Surgical therapy of extracranial carotid artery aneurysms: long-term results over a 24-year period.

BACKGROUND: To evaluate long-term results of surgical therapy of extracranial carotid artery aneurysms (ECCA) and to provide a morphologic classification for individual surgical reconstruction techniques. PATIENT AND METHODS: This retrospective analysis includes 57 patients (43 male, mean age 61.9 years.) with 64 carotid reconstructions for ECCA between 1980 and 2004. In 29 (50.9%) of the patients there was found a cerebral ischemic event as an initial symptom (18 transient ischemic attacks, 11 strokes). In patients without cerebral events, the presenting symptom was pulsatile cervical mass in 19 and cranial nerve dysfunction in 3 cases. ECCA was morphologically stratified in Type I=isolated aneurysms of the internal carotid artery (n=25), Type II=aneurysms of the complete internal carotid artery with involvement of the bifurcation (n=8), Type III=aneurysms of the carotid bifurcation (n=20), Type IV=combined aneurysm of the internal and common carotid artery (n=5) and Type V=isolated aneurysm of the common carotid artery (n=6). RESULTS: Perioperative stroke rate was 1.6%. 4 patients suffered from transient ischemic attacks (6.3%). Permanent and transient cranial nerve injury rate was 6.3% and 20.3% respectively. After 5, 10, 15 and 20 years the actuarial survival was 90%, 77%, 65% and 57%. The ipsilateral stroke-free time was 96%, 96%, 93% and 87%, respectively. CONCLUSIONS: Surgical reconstruction of extracranial carotid aneurysms is a safe procedure with good long-term results. The risk of a permanent, perioperative cerebral neurological deficit is low, but there is a considerable risk of cranial nerve injury.

The visceral hybrid repair of thoraco-abdominal aortic aneurysms--a collaborative approach.

OBJECTIVE: To report the collaborative data of 3 major European Vascular Units using the 'visceral hybrid' procedure for thoraco-abdominal aortic aneurysms and dissections. METHODS: A consecutive series of 107 urgent and elective high-risk patients were included in a prospectively collected database. RESULTS: All stents involved the entire thoracic and abdominal aorta with left subclavian coverage in 19 and revascularisation in 12. The distal landing zone was in the infra-renal aorta in 75% and in the iliac artery in 25%. The 30-day mortality rate was 16/107 (14.95%). 13/107 (12.1%) of the patients suffered spinal cord ischaemia which was complete and permanent in 9/12 (8.4%). 4 patients (3.7%) required long term dialysis and a segment of gut infarction requiring resection occurred in 3 (2.8%). Most patients had visceral bypass grafting and aortic stent-grafting performed in one stage. In 18 patients the stenting was performed later. Three of these patients ruptured before the stenting procedure was undertaken. CONCLUSION: These early results of visceral hybrid repair for high-risk patients with complex thoraco-abdominal aortic aneurysms are encouraging, in a group of patients in whom fenestrated/branched stent-grafting is not an option and open surgery hazardous.

30 day results from the SPACE trial of stent-protected angioplasty versus carotid endarterectomy in symptomatic patients: a randomised non-inferiority trial.

BACKGROUND: Carotid endarterectomy is effective in stroke prevention for patients with severe symptomatic carotid-artery stenosis, and carotid-artery stenting has been widely used as alternative treatment. Since equivalence or superiority has not been convincingly shown for either treatment, we aimed to compare the two. METHODS: 1200 patients with symptomatic carotid-artery stenosis were randomly assigned within 180 days of transient ischaemic attack or moderate stroke (modified Rankin scale score of < or =3) carotid-artery stenting (n=605) or carotid endarterectomy (n=595). The primary endpoint of this hospital-based study was ipsilateral ischaemic stroke or death from time of randomisation to 30 days after the procedure. The non-inferiority margin was defined as less than 2.5% on the basis of an expected event rate of 5%. Analyses were on an intention-to-treat basis. This trial is registered at Current Controlled Trials with the international standard randomised controlled trial number ISRCTN57874028. FINDINGS: 1183 patients were included in the analysis. The rate of death or ipsilateral ischaemic stroke from randomisation to 30 days after the procedure was 6.84% with carotid-artery stenting and 6.34% with carotid endarterectomy (absolute difference 0.51%, 90% CI -1.89% to 2.91%). The one-sided p value for non-inferiority is 0.09. INTERPRETATION: SPACE failed to prove non-inferiority of carotid-artery stenting compared with carotid endarterectomy for the periprocedural complication rate. The results of this trial do not justify the widespread use in the short-term of carotid-artery stenting for treatment of carotid-artery stenoses. Results at 6-24 months are awaited.

