Endovascular treatment for ruptured abdominal aortic aneurysm.

BACKGROUND: An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) is a condition that can occur as a person ages. It is most commonly seen in men older than 65 years of age. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, which is fatal unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. Endovascular aneurysm repair (EVAR), a minimally invasive technique, has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. More recently emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in select patients; however, it is unclear if eEVAR will lead to significant improvements in outcomes for these patients or if indeed it can replace conventional open repair as the preferred treatment for this lethal condition. This is an update of the review first published in 2006. OBJECTIVES: To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by comparing the effects of eEVAR and conventional open surgical repair on short-term mortality, major complication rates, aneurysm exclusion (specifically endoleaks in the eEVAR treatment group), and late complications. SEARCH METHODS: For this update the Cochrane Vascular Information Specialist searched the Cochrane Vascular Specialised Register (last searched June 2016), CENTRAL (2016, Issue 5), and trials registries. We also checked reference lists of relevant publications. SELECTION CRITERIA: Randomised controlled trials in which participants with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed studies identified for potential inclusion for eligibility. Two review authors also independently completed data extraction and quality assessment. Disagreements were resolved through discussion. We performed meta-analysis using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. MAIN RESULTS: We included four randomised controlled trials in this review. A total of 868 participants with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low, but we considered one study that performed randomisation in blocks by week and performed no allocation concealment and no blinding to be at high risk of selection bias. Another study did not adequately report random sequence generation, putting it at risk of selection bias, and two studies were underpowered. There was no clear evidence to support a difference between the two interventions for 30-day (or in-hospital) mortality (OR 0.88, 95% CI 0.66 to 1.16; moderate-quality evidence). There were a total of 44 endoleak events in 128 participants from three studies (low-quality evidence). Thirty-day complication outcomes (myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, reoperation, amputation, and respiratory failure) were reported in between one and three studies, therefore we were unable to draw a robust conclusion. We downgraded the quality of the evidence for myocardial infarction, renal complications, and respiratory failure due to imprecision, inconsistency, and risk of bias. Odds ratios for complications outcomes were OR 2.38 (95% CI 0.34 to 16.53; 139 participants; 2 studies; low-quality evidence) for myocardial infarction; OR 1.07 (95% CI 0.21 to 5.42; 255 participants; 3 studies; low-quality evidence) for renal complications; and OR 3.62 (95% CI 0.14 to 95.78; 32 participants; 1 study; low-quality evidence) for respiratory failure. There was low-quality evidence of a reduction in bowel ischaemia in the eEVAR treatment group, but very few events were reported (OR 0.37, 95% CI 0.14 to 0.94), and we downgraded the evidence due to imprecision and risk of bias. Six-month and one-year outcomes were evaluated in three studies, but only results from a single study could be used for each outcome, which showed no clear evidence of a difference between the interventions. We rated six-month mortality evidence as of moderate quality due to imprecision (OR 0.89, 95% CI 0.40 to 1.98; 116 participants). AUTHORS' CONCLUSIONS: The conclusions of this review are currently limited by the paucity of data. We found from the data available moderate-quality evidence suggesting there is no difference in 30-day mortality between eEVAR and open repair. Not enough information was provided for complications for us to make a well-informed conclusion, although it is possible that eEVAR is associated with a reduction in bowel ischaemia. Long-term data were lacking for both survival and late complications. More high-quality randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

Carotid-access transcatheter aortic valve replacement in a patient with a previous mitral valve replacement.

We describe a case of transcatheter aortic valve replacement (TAVR) using carotid artery access and regional anesthesia in a patient with rheumatic heart disease, previous mitral valve replacement, and multiple co-morbidities. It highlights the role of the multidisciplinary Heart Team and multimodality imaging in reaching and implementing an appropriate management plan in this complex patient group.

Endovascular treatment for ruptured abdominal aortic aneurysm.

