Long-term results after endovascular abdominal aortic aneurysm repair using the Cook Zenith endograft.

OBJECTIVE: This study assessed the long-term outcome of patients with abdominal aortic and aortoiliac aneurysms treated with the Cook Zenith endovascular graft (Cook Inc, Bloomington, Ind). METHODS: Between September 1998 and October 2003, 143 patients underwent elective endovascular aneurysm repair (EVAR) using the Cook Zenith endograft. Data from these patients were reviewed from a prospective database in October 2008. Primary outcome measures were overall survival, intervention-free survival, and freedom from aneurysm rupture. Secondary outcome measures were early and late postoperative complications, including endoleaks. RESULTS: Mean follow-up was 66.4 months (range, 1.9-121.0 months). Overall survival was 72.1% at the 5-year follow-up and 50.9% at the 8-year follow-up. Intervention-free survival was 77.1% at 5 years and 63.8% at 8 years. There were no reintervention-related deaths. Six patients had a late aneurysm rupture, which was fatal in three. Freedom from aneurysm rupture was 98.1% at 5 years and 91.0% at 8 years. Late complications occurred throughout the follow-up period, with a tendency for aneurysm rupture and surgical conversion to occur at a later stage in the follow-up period. Aneurysm sac enlargement during follow-up was associated with late aneurysm rupture and with the need for reintervention. CONCLUSION: Elective EVAR using the Cook Zenith endograft provides excellent results through a mean follow-up of >5 years. There is a low aneurysm-related mortality and an acceptable rate of postoperative complications and reinterventions. The occurrence of late complications throughout the follow-up period stresses the need for continued postoperative surveillance in EVAR patients.

Esophageal necrosis after endoprosthesis for ruptured thoracoabdominal aneurysm type I: can long-segment stent grafting of the thoracoabdominal aorta induce transmural necrosis?

BACKGROUND: To study the pathophysiology of esophageal necrosis after endoprosthesis was performed for a ruptured aneurysm and to define preventive measures and possible treatment options. METHOD: A 72-year-old man with thoracoabdominal aneurysm type I and dysphagia underwent an emergent carotico-carotid bypass in combination with thoracic endovascular aortic aneurysm repair starting at a point distal to the brachiocephalic trunk and ending proximal to the superior mesenteric artery. On day 12, a decortication was performed for treating an infection in the remaining hematoma. However, further deterioration occurred as a result of mediastinitis secondary to the transmural necrosis of the middle third of the esophagus combined with accompanying mediastinitis. The patient's family refused to give consent for further treatment by esophagectomy. He died 24 days after the initial operation. CONCLUSION: Dysphagia aortica, mucosal abnormalities on esophagogastroscopy, and mediastinal compression by hematoma at the time of rupture draws our attention toward ischemia of the esophagus after thoracic endovascular aortic aneurysm repair. Repeated esophagoscopy can provide us with the opportunity to act before full thickness necrosis and mediastinitis occur.

Outcome of proximal internal iliac artery coil embolization prior to stent-graft extension in patients previously treated by endovascular aortic repair.

PURPOSE: To assess the safety, feasibility, and effectiveness of coil embolization of the proximal internal iliac artery (IIA) before stent-graft extension in patients previously treated by endovascular aortic repair (EVAR). MATERIALS AND METHODS: Over a period of 9 years, 16 ipsilateral, proximal IIA coil embolization procedures were performed before stent-graft extension in 13 patients previously treated by a modular aortic stent graft. Indication for coil embolization and concomitant stent-graft extension were secondary (ie, late) distal type I endoleak (n = 9) and late onset of an isolated common iliac artery aneurysm (n = 7) as a result of increasing dilation of a common iliac artery during follow-up after EVAR; mean common iliac artery diameter before coil embolization was 26.1 mm (range, 15-35 mm). Clinical and radiologic follow-up (mean, 39 months; range, 6-102 months) was done in accordance with an established registry. RESULTS: All procedures were successful except for one performed with 0.035-inch coils. Clinically, buttock claudication was noted in five of 13 patients (38%). No type II endoleak occurred through the coil-embolized internal iliac arteries. The mean common iliac artery diameter at 6-month follow-up was 23.0 mm (range, 14-30 mm; P = .0005). CONCLUSIONS: Ipsilateral coil or microcoil embolization of the proximal IIA before stent-graft extension in patients previously treated by an aortic stent graft seems to be safe and feasible, with favorable outcomes after a mean follow-up of 39 months.