An unusual cause of peripheral artery embolism: floating thrombus of the thoracic aorta surgically removed.

Intraluminal mobile thrombus of the descending aorta are rare disorders. They are at high risk for peripheral embolism and therefore indication for treatment is mandatory. We report on a 54-year-old patient with peripheral arterial embolization who was treated by surgical thrombus removement by thoracotomy and staged peripheral bypass grafting. New diagnostic tools are presented, therapy and prognosis are discussed.

Intermittent claudication secondary to a traumatic arteriovenous fistula.

Arteriovenous fistula (AVF) formation is a recognized complication of arterial trauma. A 63-year-old man with no known risk factors for atheroma and a history of a 20-year delay in the diagnosis and treatment of a traumatic AVF presented with right calf claudication (maximal walking distance = 150 m). A duplex ultrasound scan and a magnetic resonance angiography showed an aneurysmatic dilatation and partial thrombosis of the infrarenal aorta and the right leg feeding arteries. Selective angiography revealed a complete occlusion of the right popliteal artery in the segment 2 and the infrapopliteal arteries with good collateral formation in the lower leg. At this time, there is no indication for infragenual arterial revascularisation in this patient. Instead, therapy consists of exercise training and antiplatelet therapy. We concluded, that peripheral microembolism from the aneurysmatic aorta, iliac or femoral arteries is most probably the reason for the popliteal occlusion in this patient, representing a rare, nonatherosclerotic cause of claudication.

[Leiomyosarcoma of the inferior vena cava]. / Leiomyosarkom der V. cava inferior.

Leiomyosarcomas of the inferior vena cava are rare and the clinical symptoms unspecific. We report a case of leiomyosarcoma of the inferior vena cava in an 82-year-old woman presenting with weight loss and abdominal pain. Following elaborate preoperative examinations, surgical resection was performed and the inferior vena cava was reconstructed. Clinical signs, diagnosis, therapy, and prognosis are discussed.

Hybrid aortic procedures for endoluminal arch replacement in thoracic aneurysms and type B dissections.

The aim of this study was to report our clinical experience with and review current literature on endoluminal aortic hybrid techniques and to evaluate outcome in high-risk patients treated for complex aortic arch lesions combining conventional supra-aortic debranching bypasses with subsequent or staged thoracic endovascular grafting. Of 172 patients treated with thoracic endografts for different thoracic aortic pathologies within the last 8 years, the mid-aortic arch was involved in 25, i.e. at least the left common carotid artery had to be overstented and revascularized to provide a proper proximal landing zone. These debranching bypasses were performed as a simultaneous or a staged procedure. All patients were at high-risk and were excluded by cardiac surgeons as ineligible for conventional arch repair. After partial (n=16) or complete (n=9) supra-aortic transposition, 4 different commercially available endografts (80% TAG, WL Gore) were implanted transfemorally or via iliac conduit. Deployment success was 100% in 25 patients after simultaneous or staged supra-aortic transposition; in 32% an emergency procedure was performed due to contained rupture; in 36% more than 1 endograft system was implanted (2 in 20%, 3 in 8% und 4 in 8%). The overall perioperative thirty-day mortality was 5 of 25 (20%) due to interoperative proximal bare stent perforation (n=1), transfusion related acute lung injury (TRALI n=1), cardiac failure (n=1), embolic stroke (n=1) and pneumonia (n=1). The mean follow-up was 21 months. All endoleaks type I (n=3) were corrected with another endograft; the 2 endoleaks type II sealed spontaneously. The major adverse events were: prolonged ventilation in 5 (20%), temporary renal insufficiency with hemodialysis (n=2), bypass infection (n=1), without any complications (n=9). No cases of paraplegia were recorded. Hybrid aortic arch repair is technically challenging but feasible. This novel approach may be an alternative to standard open procedures in high-risk patients and emergency cases. However, the promising early results need to be confirmed by longer follow-up and larger series.

[Vascular surgery in the elderly]. / Gefässchirurgie im Alter.

