Aneurysm sac shrinkage after endovascular repair: predictive factors and long-term follow-up.

BACKGROUND: The aim of this study was to determine the predictive factors of reduction in diameter ≥10 mm of the aneurysm sac after endovascular treatment and analyze evolution in these patients. METHODS: Between December 1997 and December 2008, all patients electively treated at our center for an infrarenal abdominal aortic aneurysm (AAA) were included in a prospective registry. We did a retrospective study between patients whose aneurysm was reduced by at least 10 mm in diameter on computed tomography scan during follow-up (Group 1) and the other patients who did not (Group 2). A univariate and multivariate statistical analysis was performed. RESULTS: The files of 197 patients (mean age 74.8 years) with a mean follow-up of 54.8 months were reviewed. One hundred two patients (51.8%) had a reduction of ≥10 mm of AAA diameter (Group 1); this reduction was achieved after an average follow-up of 23.6 months. The delay to obtain at least a 10-mm diameter reduction was not influenced by any preoperative characteristics of patients or characteristics of the AAA. Patients in Group 1 were younger (74 vs. 76 years, P = 0.039), with a longer (31 vs. 27.7 mm, P = 0.038) and narrower upper neck (23.1 vs. 24.0 mm, P = 0.02) compared with Group 2. After multivariate analysis, these 3 variables were independently predictive of reduction in AAA diameter. In Group 1, secondary procedures were performed in 13 patients after a diameter reduction of ≥10 mm, including 3 type 1 endoleaks treated after 36 months (1 case) and after 123 months (2 cases) and 1 type 3 endoleak treated after 78 months. In Group 2, secondary procedures were performed in 28 patients, including 9 type 1 endoleaks treated after a median time of 26 months and no type 3 endoleak. Secondary procedures were significantly more frequent in Group 2 than in Group 1 (29.4% vs. 12.7%, respectively; P = 0.005). Freedom from secondary procedure at 5 years was 87.9% in Group 1 and 65.4% in Group 2 (P = 0.003). Freedom from AAA rupture at 8 years was significantly superior in Group 1 than in Group 2 (100% vs. 83.5%, P = 0.008). CONCLUSIONS: Sac shrinkage after endovascular aortic aneurysm repair is more likely observed in younger patients with long and small proximal neck anatomy and is associated with better long-term outcomes. However, late failures do occur even in those with significant sac shrinkage; therefore, follow-up should continue lifelong.

Secondary procedures after infrarenal abdominal aortic aneurysms endovascular repair with second-generation endografts.

BACKGROUND: To study the incidence, the types, and the results of secondary procedures performed after endovascular treatment of infrarenal abdominal aortic aneurysm (AAA). To compare the population of patients who underwent secondary procedure (P2) with the population of those who did not require it. MATERIAL AND METHODS: Between 1998 and 2008, this study included all the patients electively treated for AAA with stentgrafts that were still available on the market on January 1, 2009. Data were prospectively collected and retrospectively analyzed. The postoperative follow-up included at least a systematic computed tomography scan at 6, 12, 18, and 24 months and then every year. P2 were defined as any additionnal procedures performed to treat aneurysm related complications after initial stentgraft implantation. RESULTS: We studied 162 patients with a mean 40 ± 31 months' follow-up. In 32 patients (19.7%), there were 46 P2, 3 of them were surgical conversion and 1 with endovascular conversion. Thirty-nine P2 were scheduled, and seven were performed in emergency. Nine patients underwent more than one P2. P2 was indicated for type II endoleak in 17 cases, 13 of them with a diameter increase; for type I endoleak in 10 cases; for AAA rupture in 3 cases; for occlusion or stentgraft stenosis in 13 cases; and for 1 type III endoleak, 1 endotension, and 1 femoro-femoral crossover bypass infection. Two ruptures occurred in patients who had undergone P2. The immediate technical success was 89.1%. At 30 days, morbidity was 10.9%, and there was no mortality. Survival rates at 3 and 5 years were respectively 85.2% and 71.9% in patients with secondary procedure and 70.6% and 47.5% in the others (p = 0.046). CONCLUSIONS: In patients treated for AAA with second generation stentgrafts, in the long term, secondary procedure rate was 19.7%. Survival rate for patients who underwent a secondary procedure was better, which was probably related to the fact that they were younger at the time of stentgraft implantation. Large AAA diameter was a secondary-procedure risk factor.

Challenging catheterization of a branch in an endovascular thoracoabdominal aneurysm repair.

PURPOSE: To describe a novel technique of cannulating a side branch during endovascular repair of a thoracoabdominal aneurysm (TAAA). TECHNIQUE: The approach evolved during endovascular repair of a type III TAAA in which a custom-designed graft with 3 caudally directed branches was being deployed in a patient who had a prior surgical repair for a type IV TAAA. Two of the branches were successfully cannulated and stented, but repeated efforts to cannulate the left renal branch and artery via the standard brachial approach were unsuccessful. A catheter positioned between the graft and the aneurysm sac was used to gain retrograde access to this branch. From a left brachial access this guidewire was snared and used to allow bridging stent deployment between the branch and the renal artery, thus completing the procedure. CONCLUSION: This report describes a novel technique to deal with challenging side branch cannulation that may be encountered during branched stent-graft deployment.

False aneurysm at the origin of the anterior tibial artery after opening wedge osteotomy.

We report the case of a false aneurysm at the origin of the anterior tibial artery complicating upper tibial osteotomy. The proximally located lesion compressed the posterior tibial nerve, and despite successful decompression, the patient suffers from probably irreversible neurologic after-effects. Even though it is rare, this complication must be considered when faced with leg pain consecutive to upper tibial osteotomy without deep venous thrombosis.