BACKGROUND: An abdominal aortic aneurysm (AAA) (pathological enlargement of the aorta) can develop in both men and women as they grow older. It is most commonly seen in men over the age of 65 years. Progressive aneurysm enlargement can lead to rupture and massive internal bleeding, a fatal event unless timely repair can be achieved. Despite improvements in perioperative care, mortality remains high (approximately 50%) after conventional open surgical repair. A newer minimally invasive technique, endovascular aneurysm repair (EVAR), has been shown to reduce early morbidity and mortality as compared to conventional open surgery for planned AAA repair. Emergency endovascular aneurysm repair (eEVAR) has been used successfully to treat ruptured abdominal aortic aneurysm (RAAA), proving that it is feasible in selected patients. However, it is not yet known if eEVAR will lead to significant improvements in outcomes for these patients or indeed if it can replace conventional open repair as the preferred treatment for this lethal condition. OBJECTIVES: To assess the advantages and disadvantages of emergency endovascular aneurysm repair (eEVAR) in comparison with conventional open surgical repair for the treatment of ruptured abdominal aortic aneurysm (RAAA). This will be determined by the effect on short-term mortality, major complication rates, aneurysm exclusion, and late complications when compared with the effects in patients who have had conventional open repair of RAAA. SEARCH METHODS: For this update the Cochrane Peripheral Vascular Diseases Group Trials Search Co-ordinator searched the Specialised Register (last searched February 2014) and CENTRAL (2014, Issue 2). Reference lists of relevant publications were also checked. SELECTION CRITERIA: Randomised controlled trials in which patients with a clinically or radiologically diagnosed RAAA were randomly allocated to eEVAR or conventional open surgical repair. DATA COLLECTION AND ANALYSIS: Studies identified for potential inclusion were independently assessed for eligibility by at least two review authors. Data extraction and quality assessment were also completed independently by two review authors. Disagreements were resolved through discussion. Meta-analysis was performed using fixed-effect models with odds ratios (ORs) and 95% confidence intervals (CIs) for dichotomous data and mean differences with 95% CIs for continuous data. MAIN RESULTS: Three randomised controlled trials were included in this review. A total of 761 patients with a clinical or radiological diagnosis of RAAA were randomised to receive either eEVAR or open surgical repair. Overall risk of bias was low but one study did not adequately report random sequence generation, putting it at risk of selection bias, two studies did not report on outcomes identified in their protocol, indicating reporting bias, and one study was underpowered. There was no clear evidence to support a difference between the two interventions on 30-day (or in-hospital) mortality, OR of 0.91 (95% CI 0.67 to 1.22; P = 0.52). The 30-day complications included myocardial infarction, stroke, composite cardiac complications, renal complications, severe bowel ischaemia, spinal cord ischaemia, re-operation, amputation, and respiratory failure. Individual complication outcomes were reported in only one or two studies and therefore no robust conclusion can currently be drawn. For complication outcomes that did include at least two studies in the meta-analysis there was no clear evidence to support a difference between eEVAR and open repair. Six-month outcomes were evaluated in only a single study, which included mortality and re-operation, with no clear evidence of a difference between the interventions and no overall association. Cost per patient was only evaluated in a single study and therefore no overall associations can currently be derived. AUTHORS' CONCLUSIONS: The conclusions of this review are currently limited by the paucity of data. From the data available there is no difference in the outcomes evaluated in this review between eEVAR and open repair, specifically 30-day mortality. Not enough information was provided for complications in order to make a well informed conclusion at this time. Long-term data are lacking for both survival and late complications. More high quality, randomised controlled trials comparing eEVAR and open repair for the treatment of RAAA are needed in order to better understand if one method is superior to the other, or if there is no difference between the methods on relevant outcomes.

Femoral nerve compression after migration of bone cement to the groin after hip arthroplasty.

Although often a benign complication of total hip arthroplasty, cement extrusion can cause nerve, vessel, and organ compression. We report the case of a 70-year-old male patient in whom an extruded cement mass migrated anteriorly and compressed the femoral nerve and impinged on the femoral artery producing acute, severe groin pain with neuralgia 9 years postoperatively. Paresthesia of the anterior and medial thigh was found on examination. Radiographic, ultrasound, and computed tomographic studies confirmed a 6 × 1.5-cm mass of bone cement in the right groin compressing the femoral nerve that was removed successfully at surgery. Six months postoperatively, the patient's pain had resolved, but hyperesthesia of the medial thigh remained.

Effect of suprarenal fixation of aortic stent-grafts on the renal artery ostia: assessment of morphological changes by virtual intravascular endoscopy.

PURPOSE: To investigate the morphological effects of suprarenal fixation of aortic stent-grafts on the renal artery ostia (RaO) by analysis of suprarenal stent wire distribution and vascular calcification across the RaO using virtual intravascular endoscopy (VIE). METHODS: Fourteen consecutive patients (11 men; mean age 75 years) from a single institution were studied following endovascular aortic aneurysm repair (EVAR) using the Zenith endograft system from September 1999 to March 2002. Imaging assessment included computed tomographic (CT) measurement of renal artery intraluminal ostial diameter and quantification and analysis of uncovered stent struts across the RaO and radiological determination of RaO calcification. Morphological changes following EVAR at 3 time points (before and within 1 week after stent-grafting, and at the most recent follow-up) were compared for each patient to determine whether suprarenal stent struts or RaO calcification affected intraluminal ostial diameter. Renal function was assessed by temporal measurements of serum creatinine concentration and creatinine clearance. RESULTS: The renal ostium was distorted to variable degrees in all cases at a mean follow-up of 41+/-6.6 months. An increase in ostial diameter was identified in most patients if the right RaO was calcified when comparing the 1-week postoperative and most recent follow-up CT images (p<0.05). There was no direct relationship between the number of stent struts crossing the RaO and the morphological/dimensional changes (p>0.05). Renal function was not significantly affected. CONCLUSION: Patients undergoing suprarenal fixation of aortic stent-grafts experienced morphological changes of the RaO to a variable extent at midterm follow-up. Although the presence of stent struts did not significantly affect dimensional changes, we observed that calcification at the renal artery ostium may influence the development of atherosclerotic effects as a direct relationship between the calcification and ostial diameter. Future studies utilizing VIE to determine the long-term safety of this technique in these particular patients requires investigation.

