Endovascular treatment of acute aortic syndrome.

BACKGROUND: The term acute aortic syndrome (AAS) encompasses a range of conditions that have a risk of imminent aortic rupture and where delays in treatment result in increased mortality. Endovascular treatment offers an attractive alternative to open surgery but little is known about the durability of the repair and the factors that predict mortality. METHODS: Prospective data were collected for a cohort of 110 consecutive patients with endovascular treatment for AAS. Patient and procedural characteristics were related to short- and midterm outcome using multivariate logistic regression analysis. RESULTS: There were 75 men and 35 women with a median age of 68 (range 57-76) years. The pathologies treated were acute dissection (35), symptomatic aneurysm (32), infected aneurysm (18), transection (12), chronic dissection (9), penetrating ulcer (3), and intramural hematoma (1). Thirty-day mortality was 12.7% and this was associated with hypotension (odds ratio [OR], 5.25), use of general anesthetic (OR, 5.23), long procedure duration (OR, 2.03), and increasing age (OR, 1.07). The causes of death were aortic rupture (4), myocardial infarction (4), stroke (3), and multisystem organ failure (3). The stroke and paraplegia rates were 7.3% and 6.4%, respectively. The 1-year survival was 81% and the 5-year survival 63%. Secondary procedures were required in 13 (11.8%) patients. Factors associated with death at 1 year were presence of an aortic fistula (OR, 9.78), perioperative stroke (OR, 5.87), and use of general anesthetic (OR, 3.76); and at 5 years were aortic fistula (OR, 12.31) and increasing age (OR, 1.06). CONCLUSIONS: Acute aortic syndrome carries significant early and late mortality. Emergency endovascular repair offers a minimally invasive treatment option associated with acceptable short and midterm results. Continued surveillance is important as secondary procedures and aortic-related deaths continue to occur throughout the follow-up period.

Endovascular repair of a tuberculous mycotic thoracic aortic aneurysm with a custom-made device.

Mycotic aortic aneurysms are rare and it is unlikely that any center will obtain extensive experience in their management. The aim of treatment is to repair the aorta and eradicate the infection with minimal operative and postoperative risk. We describe a case in which a custom-made endovascular stent graft provided the optimal treatment strategy and remained durable at 4 years of follow-up.

Medium-Term Outcomes Following Endovascular Repair of Infrarenal Abdominal Aortic Aneurysms with an Unfavourable Proximal Neck.

PURPOSE: The purpose of this study was to evaluate medium-term outcomes following endovascular repair of abdominal aortic aneurysms (EVAR) with unfavourable neck anatomy using stent grafts with a 36 mm or larger proximal diameter. MATERIALS AND METHODS: A retrospective review of 27 patients who underwent elective EVAR between 2006 and 2008 using a stent graft with a 36 mm or larger proximal diameter was carried out. All patients had computed tomography angiography (CTA) for procedure planning, and detailed assessment of the aneurysm neck was performed using a three-dimensional CTA workstation. Patients were followed up with CTA at 3 and 12 months and annual duplex thereafter. RESULTS: The median aneurysm diameter was 7 cm, and the median aneurysm neck diameter was 31 mm. Cook Zenith stent grafts were used in all patients, with a proximal diameter of 36 mm (n = 25) and 40 mm (n = 2). Primary and assisted primary technical success rates were 74 and 93%, respectively. The follow-up period ranged from 62 to 84 months, with a median of 72 months. 15 patients died during follow-up. Two patients died from aortic rupture, and the remaining patients died from cardiac disease (n = 4), chest sepsis (n = 6), cancer (n = 2) and renal failure (n = 1). Complications included type I endoleak (n = 5), limb occlusion (n = 2), limb stenosis (n = 2), limb kinking (n = 1), dissection of an artery (n = 1), occlusion of a femorofemoral cross-over graft (n = 1) and poor attachment of a distal limb (n = 1). CONCLUSIONS: EVAR using stent grafts in the presence of an unfavourable neck has a high risk of complications. Medium-term survival in this group is low but mainly due to patient co-morbidities.

Predictors of reintervention after endovascular repair of isolated iliac artery aneurysm.

The objective of this study was to identify factors predicting the need for reintervention after endovascular repair of isolated iliac artery aneurysm (IIAA). We reviewed prospectively collected database records of all patients who underwent endovascular repair of IIAA between 1999 and 2008. Detailed assessment of the aneurysms was performed using computed tomography angiography (CTA). Follow-up protocol included CTA at 3 months. If this showed no complication, then annual duplex scan was arranged. Multivariate analysis and analysis of patient survival and freedom from reintervention were performed using Kaplan-Meier life tables. Forty IIAAs (median diameter 44 mm) in 38 patients were treated (all men; median age 75 years), and median follow-up was 27 months. Endovascular repair of IIAA was required in 14 of 40 aneurysms (35%). The rate of type I endoleak was significantly higher with proximal landing zone (PLZ) diameter >30 mm in the aorta or >24 mm in the common iliac artery or distal landing zone (DLZ) diameter >24 mm (P = 0.03, 0.03, and 0.0014, respectively). Reintervention rate (RR) increased significantly with increased diameter or decreased length of PLZ; increased DLZ diameter; and endovascular IIAA repair (P = 0.005, 0.005, 0.02, and 0.02 respectively); however, RR was not significantly affected by length of PLZ or DLZ. Freedom-from-reintervention was 97, 93, and 86% at 12, 24, and 108 months. There was no in-hospital or aneurysm-related mortality. Endovascular IIAA repair is a safe treatment option. Proper patient selection is essential to decrease the RR.

Results of endovascular repair of abdominal aortic aneurysms with an unfavorable proximal neck using large stent-grafts.

The purpose of this study was to evaluate the early outcome of endovascular repair of abdominal aortic aneurysms (EVAR) with an unfavorable neck anatomy using extralarge stent-grafts. We carried out a retrospective review of all patients who underwent elective EVAR using large diameter stent-grafts between June 2006 and February 2008. All patients had computed tomography angiography (CTA) for procedure planning, and detailed assessment of the aneurysm neck was performed using a three-dimensional CTA workstation. All patients were followed up with CTA at 3 and 12 months and annual duplex thereafter when appropriate. This analysis included 25 patients (23 men, 2 woman; median age, 76 years; age range, 60-88 years). The median aneurysm diameter was 7 cm, and the median aneurysm neck diameter was 31 mm. Extralarge Cook-Zenith stent-grafts were used in all patients, with a top-end diameter of 36 mm (n=23) and 40 mm (n=2). The follow-up period ranged from 3 to 24 months, with a median of 6 months. Primary and assisted primary technical success rates were 80% and 96%, respectively. Reintervention was required to treat proximal type I endoleak (n=1), iliac limb kink (n=2), and occluded femorofemoral crossover graft (n=1). These early results show that EVAR using extralarge stent-grafts with suprarenal fixation can be a reliable modality to treat infrarenal aortic aneurysms with an unfavorable neck anatomy.