The prevalence of vascular disease among the elderly population is high (approximately 20%). The morbidity and mortality of many vascular operations show no differences between the fit elderly and younger patients. A major problem is that the elderly are often not diagnosed and treated early enough to prevent emergency operations, which carry a much higher mortality. Many new surgical techniques, especially endovascular interventions, have made vascular surgery less invasive. These advances have increased the potential of life saving and prolonging vascular surgery that can be offered to all patients regardless of age. Risk-benefit analysis, especially in elderly patients, is a cornerstone of proper patient selection. The main goal of vascular surgery in the elderly is preservation of quality of life and independence. Surgery of a ruptured aneurysm is a life saving exception. Indications for treatment in the elderly remains an individual decision making process. Advanced age should not be considered as a limitation or contraindication for carotid, aneurysm and bypass surgery. Age is not a disease, it is just a chapter of life.

[Early transfer from intensive care does not influence clinical results of carotid endarterectomy]. / Limitierte Uberwachung nach Karotisthrombendarteriektomie. Frühverlegung aus der Uberwachungseinheit beeinflusst nicht das klinische Ergebnis.

The purpose of this prospective observational study was to examine the necessity of intensive care after carotid endarterectomy (CEA). In consideration of the neurological stage and comorbidities, morbidity and mortality after early transfer from the intensive care unit (ICU) were examined. The CEA patients were assigned preoperatively to short or long monitoring. Those with symptomatic stenosis ranking > or =2 (stroke within 6 weeks before surgery) and ischemic areas in cCT were observed overnight (long) in the ICU. Within 5.5 months, 100 consecutive patients had received 107 CEAs. Preoperatively, seven of these (6.54%) were assigned to ICU overnight monitoring. 14 patients (13%) needed postoperative over night ICU. We observed no perioperative stroke or mortality in the 107 consecutive CEAs. We could not detect any risk factor in preoperatively determining the length of postoperative ICU monitoring. This prospective, single center study showed that, after CEA, it is safe to monitor patients for only a short period (4-8 h) in the ICU. Morbidity and mortality after early transfer to the regular ward did not increase.

Predictive value of exercise renography for presurgical evaluation of nephrogenic hypertension.

Functional omicron-iodohippurate scintigrams were obtained in 18 hypertensive patients. Each patient was examined in the prone position and during exercise. An exercise-induced transient, bilateral, hippurate transport disturbance was sought as an expression of an exercise-mediated cortical perfusion abnormality. The study sought to test the hypothesis that patients who present evidence for an exercise-induced renal perfusion disturbance would have stabilized hypertension that was no longer surgically curable because of morphological changes of the peripheral vasculature. All 18 patients continued on to therapy: 13 proceeded to renovascular reconstructive surgery, 2 had a unilateral nephrectomy, and 3 were treated with percutaneous transluminal renal angioplasty. During preoperative exercise renography, evidence of bilateral renal dysfunction developed in 10 of 18 hypertensive patients during ergometric stress (abnormal exercise response). Following surgical therapy nine of these patients with abnormal exercise scintigrams continued to have hypertensive disease, while one patient was cured. The exercise renograms of eight hypertensive patients were not influenced by the exercise protocol, and operation cured seven of these eight patients. The results suggest that an accentuated vascular response to exercise occurs in the maintenance phase of renovascular hypertension, a disturbance not observed while the hypertension is curable by surgical therapy.

Abdominal aortic aneurysm. Detection of multilevel vascular pathology by time-resolved multiphase 3D gadolinium MR angiography: initial report.

OBJECTIVE: To evaluate multiphasic 3D gadolinium-enhanced magnetic resonance angiography (3D-Gd-MRA) for detection of vascular pathology at multiple levels of the aorta and iliac arteries. METHODS: In 18 patients with abdominal aortic aneurysm (n = 13), dissection (n = 3), or both (n = 2), multiphase 3D-Gd-MRA was performed acquiring five consecutive (6.8 seconds) 3D data sets in a single breath-hold. In each of the five time-resolved phases, vessel visibility of the abdominal aortic branches and iliac arteries was assessed. The extent of vessel involvement by the aneurysm or dissection seen on multiphase 3D-Gd-MRA was compared with standard imaging and surgical findings. Digital subtraction angiography was available for comparison in 4 cases, CT angiography in 10 cases. RESULTS: Due to the delayed filling of the aortic aneurysm, the proximal aortic branches and the aneurysm neck demonstrated an inversely related enhancement compared with the distal abdominal and iliac vessels (P < 0.001). Review of all five phases of multiphase 3D-Gd-MRA allowed optimal visualization of each vessel segment without any artifacts due to parenchymal or venous overlay. In dissections, review of three phases was required (P < 0.001) for diagnostic evaluation of the true and false lumens. Substantially more vessel involvement was detected on multiphase 3D-Gd-MRA; this was surgically confirmed in 10 of 11 cases and affected therapy management in 11 of 18 cases. CONCLUSIONS: Multiphase 3D-Gd-MRA is a convenient, robust, and safe technique for presurgical anatomic mapping of complex aortic aneurysms and dissections.

