Is Mini-Invasive Surgery an Alternative for the Treatment of Juxtarenal Aortic Aneurysms?

INTRODUCTION: Aim of our study is to evaluate the outcomes of mini-laparotomy, suprarenal cross-clamping, and enhanced recovery after elective open surgical repair for juxta-renal abdominal aortic aneurysms (JAAA) in a tertiary referral center. METHODS: Data of all consecutive patients with abdominal aortic aneurysms (AAA) electively treated with left sub-costal mini-laparotomy requiring infrarenal or suprarenal cross-clamping between 2013 and 2018 were retrospectively collected. Patients were divided into two groups: infra-renal cross-clamping (group A) and JAAA requiring supra-renal cross-clamping (group B). Early and mid-term mortality, postoperative renal dysfunction according to RIFLE criteria and factors affecting postoperative outcome were analysed. RESULTS: Four hundred one patients, 356 (88.8%) men, mean age 70.8 yrs, underwent open surgical repair (OSR), 343 (85.5%) AAA in group A, 58 (14.5%) JAAA in group B. Mean diameter of the aneurysms was 54 ± 11.4 mm vs. 52 ± 9 mm and mean time of intervention 154.9 ± 56.3 min vs. 180.1 ± 65.7 min respectively. Total clamp time was 72.27 ± 31.4 vs. 75 ± 33.1 and suprarenal clamp time in group B 27.82 ± 14.1 min. Mean hospital length of stay was 5.1 ± 2.8 vs. 5.37 ± 3.4 days respectively. At 30 days, 3 (0.9%) patients died in group A and no one in group B; at 24 months 7 (2%) deaths in group A and 4 (6.9%) in group B. Preoperative, postoperative and discharge serum creatinine mean value, in group B, were 1.07 ± 0.32, 1.31 ± 0.36 and 1.83 ± 1.24 respectively. Based on RIFLE criteria for renal function, we observed Risk in 14.2% and Injury in 12.7% of patients after suprarenal cross clamping. CONCLUSIONS: Our results show that mini-invasive open repair for JAAA with a suprarenal cross-clamping can be performed with acceptable morbidity and mortality rates similar to traditional surgical approach without significant modifications of renal functions.

Abdominal aortic aneurysm treatment: minimally invasive fast-track surgery and endovascular technique in octogenarians.

BACKGROUND: We conducted a retrospective study on patients aged over eighty who underwent elective surgery for an abdominal aortic aneurysm between January 2006 and December 2010. We compared our results with fast-track abdominal aortic surgery (OPEN group) and with endovascular aneurysm repair (EVAR group). METHODS: We followed 97 consecutive octogenarians affected by abdominal aortic aneurysm who underwent elective surgery. A total of 55 patients were enrolled in the OPEN group (56.7%) and 42 were enrolled in the EVAR group (43.3%). RESULTS: Eight patients (14.5%) in the OPEN group and six patients in the EVAR group (14.2%) received transfusions. None of the patients required admission to the intensive care unit. In total, 53 patients (98%) in the OPEN group and 34 patients (80%) in the EVAR group were able to get up and walk in the afternoon after the end of surgery. The recovery of intestinal transit was on day 2 in the OPEN group and on day 1 in the EVAR group. Patients in both groups were discharged on average on the fourth postoperative day. There were no perioperative mortalities in the OPEN and the EVAR groups. CONCLUSIONS: Minimally invasive treatment with the fast-track protocol and EVAR are both valid options in octogenarian patients because we obtained comparable results in terms of resumption of feeding, early ambulation, days of hospitalization, perioperative rate of mortality and morbidity.

Are abdominal aortic aneurysms with hostile neck really unsuitable for EVAR? Our experience.

OBJECTIVE: To evaluate the effectiveness of endovascular treatment of abdominal aortic aneurysms with hostile neck, comparing the results with those of patients with ideal anatomical conditions. MATERIALS AND METHODS: From January 2005 to December 2013, 300 patients were treated with EVAR at our institution. Patients with a prior Angio-CT scan were included in the study and they were then retrospectively divided into two groups: patients with suitable anatomy that were treated within guidelines of the manufacturers (wIFU: 94 patients, four treated in emergency) and those with unsuitable anatomy that were treated outside of said guidelines (oIFU: 70 patients, 16 treated in emergency). Patients without prior CT study and without follow-up were excluded from the study. RESULTS: Postoperative mortality was 6.3 % in the wIFU group while it was 7.8 % in the oIFU group. There was not a statistically significant difference in the rate of postoperative mortality (p = 0.653). Technical success was 98.6 % in the wIFU group while it was 94.5 % in the oIFU group. All the patients of the wIFU group were treated with a stent-graft with under-renal sealing while in the oIFU group always an over-renal stent-graft was used. No deaths related to the aneurysm were highlighted at follow-up in both groups. There was a statistically significative difference between the two groups regarding intraoperative occlusion of renal arteries (wIFU = 1.1 %; oIFU = 4.7 %; p < 0.05) and in the development of type I endoleak (wIFU = 2.8 %; oIFU = 8.8 %; p < 0.05) CONCLUSION: EVAR in patients with hostile neck is feasible and effective with an acceptable rate of complications.