Suprarenal fixation of endovascular aortic stent grafts: assessment of medium-term to long-term renal function by analysis of juxtarenal stent morphology.

OBJECTIVE: The effect of suprarenal stent fixation during endovascular aortic aneurysm repair (EVAR) on renal function remains unclear. A unique validated three-dimensional intraluminal imaging technique was used to analyze the effect of suprarenal stent position relative to renal artery orifices. Also analyzed was its medium-term to long-term effects on renal function. METHODS: The study cohort comprised 29 of 34 consecutive patients who underwent EVAR with the Zenith endograft system from September 1999 to March 2002 at a single institution. The precise locations of the uncovered suprarenal stent struts were assessed by a virtual endoscopic imaging technique. Anatomic and quantitative categorization of patients was made according to the configuration of uncovered stent struts across the renal artery ostia (RAO). The anatomic subgroups were defined as struts located centrally or peripherally across both RAO. The quantitative subgroups were defined as RAO crossed by multiple struts, a solitary strut, or no struts. The subgroups were compared for their renal function, as assessed by temporal measurements of serum creatinine concentration and creatinine clearance, and renal parenchymal perfusion defects, as assessed using contrast-enhanced computed tomography (CT). RESULTS: Mean follow-up was 52.7 months. Separate subgroup analysis for both anatomic and quantitative configurations did not demonstrate any significant difference in renal function between the different strut permutations (P > .05). Follow-up imaging confirmed one case of renal infarction secondary to an occluded accessory renal artery, although this patient had normal serum creatinine levels. CONCLUSION: RAO coverage by suprarenal uncovered stents does not appear to have a significant effect on renal function as evaluated by creatinine measurements in patients with normal preoperative renal function.

Prosthetic stent graft infection after endovascular abdominal aortic aneurysm repair.

OBJECTIVE: The purpose of this report is to discuss the incidence, diagnosis, and management of stent graft infections after endovascular aneurysm repair (EVAR). METHODS: Data were collected from the hospital database and medical case notes for all patients with infected endografts after elective or emergency EVAR for abdominal aortic aneurysm (AAA) during the last 8 years in two university teaching hospitals in Northern Ireland. The data included the patient's age, gender, presentation of sepsis, treatment offered, and the ultimate outcome. The diagnosis of graft-related sepsis was established by a combination of investigations including inflammatory markers, labelled white cell scan, computed tomography (CT) scan, microbiology cultures, and postmortem examination. RESULTS: Graft-related septic complications occurred in six of 509 patients, including 433 elective repairs and 76 emergency endografts for ruptured AAA. Two patients presented with left psoas abscess and were treated successfully with extra-anatomic bypass and removal of the infected stent graft. Two more patients presented with infected graft without other evidence of intra-abdominal sepsis: one underwent successful removal of the infected prosthesis with extra-anatomical bypass, and the other was treated conservatively and died of progressively worsening sepsis. The fifth patient presented with unexplained fever and died suddenly, with a postmortem diagnosis of aortoenteric fistula and ruptured aneurysm. The last patient presented with an aortoenteric fistula, was treated conservatively in view of concurrent myelodysplasia, and died of possible aneurysm rupture. CONCLUSION: This report emphasizes the need for continued awareness of potential graft-related septic complications in patients undergoing EVAR of AAA. Attention to detail with regard to sterility and antibiotic prophylaxis during stent grafting and during any secondary interventions is vital in reducing the risk of infection. In addition, early recognition and prompt treatment are essential for a successful outcome.

The use of direct thrombin injection to treat a type II endoleak following endovascular repair of abdominal aortic aneurysm.

This report describes the use of thrombin to treat a type II endoleak which was causing continued abdominal aortic aneurysm expansion in a patient who had undergone endovascular repair. A small quantity of thrombin was injected into the leak by a percutaneous approach directly into the aneurysm sac using color doppler ultrasound. The procedure was successful and required only a few minutes to perform. We believe this procedure is an alternative to some of the more complex and technically challenging means of treating this lesion.