Paraparesis after thoracic stent-graft relining for an unrecognized type III endoleak.

BACKGROUND: We examined the reasons for missing a type III endoleak on conventional imaging and the pathophysiology of paraparesis after relining this stent graft. METHODS AND RESULTS: A 46-year-old man was treated with a thoracic stent graft for thoracic rupture of a chronic type B thoracoabdominal dissection with aneurysm formation. In a second intervention, retrograde revascularization of the visceral and renal arteries was performed in combination with insertion of an abdominal stent graft. After initial shrinkage of the aneurysmal sac, the thoracic aortic diameter started increasing again. Consecutive three-phase helical computed tomographic scans did not reveal any endoleak. Because of unbearable back pain, an open surgical exploration was performed. This showed a type III endoleak. Relining of the thoracic stent graft was performed, but paraparesis developed. CONCLUSION: In patients with unexplained increase of the aneurysmal sac contrast-enhanced magnetic resonance imaging could help to illuminate the underlying endoleak. The collateral network concept can explain spinal cord injury by even minor hemodynamic changes.

Endovascular treatment of an iliocaval arteriovenous fistula presenting with multiple organ failure.

Iliocaval arteriovenous fistula is an uncommon, but challenging condition. The most common cause is spontaneous rupture of the iliac artery into the venous system due to aneurismal dilatation. We report a case of iliocaval fistula after previous aortic surgery presenting as acute liver failure as most prominent part of multiple organ failure and successful endovascular repair.

Heparin-bonded ePTFE grafts compared with vein grafts in femoropopliteal and femorocrural bypasses: 1- and 2-year results.

OBJECTIVE: Many patients with peripheral arterial occlusive disease who require a lower-limb bypass have no available autologous saphenous vein (ASV) for the procedure and thus require a prosthetic graft. Expanded polytetrafluoroethylene (ePTFE) grafts are commonly used, but results with these prostheses have varied, especially when the distal anastomosis is below the knee. However, there is increasing evidence that ePTFE grafts to which heparin has been bound with use of covalent endpoint linkage provide better results. This nonrandomized study compared the performance of these grafts with that of ASV conduits in the largest clinical series of heparin-bonded ePTFE graft implantations reported so far. METHODS: The records of 350 patients who underwent a lower-limb bypass procedure that used either a heparin-bonded ePTFE graft (n = 240) or an ASV graft (n = 110) were reviewed, and preoperative, operative, and follow-up data were recorded. Kaplan-Meier analyses were used to calculate primary patency and limb salvage rates in the two graft groups; results were compared by using log-rank testing. RESULTS: The primary patency rates at 1 year for the heparin-bonded ePTFE grafts were 92% for above-knee femoropopliteal (AK FP) bypasses, 92% for below-knee femoropopliteal (BK FP) bypasses, and 79% for femorocrural (FC) applications. The corresponding 2-year rates were 83%, 83%, and 69%, respectively. In the ASV group, the 1-year primary patency rates for AK FP, BK FP, and FC bypasses were 91%, 72%, and 69%, respectively; the 2-year rates were 80%, 72%, and 64%, respectively. There were no significant differences in patency when AK FP, BK FP, or FC procedures were considered separately. Two-year limb salvage rates in the heparin-bonded ePTFE graft group were 92%, 98%, and 87%, respectively, for AK FP, BK FP, and FC bypasses; in the ASV group, the rates were 100%, 91%, and 96%, respectively. Two infections occurred in patients given a heparin-bonded ePTFE graft. CONCLUSION: In this large retrospective study, heparin-bonded ePTFE grafts had 1- and 2-year primary patency results that were not significantly different from those for ASV grafts. Results in BK FP and FC applications were especially promising. Randomized studies comparing the use of heparin-bonded ePTFE and ASV grafts in the treatment of peripheral arterial disease are needed to substantiate our results.