High prevalence of peripheral arterial disease and low treatment rates in elderly primary care patients with diabetes.

Representative data on peripheral arterial disease (PAD) in community-based office practice are scarce while at the same time of high interest. Thus, we aimed to determine the prevalence of peripheral arterial disease (PAD), comorbidity of atherothrombotic manifestations, and treatment intensity among elderly diabetic patients in primary care. In this monitored cross-sectional study, 344 general practitioners throughout Germany determined the ankle-brachial index (ABI) of 6880 consecutive, unselected patients aged 65 years or older with bilateral Doppler ultrasound measurements. PAD was defined according to the recent American Heart Association guidelines (using the higher of the 2 systolic ankle pressures: ABI < 0.9) or peripheral revascularisation, or amputation because of PAD. Coronary events (CAD) and cerebrovascular events (CVD) were taken from the patient's history without additional diagnostic measures. Diabetes was defined according to the clinical diagnosis of the physician and/or HbA1c > or = 6.5 % and/or intake of oral antidiabetic medication and/or application of insulin. 1.743 patients were classified as diabetics: the median disease duration was 6 years (1st; 3rd quartile: 2; 11), median HbA1c 6.6 % (5.9; 7.3), mean age 72.5 +/- 5.4 years, and 51.4 % were females. Diabetics had in comparison with non-diabetics a higher prevalence of PAD defined as ABI < 0.9 (26.3 % vs. 15.3 %, univariate odds ratio 2.0 [95 % confidence interval: 1.7; 2.3]), intermittent claudication (5.1 % vs. 2.1 %, OR: 2.5 [1.9; 3.4]), known CAD (16.1 % vs. 10.6 %, OR: 1.6 [1.4; 1.9]), and known CVD (6.8 % vs. 4.8 %; OR: 1.4 [1.2; 1.8]). 57.4 % of the diabetics with previously known PAD (as only atherothrombotic manifestation) received antiplatelet therapy (vs. 75.1 % with CAD and/or CVD only). The ABI was suitable as screening measure in the primary care setting. In elderly diabetics in comparison to non-diabetics, the prevalence of PAD was very high. Despite the known benefits of antiplatelet therapy, PAD patients were less intensively treated than patients with CAD or CVD.

The value of preoperative lytic therapy in limb-threatening acute ischemia from popliteal artery aneurysm.

In a retrospective study, we analyzed our experiences in 24 patients with acute ischemia from popliteal artery aneurysms over a period of 27 years and evaluated the value of a preoperative lytic therapy as an adjunct to surgical revascularization, compared to surgery alone. Preoperative urokinase therapy revealed a satisfactory improvement of the runoff in all cases. Follow-up angiography showed complete lysis in 6 and incomplete lysis in 3 of 9 patients. In contrast, in patients treated by surgery alone, postoperative angiography showed residual clots in all cases. The overall amputation rate was 25% (6/24) in 24 popliteal aneurysms with acute ischemia, including four patients with primary amputation for irreversible gangrene. Bypass grafting alone resulted in an early amputation rate of 9% (1/11) and occlusive complications of 45% (5/11) compared to no limb loss and no bypass complication in patients who underwent combined surgery and preoperative lysis (0/9). Our results underline the value of preoperative lytic therapy as an important factor in the management of acute ischemia in popliteal artery aneurysms.

Degree of carotid artery stenosis. Comparison of selective and non-selective angiographic findings with surgical specimens.

