Fenestrated and chimney endografts for juxtarenal aneurysms: early and midterm results.

AIM: To assess the early and short-term outcome of fenestrated and chimney grafting for juxtarenal aortic aneurysms. MATERIAL AND METHODS: A prospective vascular registry of 28 patients who had undergone elective primary endovascular repair for abdominal aortic aneurysm between December 2007 and August 2011 with infrarenal neck anatomy unacceptable for conventional endovascular repair. Fenestrated endografts were designed based on reconstructed computed tomography (CT) data by the authors. Off-the-shelf grafts and stents were used for chimney cases. Patients were followed up until 31 May 2012. RESULTS: A total of 21 (75%) patients were treated with fenestrated endografts, while 7 (25%) received chimney grafts. The mean aneurysm diameter was 65 mm (standard deviation = 7 mm) and the median neck length 2.5 mm (range: 0-10 mm). Altogether, 63 (mean = 2.3/patient) visceral arteries were incorporated (42 renal, 21 superior mesenteric arteries). The overall primary technical success rate was 93% (one type I and one type III endoleak). The mean follow-up was 22 months (standard deviation: 14 months). The primary type III endoleak resolved spontaneously with thrombosis of the target vessel, while the patient with primary type I endoleak died of acute myocardial infarction 3 weeks after the procedure. Two late endoleaks developed: one type II endoleak without aneurysm sac growth remains under surveillance, while in another patient, multiple attempts to treat type I endoleak proved unsuccessful and the patient later died of gastrointestinal bleeding. A total of 4 (14%) patients so far required additional procedures. Two patients died within 30 days of the device implantation and another six during the follow-up. No rupture occurred. The cumulative survival for patients with fenestrated endografts was 85% at 1 year and for those treated with chimney technique 57%. CONCLUSIONS: The treatment of juxtarenal aortic aneurysms seems to be feasible by exploiting various endovascular techniques. Even with a low volume of cases, good immediate and short-term results can be achieved, especially with fenestrated endografts.

Ten-year outcomes after endovascular aneurysm repair (EVAR) and magnitude of additional procedures.

BACKGROUND AND AIMS: With any new technology complications are possible, and problems with first-generation aortic stentgrafts have been extensively reported. The longterm outcome of this patient population and the magnitude of additional secondary procedures are, however, less well covered. MATERIALS AND METHODS: Between February 1997 and November 1999, 48 patients (44 men and 4 women; mean age 70 years; range 54-85) with AAA (average 57mm, range 40-90mm) were treated with a Vanguard endoprosthesis. Stentgrafts were sized by CT and angiography-based measurements. Results were continuously assessed using contrast-enhanced CT before discharge, 1, 3, 6 and 12 months after the procedure and thereafter annually. Since 2001 plain abdominal X-rays have been performed annually. RESULTS: The technical implant success rate was 100%. Median follow-up was 91 months (range 7.6-120 months). None of the patients was lost during this period. Hospital mortality was 0%. There were 25 subsequent deaths (52%), the most common cause being coronary artery disease. There were ten late conversions to open surgical repair, including three emergency operations: two due to rupture and one to thrombosis. EVAR-related complications were encountered in 43 patients (90%): 12 primary endoleaks (all type II), 36 late endoleaks (16 type I, 2 type II and 18 type III), 22 migrations, 25 row separations, 20 thromboses, one endotension and 3 ruptures of the AAA. Secondary procedures were required in 39 patients (81%): 1 re-endografting by aortoiliac bifurcated graft and 3 with a uni-iliac graft; 33 limb graft repairs were performed and 19 infrarenal cuffs were placed. There were 4 late embolizations and 4 attempts, and 6 thrombolyses, four of which were successful. Further, 9 femoro-femoral crossover by-pass and 2 axillofemoral by-pass operations and 2 amputations were carried out during the follow-up. Only one patient was alive without complications. CONCLUSIONS: The impact of long-term follow-up of patients treated with the new technology was emphasized in this patient population. A careful surveillance protocol and active endovascular treatment of complications can yield acceptable results and low AAA rupture and aneurysm mortality rates, also with the first-generation endovascular graft. A new technology, however, may involve unpredictable problems which can magnify the workload and incur high costs over several years after the initial procedure.

Hormonal stress response and hemodynamic stability in patients undergoing endovascular vs. conventional abdominal aortic aneurysm repair.

BACKGROUND AND AIMS: To investigate the effect of two different surgical techniques with different anesthetic modes on intraoperative and postoperative hormonal stress response, hemodynamic stability, fluid loading and renal function in patients scheduled for elective infrarenal abdominal aortic aneurysm (AAA) repair. MATERIALS AND METHODS: Forty consecutive patients scheduled for elective infrarenal AAA repair were allocated without randomizing into two groups: an endovascular (EVAR, n = 20) and a conventional (CAR, n = 20) aneurysm repair group according to aneurysm morphology as determined by preoperative computed tomography and angiography. The EVAR group were operated under spinal anesthesia and the CAR group using general anesthesia with epidural blockade. RESULTS: Patients undergoing CAR showed lower intraoperative mean arterial pressure and significantly higher plasma norepinephrine before aortic cross-clamping and significantly higher lactate after aortic declamping and postoperatively than patients in the EVAR group. Postoperatively, vasopressin and serum cortisol were also significantly higher in the CAR group. Fluid loading and estimated blood loss were more excessive in the CAR group. CONCLUSIONS: Stress response was lower and hemodynamic stability and lower body perfusion superior and renal function also better maintained in patients undergoing EVAR under spinal anesthesia as compared to those undergoing CAR using general anesthesia with epidural blockade.