Fast-track in abdominal aortic surgery: experience in over 1,000 patients.

BACKGROUND: Fast-track recovery programs have led to reduced patient morbidity and mortality after surgery. Minimally invasive surgery and anesthesia, with programs of early postoperative recovery are the main aspects of fast-track recovery programs. The optimization of pain control, early mobilization, and oral feeding allows for a rapid functional rehabilitation, which leads to minor morbidity and early discharge from the hospital to home. METHODS: We enrolled all nonemergent patients treated for elective abdominal aortic surgery for an aneurysm or obstructive disease from April 2000 to June 2014. The fast-track protocol was applied to all these patients. A transperitoneal aortic approach was used through a left subcostal incision and was complemented with epidural anesthesia-analgesia and a protocol of early rehabilitation. RESULTS: A total of 1,014 patients were treated for elective aortic surgery. For 980 patients (96.6%), clear liquids followed by a semisolid diet were tolerated starting on the afternoon of the day of intervention (day 0). Nine hundred eighty-seven patients (97.3%) began early ambulation on day 0, and for 81.2% of the population, regular colonic function returned within the second postoperative day. Seventeen deaths (1.7%) occurred. Nine hundred ten patients (89.7%) had no complications. The median hospital length of stay was 3 days for the entire series, and 80.4% of patients (n = 815) were discharged to their homes between the second and fifth days after surgery. CONCLUSIONS: The fast-track program can be efficiently and safely applied to aortic surgery and that this program improves surgical outcomes, allows for earlier discharge, and reduces costs.

Isolated iliac artery aneurysms: a single-centre experience.

PURPOSE: This paper reviews our experience in endovascular treatment of isolated iliac artery aneurysms (IIAAs) with a large number of patients. MATERIALS AND METHODS: From May 2005 to September 2013, 45 patients (43 men and two women; mean age, 74 ± 10 years) with a total of 59 IIAAs underwent endovascular treatment at our institute. We evaluated technical success, long-term patency, early and late complications and overall mortality. Patients were divided into two groups: emergency-treatment group and elective-treatment group. RESULTS: At a median follow-up of 34.3 months, we achieved a technical success of 97.8 %, a primary patency of 95.5 % and a secondary patency of 100 %, with complete exclusion of the aneurysm in 84.5 % of cases. The incidence of endoleaks was of 15.5 %: eight were type II and one was type III; perioperative mortality was 4.7 %. CONCLUSIONS: Our study documents the effectiveness, in both emergency and elective settings, of the endovascular treatment of iliac aneurysms (EVIAR), which has become the first-choice treatment at our institute. In particular cases, it is also possible to avoid embolisation of the internal iliac artery.

Endovascular treatment of ruptured abdominal aortic aneurysms: is now EVAR the first choice of treatment?

OBJECTIVE: This study was designed to evaluate the effectiveness of endovascular treatment (EVAR) for ruptured abdominal aortic aneurysms (rAAAs). METHODS: Between September 2005 and December 2012, 44 patients with rAAA suitable for endovascular repair underwent emergency EVAR. We did not consider hemodynamic instability to be a contraindication for EVAR. RESULTS: Successful stent-graft deployment was achieved in 42 patients, whereas 2 required open surgical conversion. The overall 30-day mortality was 10 of 44 patients (5/34 in stable patients, 5/10 in unstable patients). Postoperative complications were observed in 7 of 44 patients (16 %): 5 patients developed abdominal compartment syndrome requiring decompressive laparotomy; 1 patient developed bowel ischemia; 1 patient had limb ischemia, and 1 had hemodynamic shock. Mean length of intensive care unit stay was 2.9 (range 2­8) days, and mean length of hospital stay was 8.6 (range 0­18) days. At a mean follow-up of 22.2 (range 1­84) months, the overall incidence of endoleak was 23.5 %: 1 type I and 7 type II endoleaks. CONCLUSIONS: Our study demonstrates that EVAR of rAAA is associated with acceptable mortality and morbidity rates in dedicated centers.

