Three-dimensional teleradiology for surveillance following endovascular aortic aneurysm repair: a feasibility study.

PURPOSE: To study the feasibility of 3-dimensional (3D) teleradiology in surveillance of patients treated with stent-grafts for abdominal aortic aneurysm (AAA). METHODS: Between April 2002 and November 2003, 8 AAA patients (7 men; median age 73 years, range 62-84) with stent-grafts had follow-up computed tomograms (CT) performed at their local hospital and transmitted without loss across a broadband connection to the university hospital. On both monitors, the radiologists were presented with the complete CT axial dataset, sagittal and coronal reformatted slices, and a 3D volume-rendered reconstruction. The two radiologists were then able to simultaneously perform measurements and real-time manipulations of the axial and 3D pictures, which were discussed over the telephone or using a videoconferencing unit. Patient satisfaction, the radiologists' evaluation of the method, and the potential cost savings were explored. RESULTS: Twelve follow-up CT scans were performed on the 8 patients. The time for transmission over the teleradiological network averaged 5 minutes, and the evaluation required 15 minutes at the university hospital. The overall technical quality of the images was rated as good by the university radiologist. In 11 studies, the stent-grafts were satisfactory, but a type III endoleak was detected in one 5.5-year-old stent-graft. Neither radiologist had a problem identifying the endoleak. Patients had confidence that the examination at the local hospital was of good quality; they all felt that they received good care and were pleased with avoiding travel to the university hospital. From the economic analysis, an annual savings of 40,000 Euros (USD 52,304) was projected, mostly due to avoiding hospital stays and outpatient consultations at the university hospital. CONCLUSIONS: The experiences from this study are encouraging, but a larger series will be necessary for a thorough evaluation of 3D teleradiology as a surveillance method for aortic stent-graft patients.

[Nine years' experience with endovascular treatment of abdominal aortic aneurysms]. / Ni års erfaring med endovaskulaer behandling av abdominale aortaaneurismer.

BACKGROUND: Endovascular repair of abdominal aortic aneurysm was started nine years ago at our institution. Our purpose was to evaluate the results over this period. MATERIAL AND METHODS: From 1995 to 2003, a total of 148 patients were treated for infrarenal abdominal aortic aneurysms by endovascular repair. The material includes 31 patients (21%) who were unfit for open surgery because of comorbidity or poor general condition. The patients have been followed up at regular intervals with clinical investigation, plain abdominal X-ray, and CT scans. Regional anaesthesia was used for 143 procedures; 5 were carried out under general anaesthesia. RESULTS: 30-day mortality following elective procedures was 2.3%. 31 endo-leaks were observed, 16 early and 15 late. Furthermore, 22 graft limb occlusions were diagnosed and thirteen of them repaired with femoro-femoral bypass. Secondary procedures were necessary in 42 (28.4%) of the patients, including 7 late conversions to open surgery. Some patients had more than one secondary procedure. With better stent grafts, the incidence of complications and secondary procedures has decreased significantly. During the last 4.5 years, only 4 secondary procedures (5.8%) have been necessary in 69 patients. In the total material the accumulated five-year survival rate was about 60%. INTERPRETATION: Results from endovascular repair of abdominal aortic aneurysm have improved in recent years. Ongoing prospective randomised studies could give us the information we need in order to establish what role this treatment should have.

Endovascular treatment of thoracic aortic diseases: combined experience from the EUROSTAR and United Kingdom Thoracic Endograft registries.

PURPOSE: The objective of this study was to assess the initial and 1-year outcome of endovascular treatment of thoracic aortic aneurysms and dissections collated in the European Collaborators on Stent Graft Techniques for Thoracic Aortic Aneurysm and Dissection Repair (EUROSTAR) and the United Kingdom Thoracic Endograft registries. METHODS: Four hundred forty-three patients underwent endovascular repair of thoracic aortic disease between September 1997 and August 2003 (EUROSTAR, 340 patients; UK, 103 patients). Patients represented 4 major disease groups: degenerative aneurysm (n = 249), aortic dissection (n = 131), false anastomotic aneurysm (n = 13), and traumatic aortic injury (n = 50). RESULTS: Mean age in the entire study group was 63 years. Fifty-two percent of patients were deemed at high risk for open surgery because of major comorbidity. Sixty percent of patients underwent an elective procedure, and 35% required emergency treatment. Conventional indications for treatment of aortic dissection, including aortic expansion, continuous pain, rupture, or symptoms of branch occlusion constituted the basis for endograft placement in 57% of patients, whereas in 43% of patients aortic dissections were asymptomatic. Primary technical success was obtained in 87% of patients with degenerative aneurysm and in 89% with aortic dissection. Paraplegia was a postoperative complication in 4.0% of patients with degenerative aneurysm and 0.8% of patients with aortic dissection (not significant). Thirty-day mortality in the entire study group was 9.3%, with mortality rates after elective procedures of 5.3% for degenerative aneurysms and 6.5% for aortic dissection. Mortality for degenerative aneurysm after emergency repair was higher (28%; P <.0001) then after elective procedures. For aortic dissection the emergency repair rate was 12% (not significant compared with elective repair of aortic dissection, and P = .025 compared with emergency repair of degenerative aneurysm). One-year follow-up was complete in 195 patients. The outcome at 1 year was more favorable for aortic dissection than for degenerative aneurysm with regard to aortic expansion (0% vs 15%; P = .001) and late survival (90% vs 80%; P = .048). In the groups with false anastomotic aneurysm and traumatic aortic injury, 30-day mortality rates were 8% and 6%, respectively. CONCLUSION: This multicenter experience demonstrates acceptable rates for operative mortality and paraplegia after endovascular repair of thoracic aortic disease. Outcome after 30 days and 1 year was more favorable for aortic dissection than for degenerative aneurysm. However, the durability of this technique is currently unknown, and continued use of registries should provide data from long-term follow-up.

Combined open and endovascular treatment of complex aortic disease.

The purpose of this article is to report whether combined open and endovascular treatment could be applied in patients with complex aortic disease. A retrospective study including four patients with complex aortic disease was undertaken. In all patients, extra-anatomic bypass to the visceral arteries was made through a laparotomy while the aortic lesion was repaired by stent grafting. One patient died on the first postoperative day and another died 3 months after treatment from a myocardial infarction. The other two patients were alive 13 and 34 months after treatment, respectively. However, a patient treated for a ruptured thoracoabdominal type 2 aneurysm on the basis of a dissection suffers from postoperative paraplegia. The combination of open surgery with extra-anatomic bypass to visceral arteries and stent grafting could be an option for the treatment of patients with complex aortic disease, especially in high-risk cases in which more extensive open surgery is contraindicated.

Type III endoleak from a thoracic aortic stent-graft.

PURPOSE: To present an as yet unreported late complication of an Excluder thoracic endograft. CASE REPORT: A 78-year-old man underwent surgery for a ruptured type V thoracoabdominal aortic aneurysm in 1996. Four years later, an aneurysm was detected in the proximal thoracic aorta and repaired with 2 Excluder endoprostheses. At 12 months, computed tomography showed an increase in the aneurysm sac diameter and a type III endoleak, which was traced to a hole in the stent-graft fabric on arteriography. No fracture of the metal components was detected in the stent-grafts. Another Excluder device was implanted within the distal endograft. Satisfactory exclusion of the leak has been maintained for 6 months. CONCLUSIONS: The risk of type III leaks must be minimized before stent-grafting can be regarded as a routine procedure in the treatment of thoracic aortic aneurysms.