6%), and at 12 months, aneurysms were occluded in 29 of 30 patients (96.7%). The maximum diameter of the aneurysm decreased from 55 mm +/- 11 (median +/- SD) before intervention to 53 mm +/- 13 at 6 and 12 months. None of the patients showed aneurysm growth. CONCLUSION: This newly designed stent-graft proved to be effective and safe for treatment of AAAs.

Endovascular treatment of a multimorbid patient with late AAA rupture after stent-graft placement: 1-year follow-up.

PURPOSE: To report successful endovascular management of a ruptured abdominal aortic aneurysm (AAA) in a multimorbid patient 40 months after primary stent-grafting. CASE REPORT: A 64-year-old man presented with hypotension, severe back pain, and abdominal distension. Immediate computed tomography revealed a proximal type I endoleak due to distal migration of the stent-graft with subsequent rupture of the aneurysm. The patient was hemodynamically unstable, and open surgery was refused because of severe comorbidities that were the indications for initial endovascular repair. The diameter of the proximal aneurysm neck required the use of a thoracic stent-graft that was overly long, which led to occlusion of the contralateral stent-graft limb supplying not only the left leg but also a left kidney transplant. A crossover bypass was implanted to revascularize both. CONCLUSION: Minimally invasive strategies, even when challenged by complex vascular reconstructions, offer the possibility of managing ruptured aortic aneurysms in patients unsuitable for open surgery.