Local versus epidural anesthesia in fast-track abdominal aortic surgery.

OBJECTIVE: The aim of this study was to investigate a possible alternative to epidural anesthesia/analgesia. The authors compared thoracic epidural anesthesia/analgesia with continuous wound infiltration anesthesia/analgesia in patients scheduled for mini-invasive abdominal aortic surgery in a fast-track setting. DESIGN: A prospective randomized study. SETTING: A university hospital. PARTICIPANTS: Sixty patients undergoing fast-track abdominal aortic surgery. INTERVENTIONS: The authors compared thoracic epidural infusion (the PERI group) with continuous local wound infiltration (the LOC group) for anesthesia/analgesia. Pain scores, the resumption of oral feeding, the resumption of ambulation, the day of discharge, and postoperative complications in the immediate (ie, 30 days) and long-term periods (ie, 2 years) were evaluated. MEASUREMENTS AND MAIN RESULTS: Pain scores were low in both groups. The intraoperative LOC group needed higher doses of anesthetic/analgesic drugs. The postoperative LOC group needed significantly higher doses of bupivacaine (3.9 ± 0.7 mL/h [PERI group] and 5.7 ± 1.3 mL/h [LOC group] on day 0 [p < 0.01]; 3.8 ± 0.8 mL/h [PERI group] and 5.3 ± 1 mL/h [LOC group] on day 1 [p < 0.01]). The parameters of postoperative recovery were comparable between the 2 groups in terms of the resumption of ambulation after surgery (within 3 hours), feeding (within 6 hours), the passage of stools (mean 2 days), and the median hospital stay (3 days). In the 2-year follow-up period, a difference between the 2 groups in the incidence of wound complications was not observed. CONCLUSIONS: The results obtained showed good and similar pain control in the 2 groups, but the LOC group required higher doses of anesthetic/analgesic drugs. Parameters of the postoperative recovery were similar in both groups.

The impact of radiological equipment on patient radiation exposure during endovascular aortic aneurysm repair.

OBJECTIVES: To compare the patient radiation dose during endovascular aortic aneurysm repair (EVAR) using different types of radiological systems: a mobile fluoroscopic C-arm, mobile angiographic and fixed angiographic equipment. METHODS: Dose-area products (DAP) were obtained from a retrospective study of 147 consecutive patients, subjected to 153 EVAR procedures during a 3.5-year period. On the basis of these data, entrance surface dose (ESD) and effective dose (ED) were calculated. EVARs were performed using a fluoroscopic C-arm, mobile or fixed angiographic equipment in 79, 26 and 48 procedures, respectively. RESULTS: Fluoroscopy times were essentially equivalent for all the systems, ranging from 15 to 19 min. The clinical outcomes were not significantly different among the systems. Statistically significant differences among radiological equipment grouping were found for DAP (mobile C-arm: 32 ± 20 Gy cm(2); mobile angiography: 362 ± 164 Gy cm(2); fixed angiography: 464 ± 274 Gy cm(2); P < 10(-6)), for ESD (mobile C-arm: 0.18 ± 0.11 Gy; mobile angiography: 2.0 ± 0.8 Gy; fixed angiography: 2.5 ± 1.5 Gy; P < 10(-6)) and ED (mobile C-arm: 6.2 ± 4.5 mSv; mobile angiography: 64 ± 26 mSv; fixed angiography: 129 ± 76 mSv; P < 10(-6)). CONCLUSIONS: Radiation dose in EVAR is substantially less with a modern portable C-arm than with a fixed or mobile dedicated angiographic system. KEY POINTS : • Fluoroscopy during endovascular aortic aneurysm repair can impart a substantial radiation dose. • Radiation doses during EVAR are higher when using mobile/fixed angiographic systems. • Mobile C-arm fluoroscopy imparts a lower dose with an equivalent clinical outcome. • Procedures need to be dose-optimised when using mobile/fixed angiographic systems.

Emergency endovascular treatment of acute symptomatic or ruptured abdominal aortic aneurysm: a single-center experience.