The role of thrombolysis in acute infrainguinal bypass occlusion: a prospective nonrandomized controlled study.

Current treatment of acute infrainguinal bypass occlusion consists of either surgical revascularization or catheter-guided intra-arterial thrombolysis with adjunctive correction of the underlying flow-limiting lesion. In maintaining long-term patency, improving the number of outflow vessels could be of utmost importance. To compare the efficiency of both thrombolysis and primary surgical revascularization and to study the effect of thrombolysis on the number of patent outflow vessels, a prospective nonrandomized study was performed. Between February 2002 and August 2003, 54 patients with 56 occluded bypasses were included. Thirty bypasses were treated with thrombolysis, 26 primarily with surgery. Thrombolysis was successful in 80% of cases, with restoration of patency of the bypass but also with doubling of the amount of patent outflow vessels; surgery was successful in 85.71% of cases. However, in only 60% of the successfully lysed bypasses no adjunctive major surgery was needed. Amputation-free survival was 87.5% 1 year after surgery and 82.6% 1 year after thrombolysis. One year after thrombolysis without adjunctive major surgery, the amputation-free survival was only 39.7%. Therefore, a strategy could be to start with thrombolysis to improve outflow followed by a new bypass, whatever the underlying causative lesions are.

Mural thrombotic deposits in abdominal aortic endografts are common and do not require additional treatment at short-term and midterm follow-up.

PURPOSE: To assess the incidence and clinical significance of thrombotic, nonocclusive mural deposits in abdominal aortic stent-grafts incidentally found on follow-up computed tomography scans after endovascular aneurysm repair (EVAR). MATERIALS AND METHODS: Between 1998 and 2007, 288 patients underwent EVAR of an infrarenal aortic aneurysm. In the majority of cases, a Zenith stent-graft (n = 187) or Excluder stent-graft (n = 71) was implanted. Clinical and radiologic follow-up was performed prospectively according to the EUROSTAR registry, with mean follow-up periods of 4.69 and 5.05 years, respectively, for the Excluder and Zenith groups. RESULTS: Thrombotic deposits were found in 17% and 33% of patients in the Excluder and Zenith groups, respectively, which represents a significant difference (P = .038). Clinically, no distal atheroembolic events were noted during follow-up, and there was no significant difference in survival between patients with and without thrombotic deposits (P = .80). CONCLUSIONS: Incidentally found thrombotic deposits in abdominal aortic endografts are common and device-specific, with a lower incidence in the Excluder group versus the Zenith group. These thrombotic deposits are clinically silent, do not require additional treatment at short-term and midterm follow-up, and do not affect the overall survival of the treated patients.

Limb occlusion after endovascular repair of abdominal aortic aneurysms with supported endografts.

PURPOSE: To assess the time period of onset, etiology, and outcomes of limb occlusion after endovascular repair of abdominal aortic aneurysms with supported endografts. MATERIALS AND METHODS: From 1998 to 2007, 288 patients underwent endovascular aneurysm repair (EVAR) to exclude an infrarenal aortic aneurysm. In the majority of patients, a Zenith stent-graft (n = 187) or Excluder stent-graft (n = 71) was implanted. Nine patients presented with limb occlusion during follow-up. All occluded stent-grafts were modular (n = 8) or aortomonoiliac (n = 1) Zenith endoprostheses. One additional patient who was previously treated with a Zenith aortomonoiliac stent-graft was referred to our institution for further treatment of stent-graft thrombosis. RESULTS: The initial clinical presentations were acute ischemia (n = 5), buttock claudication (n = 3), and incidental findings on follow-up imaging (n = 2). Occlusion occurred within the first month after EVAR (n = 5), between the first and second month after EVAR (n = 2), 10 months after EVAR (n = 1), and 4-5 years after EVAR (n = 2). Underlying causes of occlusion were kinking of the stent-graft (n = 5), small-diameter endograft limb with extension to the external iliac artery (n = 3), and migration and dislocation of an endograft limb (n = 2). Treatment consisted of catheter-directed thrombolysis and stent placement (n = 3), surgical thrombectomy or bypass operation (n = 5), and expectant management (n = 2). Outcome of all revascularization procedures showed immediate clinical success in all patients and no late recurrent limb ischemia at a mean follow-up of 38.9 months. CONCLUSIONS: Limb occlusion of aortic stent-grafts mostly occurs shortly after EVAR and can be related to underlying kinking of the metallic skeleton, extension of the stent-graft into the external iliac artery, or migration and dislocation of an endograft limb. Satisfactory and durable clinical outcomes can be obtained after appropriate revascularization.