OBJECTIVE: To compare the degree of vessel narrowing seen on selective and non-selective carotid artery catheter angiograms using criteria set by NASCET and ECST with the results obtained from corresponding surgical specimens. SUBJECTS: In 40 preoperative angiograms (20 non-selective, 20 selective) the 'distal' degree of internal carotid artery (ICA) stenosis according to NASCET criteria and the 'local' degree of stenosis according to ECST criteria was assessed. These data were compared with the 'distal' and 'local' degree of ICA stenosis obtained by measuring the specimens and the diameter of the distal ICA intraoperatively. RESULTS: The median 'local' degree of stenosis was 86.5% in the specimen and 83.5% in the selective angiograms (difference not significant). In non-selective angiography the median 'local' degree of stenosis was 77.5% compared to 84% in the corresponding specimens (P < 0.01). The median 'distal' degree of stenosis in selective angiography was 76.5 versus 75.5% in the specimens (n.s.). The median 'distal' degree of non-selective angiography was 67% compared to 77.5% in the corresponding specimens (P = 0.02). The trend to underestimate high grade stenosis (above 90%) was more pronounced in non-selective than in selective angiography. Medium grade stenosis (60-80%) was slightly overestimated in selective angiography. CONCLUSION: Selective angiography is more accurate in determining the 'true' degree of stenosis in internal carotid artery disease, taking into account a slight overestimation of medium grade stenosis. High grade stenosis is underestimated in both selective and non-selective angiography. These observations extend to both the ECST and NASCET criteria of measuring the degree of stenosis, which differ by about 10%.

[The accuracy of angiography and CT angiography of the carotid bifurcation compared to macro-morphological correlation]. / Genauigkeit der Angiographie und CT-Angiographie der Karotisbifurkation im Vergleich mit dem makromorphologischen Korrelat.

PURPOSE: To compare the degree of carotid artery stenosis in angiography and CT angiography with the degree of stenosis measured in an intact eversion endarterectomy specimen. METHODS: Preoperative angiograms (intraarterial DSA, 512 x 512 matrix) and CT-angiograms (24 sec spiral scan, slice thickness 2 mm, pitch 1.5) were taken in 12 patients with symptomatic carotid stenosis. Evaluation of the degree of stenosis was performed according to the NASCET ("distal" degree) and ECST ("local" degree) methods. These data were compared with measurements of the surgical specimens. RESULTS: The median "local" degree of stenosis in angiograms was 81.5% (range: 70-99%), in CT angiograms 83% (59-94%) and in specimens 85.5% (65-96%). The "distal" degree of stenosis was 79% (50-99%) in angiograms, 85.5% (55-99%) in CT angiograms and 81% (52-95%) in specimens. CT angiography slightly overestimated the degree of stenosis compared with the specimen, whereas angiography slightly underestimated the true degree of stenosis. However, these differences were not statistically significant. CONCLUSION: CT angiography is able to predict the degree of internal carotid stenosis when compared with an intact surgical specimen. It is as accurate as the "gold standard" of invasive angiography.

Renal MR angiography.

Three-dimensional gadolinium MR angiography (3D-Gd-MRA) accurately visualizes the renal arteries with almost no degradation from inplane saturation or motion artifacts. The diagnostic accuracy for detecting and grading of renal artery stenosis, as well as the assessment of other vascular pathology, approaches that of conventional x-ray angiography. For the renovascular system, this technique requires precise contrast media bolus timing since multiple successively enhancing structures are present. Details on performing renal MR angiography, strategies for image analysis, and examples of common renal vascular pathology are reviewed. The 3D-Gd-MRA protocol can be easily combined with other MR imaging techniques to provide a comprehensive assessment of the hemodynamic and functional significance of renal artery stenosis.

[Determination of the degree of stenosis of the internal carotid artery in the surgical specimen after eversion TEA: comparison with angiography and c-w-Doppler ultrasound]. / Bestimmung des Stenosegrades der A. carotis interna am Operationspräparat nach Eversions-TEA: Vergleich mit Angiographie und c-w-Doppler-Sonographie.

UNLABELLED: 22 carotid specimens following eversion-endarterectomy were compared with preoperative assessment of carotid stenosis obtained angiographically and by c-w-Doppler-sonography. The intact, unsplit specimens were perfused with a liquid plastic material (Palavit M). After hardening of the plastic material the specimens were removed. The local degree of carotid stenosis with respect to diameter reduction was assessed by direct measurement of the plastic specimens at the narrowest site compared with the diameter of the carotid eversion specimens at the place of the maximum stenosis. The distal degree of carotid stenosis was assessed by comparison of the diameter of the distal internal carotid artery obtained intraoperatively with the measurements of the plastic specimens (1 mm vascular wall thickness of distal internal carotid artery was taken into account). RESULTS: Both the local and the distal degree of carotid stenosis diameter (mean 84.7% +/- 8.4% and 82.1% +/- 9.1% respectively) were underestimated in the preoperative angiogram (79.8 +/- 9% by ECST-criteria and 69 +/- 10.3% by NASCET-criteria) in most of the cases. The difference of the diameter reduction was statistically significant (p < 0.05 and p < 0.01 respectively, Wilcoxon signed rank test). The c-w-Doppler assessments were 82.6 +/- 8.2% (n.s.). CONCLUSION: Our results suggest that the preoperative assessment of internal carotid stenosis obtained angiographically or by c-w-Doppler-sonography easily underestimate the true degree of carotid stenosis.