The purpose of this study is to report our early experience with endovascular treatment of patients with symptomatic non-ruptured (sAAA) or ruptured (rAAA) abdominal aortic aneurysms. Between September 2005 and September 2008, all patients with a diagnosis of sAAA or rAAA were evaluated for endovascular suitability. We did not consider hemodynamic instability to be a contraindication for endovascular aneurysm repair (EVAR). Patients whose aneurysm anatomy was not suitable for EVAR received open repair (OR). A total of 46 patients with sAAA or rAAA underwent emergency EVAR: in particular, 18/46 patients were treated for sAAA and 28/46 for rAAA. Successful stent-graft deployment was achieved in 44 patients (96%); we had two open surgical conversions. The 30-day mortality rate was 19.5%. Nine patients died during the first 30 postoperative days: four patients died within 24 hours because of severe hypovolemic shock, two died of respiratory failure, one died as a result of bowel ischemia and two because of myocardial infarction after hospital discharge. Complete follow-up data were available for 35 patients (median 185 days; range 30-730 days). In conclusion, endovascular treatment is feasible and the early experience is promising. The capability of offering EVAR and OR for sAAA and rAAA according to our experience suggests that EVAR and OR should be regarded as complementary techniques to improve outcome of patients with acute AAA.

Endovascular treatment of ruptured abdominal aortic aneurysm with aortocaval fistula.

Aortocaval fistula (ACF) is a rare complication of abdominal aortic aneurysm (AAA). We report the endovascular repair of an AAA rupture into the inferior vena cava. A 78-year-old woman was admitted to our hospital for acute hypotension. She presented with a pulsatile abdominal mass and became rapidly anuric. Abdominal computed tomography (CT) showed an AAA rupture into the inferior vena cava. The features of the AAA made it suitable for endovascular repair. To prevent pulmonary embolism caused by the presence of sac thrombosis near the vena cava lumen, a temporary vena cava filter was deployed before the procedure. A bifurcated stent-graft was placed with the patient under local anaesthesia, and the AAA was successfully treated. A transient type II endoleak was detected on CT 3 days after endograft placement. At routine follow-up 6 and 12 months after the procedure, the patient was in good clinical condition, and the type II endoleak had sealed completely. Endovascular treatment offers an attractive therapeutic alternative to open repair in case of ACF; however, only small numbers of patients have been treated, and long-term follow-up interval is lacking.

Fast-track approach in abdominal aortic surgery: left subcostal incision with blended anesthesia.

OBJECTIVES: The introduction of fast-tracking multidisciplinary programs allows good results in postoperative outcome in many surgical specialties. We evaluated a multimodal clinical program (based on mininvasive surgery, epidural anesthesia and early mobilization and feeding) in abdominal aortic surgery. METHODS: Between June 2000 and October 2005, 323 unselected patients were treated for atherosclerotic aorto-iliac occlusive disease (aorto-femoral bypass) and aortic or aorto-iliac aneurysm (aorto-aortic graft or aorto-iliac bifurcated graft). The infusion of bupivacaine 0.5% through an epidural catheter at T6-T7 interspace allowed sensory block between T4-S3. A light general anesthesia was performed using sevoflurane by a laryngeal mask in spontaneous breathing; no nasogastric tube was used. The patients were placed in dorsal decubitus; a transperitoneal access was performed with a left subcostal incision parallel to the condro-costal edge and spread from the linea alba to the edge of the rectus muscle. The bowel was maintained inside the abdominal cavity and manipulated with care. Standard surgical instrumentation was used. No drains were placed. Patients were transferred to the surgical ward at the end of surgery; they were early mobilized and enforced to drink and to eat. Analgesia was achieved with a continuous epidural infusion of bupivacaine 0.25% supplemented by oral ibuprofen on request. RESULTS: We observed a mortality rate of 2.5% and a low postoperative morbidity: 1.4% of cardiac complications, 3.7% of transient creatinine increase, and no pulmonary complications. All patients ambulated a mean of 536 m (95% CI: 81.4) on the day of surgery and 2544 m (95% CI: 208.9) the day after. They consumed an oral diet, 36.2% of their daily caloric requirement on the same day of surgery and 1583 Kcal (95% CI: 105.2) the day after (77% of daily caloric requirement). Median hospital stay was three days (range 2-21). All patients were discharged home. CONCLUSIONS: Our experience suggested that hospital stay and morbidity after abdominal aortic surgery can be decreased by performing a mininvasive surgical approach, thoracic epidural anesthesia-analgesia and an aggressive postoperative nursing on the ward. Therefore, this multidisciplinary program can be proposed to all patients undergoing aortic surgery without prior selection, major technological investments and long-term surveillance.