Combined open and endovascular repair of a true right subclavian artery aneurysm without proximal neck.

A 52-year-old man, without a medical history, presented with an incidentally detected large, intrathoracic aneurysm of the right subclavian artery. The aneurysm was characterized by the absence of a proximal neck and extended distally close to the origin of the right vertebral artery. We successfully excluded this aneurysm with a combined endovascular and minimally invasive open repair, thereby avoiding a sternotomy or lateral thoracotomy: a stent-graft was placed from the proximal brachiocephalic trunk to the common carotid artery, completely covering the origin of the right subclavian artery. The right subclavian artery was oversewn just distally to the aneurysm and revascularization of the right arm was assured by a carotido-subclavian bypass. Clinical follow-up was uneventful and radiological follow-up by CT-scan showed discrete, but progressive shrinkage of the completely excluded aneurysm.

Stent-graft repair of a mycotic ascending aortic pseudoaneurysm.

A 75-year-old woman with a history of coronary artery bypass surgery complicated by mediastinitis presented with hemoptysis and fever. An enlarging pseudoaneurysm of the ascending aorta was found on computed tomography (CT) and magnetic resonance imaging. After a bypass graft procedure for cerebral and cardiac protection, two endoprosthetic cuffs, which are normally used for proximal abdominal aortic stent-graft extension, were positioned over the pseudoaneurysm neck via right carotid artery access. Blood cultures revealed methicillin-sensitive Staphylococcus aureus, and antibiotic therapy was continued for 6 weeks. Follow-up CT images demonstrated exclusion of the pseudoaneurysm with decrease in size over time. Endovascular stent-graft placement combined with antibiotic therapy may offer an alternative to surgery for the management of mycotic ascending aortic pseudoaneurysm.

Outcome of common iliac arteries after straight aortic tube-graft placement during elective repair of infrarenal abdominal aortic aneurysms.

PURPOSE: To determine the relative rates of common iliac artery (CIA) expansion after elective straight aortic tube-graft replacement of infrarenal abdominal aortic aneurysms (AAA). METHODS: Five participating centers in this 2004 study entered patients they had managed by an aortoaortic tube graft for elective AAA repair. The procedures took place between January 1995 and December 2003. Postoperative computed tomography (CT) scans were obtained for all patients in 2004 to assess changes in CIA diameter. Measurements on preoperative and postoperative CT scans were all made at the same level using the same technique. RESULTS: Entered in the study were 147 patients (138 men, 9 women) with a mean age of 68 years. Mean follow-up from aortic surgery to verification of CIA diameter on the postoperative CT scan was 4.8 years. Mean preoperative CIA diameter was 13.6 mm vs 15.2 mm postoperatively. No patient developed occlusive iliac artery disease during follow-up. Three patients (2%) required repeat surgery during follow-up for a CIA aneurysm. The 147 patients were divided into three groups based on preoperative CIA diameter shown in CT scan: group A (n = 59, 40.1%), both CIA were of normal diameter; group B (n = 53, 36.1%), ectasia (diameter between 12 and 18 mm) of at least one CIA; group C (n = 35, 23.8%), an aneurysm (diameter >18 mm) of at least one CIA. CIA diameter increased by a mean of 1 mm (9.4%) over 5.5 years in group A vs 1.7 mm (12.1%) over 4.3 years in group B and 2.3 mm (12.7%) over 4.2 years in group C. The three patients who required repeat surgery for a CIA aneurysm during follow-up were all in group C. Four variables were associated with aneurysmal change in CIA: initial CIA diameter, celiac aorta diameter on the preoperative CT scan, a coexisting aneurysm site, and the follow-up duration. CONCLUSIONS: Tube-graft placement during AAA surgery is justified even for moderate CIA dilatation (<18 mm). CIA aneurysms with a preoperative diameter > or =25 mm enlarge more rapidly and warrant insertion of a bifurcated graft during the same surgical session as AAA repair. The evolutive potential of CIA between 18 mm and 25 mm in diameter justifies a bifurcated graft when the celiac aorta diameter is >25 mm or the patient's life expectancy is > or =8 years.