Endovascular treatment of aortic aneurysms in Finland: the first four years' experience.

BACKGROUND AND AIMS: In this study the results of endovascular treatment of aortic aneurysms in Finland are presented and compared to the results of the Eurostar registry. MATERIAL AND METHODS: A total of 229 patients with aortic aneurysm were treated in five different Finnish centres during 1996-2000. The data of these patients were collected prospectively by surgeon or interventional radiologist involved. During the same period of time 2464 patients were registered in the Eurostar registry. RESULTS: The procedure was performed successfully in 97% of patients in Finland, and the 30-day mortality was 0,9%. A graft limb thrombosis was detected in 9% of the patients in Finland. A permanent primary endoleak at the first 30-day control was seen in 23 patients (10%). During the follow-up 17 secondary endoleaks (7%) were detected. A secondary intervention was necessary in 26% of the patients. Three patients (1.3%) had late rupture of the abdominal aortic aneurysm. CONCLUSIONS: According to the Finnish short-time results, endovascular treatment of aortic aneurysms is safe and associated with relatively low morbidity and mortality. The mid-term results are more disappointing with relatively many graft thromboses and endoleaks, and a frequent need of secondary interventions.

Microcatheter embolization of hemorrhages.

PURPOSE: To evaluate the efficacy of embolotherapy using microcatheters in patients with hemorrhage from various locations. METHODS: Among 29 patients there were 13 with severe epistaxis, 7 with gastrointestinal bleeding, 4 with hemorrhage in the kidney, 4 with bleeding in pelvic organs and 1 with bleeding in the shoulder region. In all cases, a Tracker-18 or Tracker-10 microcatheter was advanced coaxially through a 4.1 Fr guiding catheter in order to reach the bleeding site as distally as possible. Polyvinyl alcohol microparticles and/or platinum microcoils were used as embolic material. RESULTS: The bleeding was stopped in 90% (26 of 29) of cases. In 66% of cases the treatment was curative, in 7% preoperative, and in 17% palliative. There were 3 clinical failures. CONCLUSION: Microcatheter embolization is an effective and safe means of managing different kinds of hemorrhage of various causes from a variety of sites.

Stent grafting for abdominal aortic aneurysms in Finland--a feasibility study.

BACKGROUND AND AIMS: Endovascular repair of abdominal aortic aneurysms (AAA) is a feasible procedure in selected patients. In order to assess how many AAAs are suitable for such a procedure, a survey has been conducted in Helsinki, Kuopio, and Tampere University Hospitals. MATERIAL AND METHODS: AAAs having a maximum diameter of 45 mm or more at ultrasonography were included for further evaluation and assessment by angiography and/or spiral CT angiography to determine the length and width of infrarenal aneurysmal neck as well as the dimensions of the distal abdominal aorta and iliac arteries. RESULTS: Among a total of 75 patients with AAA examined in three centres, ultrasonography overestimated the size of the aneurysm in 12 cases that were demonstrated by angiography and CT to have a diameter of less than 45 mm. Among those patients with larger aneurysms, 17 (27%) were suitable for endovascular repair. Stent grafting has been performed in 10 patients until May, 1997. Perigraft leakage occurred in one patient who required the insertion of an additional collar stent graft. CONCLUSIONS: Large numbers of suitable patients are not easy to find but, by performing joint screening in Finland, epidemiological data on suitable aneurysms and improving co-operation between centres can be achieved. Therefore, it would be wise to centralise endovascular repair of AAA.

Local intra-arterial thrombolysis in limb-threatening ischaemia.

The purpose of this study was to determine the angiographic and clinical success rate and the immediate limb salvage and mortality rate after intra-arterial thrombolysis in limb-threatening ischaemia. A retrospective study of 66 patients treated with intra-arterial thrombolysis for 71 episodes of limb-threatening ischaemia was carried out. Immediate angiographic recanalisation rate, pre- and post-treatment ankle-brachial index (ABI) and clinical stage were established. Major amputations and deaths were recorded. The immediate primary angiographic recanalisation was complete in 25 cases and partial in 20 cases. Combined complete plus partial recanalisation rate was thus 63.4% (45/71). The overall mean ABI after treatment was significantly higher than before treatment (0.35 versus 0.68), excluding patients undergoing amputation. Clinical improvement was achieved in 59.2% of cases for one month after treatment. The amputation rate was 18.3% during the first month and 29.6% during the median follow-up of 16 weeks. The mortality rates were 6.1% and 33.3% respectively. Despite a high mortality the complications of thrombolysis were few emphasizing the relative safety of this method in treating limb threatening ischaemia. Furthermore, thrombolysis may identify the underlying pathology, which can be corrected by additional surgery or interventional procedure.