Experience with the sandwich technique in endovascular thoracoabdominal aortic aneurysm repair.

BACKGROUND: The sandwich technique is an endovascular off-the-shelf solution for patients with thoracoabdominal aortic aneurysms (TAAAs). In a sandwich configuration, the chimney stent runs in the middle of a space created by two or three aortic endografts. METHODS: All patients with TAAAs who were treated with the sandwich technique were included in the study. Self-expanding Viabahn grafts (W. L. Gore and Associates Inc, Flagstaff, Ariz) were used as parallel grafts in the renal arteries and visceral vessels. Caudad-facing chimney grafts were used for the visceral arteries and cephalad-facing periscope grafts for the renal arteries. RESULTS: During the study period, 32 patients with TAAAs were treated with sandwich grafts. Indication for the procedure in 43% was an acute onset of symptoms, including two patients with a rupture and a retroperitoneal hematoma. Three patients required an additional debranching procedure. A total of 104 chimney grafts were implanted. Two patients died postoperatively because of the operation. Major adverse events were recorded in five patients, including one patient with persistent paraplegia and two with permanent renal failure requiring dialysis. The incidence of chimney graft occlusion was higher in patients with three or four parallel grafts than in those with two chimney grafts only. Patients with chronic dissections had a 12-times higher incidence of chimney graft occlusion than aneurysm patients. The number of patients with type I or III endoleaks was higher in the group with three or four parallel grafts. CONCLUSIONS: The sandwich technique is an off-the-shelf endovascular alternative to treat patients with TAAAs in an emergent setting. The combination of chimney grafts with a periscope configuration enables a rapid endovascular aneurysm exclusion with acceptable midterm results.

Total laparoscopic aortofemoral bypass as a routine procedure for the treatment of aortoiliac occlusive disease.

The purpose of our study was to evaluate whether total laparoscopic aortofemoral bypass can be performed routinely in patients who require surgical intervention for aortoiliac occlusive disease. In a prospective study, 68 consecutive patients underwent total laparoscopic aortofemoral bypass between 2002 and 2004. Among these patients, there were 50 men and 18 women, with a mean age of 68.4 +/- 9 years. The mean operating time was 199 minutes, with a mean aortic cross-clamp time of 85.8 minutes. There were five major complications (7.3%). The mean postoperative hospital stay was 6.3 days. Most of the younger patients could be discharged on the third or fourth postoperative day. Our results show that total laparoscopic aortic surgery can be offered as a routine procedure to the majority of patients with long-segment aortoiliac occlusive disease.

Totally laparoscopic explantation of migrated stent graft after endovascular aneurysm repair: a report of two cases.

This report describes the removal of two migrated stent grafts and the repair of abdominal aortic aneurysms by laparoscopic technique. In these two cases, endovascular treatment was not indicated because of device migration into the aneurysm and the presence of thrombus within the endografts. Operative times were 245 and 230 minutes, with aortic clamp times of 95 and 66 minutes. The patients were extubated immediately after the procedure, resumed a normal diet on postoperative day 2, and were discharged home on postoperative days 5 and 6. We believe these are the first reported cases of laparoscopic explantation of migrated aortic stent grafts in the literature.

Total laparoscopically and robotically assisted aortic aneurysm surgery: a critical evaluation.

BACKGROUND: Laparoscopically assisted aortic aneurysm resection requiring a minilaparotomy can be performed as a routine procedure. It was the purpose of our study to evaluate whether a total laparoscopic operation can be offered to aneurysm patients as a minimally invasive alternative. We also wanted to test whether a master-slave robot could facilitate the total laparoscopic procedure. METHODS: A prospective, consecutive number of 50 patients was evaluated. A transperitoneal left retrocolic access was used to expose the aorta. If possible, a tube graft repair was performed. The aortic anastomosis was sutured totally laparoscopically, with the surgeon standing on the right side of the operating table. In 10 consecutive patients, the anastomosis was sutured with the help of the Zeus robot. RESULTS: After excluding 3 cases that required suprarenal cross-clamping, 47 patients were operated using a total laparoscopic approach. A totally laparoscopic operation could be performed successfully in 39 patients with aneurysms. In 8 patients (17%), conversion to a laparoscopic hand-assisted operation with a 7-cm minilaparotomy was required. The robot was used to perform the aortic anastomosis in 10 patients. In 8 patients, a tube graft repair could successfully be performed totally laparoscopically. In the remaining patients, a bifurcated graft was implanted laparoscopically. The mean operating time was 227 minutes in the laparoscopy group and was 242 minutes in those patients in whom the anastomosis was sutured with the help of the Zeus Robot. Mean cross-clamping time, +/- SD, was 81.4 + 31 minutes. None of the patients died perioperatively. Major complications occurred in three patients (6.3%). The overall morbidity was 14.8%, including one patient who required temporary hemodialysis postoperatively. The time to suture the aortic anastomosis was significantly shorter in the robotic-assistance group (40.8 +/- 4 minutes), yet total operating time was longer in this group because of the technical complexity of the robotic device. Patients with a total laparoscopic procedure asked for significantly fewer analgesics and could regain full mobility earlier compared with those patients for whom a minilaparotomy after conversion to the laparoscopic hand-assist procedure was required. CONCLUSIONS: Total laparoscopic aneurysm resection can be offered to the majority of patients in our institution. The robot still requires further refinements to reduce operating times and the aortic cross-clamping period. We now have the technique and the instrumentation to offer laparoscopic aneurysm surgery as a minimally invasive alternative for patients whose conditions are unsuitable for endovascular aneurysm repair.