Simultaneous valve replacement and venous patch repair of superior mesenteric artery aneurysm due to infective endocarditis: a case report.

BACKGROUND: Peripheral mycotic aneurysm development is a rare systemic complication of infective endocarditis. CASE REPORT: We report on a case of a mycotic aneurysm of the superior mesenteric artery in a 66-year-old man with infective endocarditis of the mitral valve. After the mitral valve was replaced by a mechanical valve, a laparotomy was performed. The mycotic aneurysm was excised and the vessel was repaired by sewing an autologous venous patch at the neck of the aneurysm. Five years after the operation, the patient is doing fine, with a normal morphology and patency of the superior mesenteric artery. CONCLUSION: Our case demonstrates that simultaneous valve surgery and repair of a superior mesenteric artery mycotic aneurysm by sewing a vein patch in the neck of the artery is a viable treatment option.

Endovascular treatment of a ureteroiliac fistula associated with ureteral double J-stenting and an aortic-bifemoral stent graft for an inflammatory abdominal aortic aneurysm.

We report an unusual case of a ureteroiliac fistula due to prolonged ureteral stenting for hydronephrosis combined with an aortic-bifemoral stent graft in an inflammatory abdominal aortic aneurysm (AAA), treated with an endovascular stent graft. In a 77-year-old man ureteral J-stents were placed for bilateral hydronephrosis due to retroperitoneal fibrosis caused by an inflammatory AAA. The aneurysm was treated with an endovascular aortic-bifemoral stent graft. Three months later, the patient suffered from severe hypovolemic shock. Emergency angiography showed a fistula between the right ureter and the right common iliac artery just distal to the right leg of the stent graft. The ureteroiliac fistula was treated with a wall graft (10F). The patient recovered well and remained asymptomatic. Ureteroiliac fistula remains a rare complication of ureteral stenting. Several risk factors have been described before. This case emphazes the increased risk of an arterial-ureteral fistula due to an indwelling ureteral stent and an inflammatory AAA, especially in combination with an additional stent graft for this inflammatory AAA.

Progressive growth of a pelvic collection five years after endovascular aneurysm repair: an atypical presentation of an asymptomatic contained rupture.

We report a case of an unusual and late presentation of an asymptomatic contained rupture after modular stent-graft implantation to treat an aortobiiliac aneurysm. Follow-up computed tomography (CT) scans 4 and 5 years after endovascular aneurysm repair showed a homogeneous, nonenhancing, but clearly growing, pelvic collection. CT-guided drainage of the collection was performed, and cultures of the evacuated brown fluid were negative for any infection. Control CT scan after drainage showed a complete collapse of both the collection and the previously excluded iliac aneurysms. A direct communication between the sterile pelvic collection and the excluded iliac aneurysm was suggested on this CT imaging and confirmed afterwards by surgery. From these imaging and surgical findings, this pelvic collection can be considered as an atypical presentation of an asymptomatic contained rupture of the excluded aneurysm.

Translumbar thrombin embolization of an aortic pseudoaneurysm complicating lumbar disk surgery.

We report a case of translumbar embolization of an aortic pseudoaneurysm complicating lumbar disk surgery. The iatrogenic pseudoaneurysm was initially treated by open repair, but due to failure of this treatment, we opted for direct translumbar thrombin injection under computed tomography (CT) guidance. The patient recovered completely, and follow-up CT scans showed progressive shrinkage of the residual retroperitoneal hematoma. This minimally invasive treatment should be considered in selected cases as a valuable treatment option for pseudoaneurysms that arise from the aorta.