Localisation of protein Z in vascular lesions of patients with atherosclerosis.

BACKGROUND: The deposition of protein Z was investigated in atherosclerotic vascular lesions of patients with diabetes mellitus or atherosclerotic vascular disease without diabetes in comparison to controls. PATIENTS AND METHODS: Protein Z antigen was evidenced by immunohistochemistry in arteries of 5 healthy control patients, 11 diabetic patients with arterio-occlusive disease and 7 patients suffering from arterio-occlusive disease without diabetes. For immunohistochemistry, a commercially available antibody was taken as first antibody, and immunopositivity was evaluated independently by two investigators (J.G.; I.K.) as negative (0), positive (+) and strongly positive (++). The results were assessed by the Whitney-Mann-Wilcoxon test. RESULTS: Macrovascular endothelial cells were stained positive for protein Z in all arteries studied. Arteries of controls did not show significant immunopositivity in cells other than macrovascular endothelial cells, while the microvascular endothelial cells of control arteries were largely negative. The proliferating subendothelial space in atherosclerotic vascular lesions showed significant immunopositivity for protein Z. In contrast to control arteries, the microvascular endothelial cells of the proliferating areas stained positive. The staining pattern of the subendothelial space was similar in atherosclerotic vessels independent of the risk factor for atherosclerosis. Plaques were immunopositive for protein Z, too. CONCLUSIONS: Protein Z is present in atherosclerotic vascular lesions of diabetic and non-diabetic patients, but not in the subendothelial space and microvascular endothelial cells of healthy controls. Since protein Z-positivity was detected in microvascular endothelium as well as in extra-vascular deposits around plaques, it may play a role in the development of these lesions.

[Endovascular and open reconstructive surgery of renal artery lesions]. / Endovasculäre und offene rekonstruktive Chirurgie der Nierenarterienläsion.

Besides antihypertensive drug treatment and reconstructive surgery, the percutaneous transluminal angioplasty became an established treatment modality for renal artery stenosis since the late 70's. The treatment aimed at curing the renovascular hypertension, at normalizing and improving of both compensated and decompensated renal insufficiency in order to avoid prolonged hemodialysis after acute renal failure. Endovascular procedures contributed significantly to reach a normotensive state, particularly in cases with renal artery stenosis concomitant with fibromuscular dysplasia and gives similar results as open surgical methods if certain morphological features are considered. However, surgery is generally more effective than endoluminal treatment when all forms of renal artery stenosis are considered together. This holds true in particular for ostial stenosis, complete obstruction of the renal artery, aneurysms and a multitude of rare renovascular diseases. Surgery should be first line treatment to preserve or improve the renal function. According to the pertinent literature, endovascular methods should be considered first for the treatment of renovascular hypertension. Despite the frequent repetition of potential advantages of PTA, a first direct comparison of both modalities demonstrated better primary results after surgical treatment. Even the total cost were similar since PTA requires frequent follow-up with short intervals necessitating secondary interventions.

[Endovascular reconstruction of infrarenal abdominal aortic aneurysm]. / Endovasculäre Rekonstruktion des infrarenalen abdominellen Aortenaneurysmas (AAA).

Animal experiments in the 80's demonstrated the feasibility of the concept first inaugurated by Dotter in 1969 of the endovascular implantation of a stent-graft prosthesis for the treatment of abdominal aortic aneurysm. In September 1990 Parodi was the first to treat a patient with an AAA using the implantation of a TPEG (transluminal placed endovascular stented graft). The rapid development of a variety of different devices can be observed since resulting in about 400 such prosthesis being implanted world wide for the treatment of AAA. The experience accumulated so far shows that severe complications can be avoided if morphology-based criteria are considered for the various treatment options (AAA classification type I, type IIa-c, type III). Despite considerable lethal incidents, technical mishaps and severe complications to date, the potential of TPEG for a structured approach to the treatment of AAA has to be evaluated. Prerequisites are 1) a competent team based on a close mutual cooperation of vascular surgeons and interventional radiologists, 2) a careful selection of patients, 3) TPEG to be performed in especially equipped operation theatres permitting the immediate application of conventional surgery if necessary, and 4) the implantation to be performed as a clinical study with flawless documentation of the procedure and follow-up.