Internal iliac artery coil embolization in the prevention of potential type 2 endoleak after endovascular repair of abdominal aortoiliac and iliac artery aneurysms: effect of total occlusion versus residual flow.

PURPOSE: To evaluate whether the presence of type 2 endoleak after internal iliac artery (IIA) coil embolization in patients with residual antegrade flow through the coils is more frequent than in patients who presented with total occlusion of the IIA after embolization. MATERIALS AND METHODS: Records were reviewed of 45 patients who underwent unilateral (n = 37) or bilateral (n = 8) IIA coil embolization between 1998 and 2004 for endovascular repair of aortoiliac aneurysms (n = 32), iliac artery aneurysms (n = 12), pseudoaneurysm (n = 1), or distal type 1 endoleak after placement of an aortoiliac stent-graft (n = 8). A total of 53 IIAs were embolized by means of coils and/or microcoils. Computed tomography (CT) was used for follow-up in 40 patients, angiography was used in three, and color Doppler ultrasonography was used in three. RESULTS: At the end of the embolization procedure, 23 IIAs were occluded and 30 IIAs demonstrated residual antegrade flow through the coils. Control CT demonstrated two type 2 endoleaks after endovascular stent-graft placement resulting from retrograde blood flow into the left IIA main branch via a patent iliolumbar artery. One of these two patients showed residual antegrade flow through the coils at the end of the IIA embolization procedure, and the other patient underwent complete coil embolization of the ostia of the anterior and posterior division but not of the main trunk of an aneurysmal IIA. CONCLUSION: IIA coil embolization with residual antegrade flow through the coils causes no greater incidence of type 2 endoleak after aortoiliac or iliac stent-graft placement. However, care must be taken in case of a proximal postostial origin of the iliolumbar artery on the IIA, which may cause type 2 endoleak if not embolized.

Iatrogenic main renal artery injury: treatment by endovascular stent-graft placement.

We report on a patient who presented with perforation of the left main renal artery as a complication of a percutaneous retroperitoneal drainage procedure. Only a small number of cases of iatrogenic main renal artery perforations have been reported, none of them due to a percutaneous drainage attempt. Endovascular treatment by means of a coronary stent-graft was successful.

Extracranial carotid artery stenting in surgically high-risk patients using the Carotid Wallstent endoprosthesis: midterm clinical and ultrasound follow-up results.

The purpose of this study was to evaluate the feasibility, safety and midterm outcome of elective implantation of the Carotid Wallstent in patients considered to be at high surgical risk. In a prospective study, 54 carotid artery stenoses in 51 patients were stented over a 24-month period. Three patients underwent bilateral carotid artery stenting. Institutional inclusion criteria for invasive treatment of carotid occlusive disease (carotid endarterectomy or carotid artery stenting) are patients presenting with a 70% or more symptomatic stenosis and those with an 80% or more asymptomatic stenosis having a life-expectancy of more than 1 year. All patients treated by carotid artery stenting were considered at high risk for carotid endarterectomy because of a hostile neck (17 patients--31.5%) or because of severe comorbidities (37 patients--68.5%). No cerebral protection device was used. Of the 54 lesions, 33 (61.1%) were symptomatic and 21 (38.8%) were asymptomatic. Follow-up was performed by physical examination and by duplex ultrasonography at 1 month, 6 months, 1 year and 2 years after the procedure. All 54 lesions could be stented successfully without periprocedural stroke. Advert events during follow-up (mean 13.9 +/- 5.7 months) were non-stroke-related death in 6 patients (11.1%), minor stroke in 4 stented hemispheres (7.4%), transient ipsilateral facial pain in 1 patient (1.8%), infection of the stented surgical patch in 1 patient (1.8%) and asymptomatic instent restenosis in 4 patients (7.4%). The percutaneous implantation of the Carotid Wallstent, even without cerebral protection device, appears to be a safe procedure with acceptable clinical and ultrasonographic follow-up results in patients at high surgical risk. But some late adverse events such as ipsilateral recurrence of non-disabling (minor) stroke or instent restenosis still remain real challenging problems.