Anatomic feasibility of endovascular treatment of abdominal aortic aneurysms in emergency in the era of the chimney technique: impact on an emergency endovascular kit.

BACKGROUND: Despite promising results, endovascular aortic repair (EVAR) of ruptured/painful abdominal aortic aneurysms (RPAAA) continues to have limited use due to anatomic constraints linked to RPAAA morphology. Currently, EVAR for RPAAA is reserved for patients presenting with a long infrarenal aortic neck, because commercially available fenestrated stent grafts are not available in an emergency setting. Recently, the chimney technique (ChT) has been utilized to treat infrarenal abdominal aortic aneurysms (AAA) with short necks, but this technique requires specific materials. The aim of this study was to determine the rate of RPAAA eligible for EVAR since the advent of the ChT and to ascertain the standard materials needed in this context. METHODS: We carried out a retrospective study of patients operated on for RPAAA (<24 hours after admission) at our center between 2006 and 2011. Patients' computed tomography (CT) scans were analyzed by two independent operators using 3-dimensional reconstruction software with a centerline of flow. To perform standard EVAR, the anatomic criteria used were those provided by the manufacturer (proximal neck diameter 18-32 mm with length >15 mm, angulation <60°, iliac diameter >7 mm). ChT anatomic feasibility criteria were: (1) a healthy aortic area >15 mm between the renal arteries and celiac trunk; (2) caudal orientation of renal arteries; and (3) a healthy descending thoracic aorta. Patients were classified according to the feasibility or nonfeasibility of standard EVAR and ChT. RESULTS: In total, over the period of study, 55 patients were operated on for RPAAA. In 5 patients (9%), CT scan quality was unsatisfactory and thus 50 patients (mean age 76 years, 75% men) were analyzed. Among them, 35 (70%) had a ruptured aneurysm and 17 (34%) were unstable. Anatomically, 22 (44%) patients were eligible for standard EVAR. Taking the ChT into consideration, an additional 11 (22%) patients were eligible for EVAR. Among these EVAR-eligible patients, mean proximal neck diameter was 23 ± 3 mm and stent grafts with 24-, 28-, and 32-mm diameters could fit in 33% (11 of 33), 51% (17 of 33), and 12% (4 of 33) of the cases, respectively. These results enabled us to determine the material that should be made available in the emergency setting in centers treating RPAAA. Among the 17 patients who were not eligible for EVAR, an iliac pathology (calcifications, stenosis) and a very hostile proximal neck (angulation, thrombus), respectively, were involved in 88% (15 of 17) and 12% (2 of 17) of the cases. CONCLUSIONS: The ChT increases EVAR feasibility by 50% in RPAAA. Taking into consideration our results, we recommend continued availability of emergency kits, including suitable aortouni-iliac stent grafts and basic material for performing ChT to allow surgeons to provide EVAR to the greatest number of RPAAA cases.

Total laparoscopic suprarenal aortic coral reef removal.

Symptomatic suprarenal coral reef aortic lesions have a poor natural history and threaten visceral and lower extremity perfusion. We report our experience with total laparoscopic suprarenal aortic coral reef removal in three patients, aged 46, 48, and 52 years. Coral reef lesions were associated with aortoiliac occlusive lesions in two cases. One patient had an associated thoracic coral reef lesion. Patients underwent total laparoscopic coral reef removal combined with laparoscopic aortobifemoral bypass in two cases and open thoracic coral reef removal in one case. Postoperative courses were uneventful. All patients were alive with patent revascularization after a mean follow-up of 38 months, 29 months, and 1 month.

Total laparoscopic versus conventional abdominal aortic aneurysm repair: a case-control study.

PURPOSE: This study was designed to identify differences in the per- and postoperative outcomes between total laparoscopic and open surgical repair of abdominal aortic aneurysms (AAA). METHODS: We reviewed 30 patients who underwent total laparoscopic AAA repair between July 2003 and December 2004 (group I). This group was matched in a case-control fashion by AAA morphology and American Society of Anesthesiologists class with a group of 30 patients who underwent conventional AAA repair between April 1997 and May 2004 (group II). Proportions and categoric data were compared with a chi(2) test. Continuous data were compared with a Mann-Whitney test. RESULTS: The two groups had comparable characteristics of age and cardiovascular risk factors. The number of tube and bifurcated grafts was 13 for group I and 17 for group II. Median operative time was 255 minutes (range, 170 to 410 minutes) in group I and 200 minutes (range, 130 to 410) in group II (P <.001). Median aortic clamping time was 80 minutes (range, 35 to 110 minutes) in group I and 50 minutes (range, 24 to 150 minutes) in group II (P < .0001). Total blood loss was 1600 mL (range, 400 to 4000 mL) for group I vd 1000 mL (range, 100 to 2900) for group II (P < .01). The mortality rate was 3.3% for group I (1 patient) vs 6.6% (2 patients) for group II (NS). There were no significant differences between the two groups in terms of postoperative systemic complications (23.3% vs 30%, NS) and local and vascular complications (10% vs 3.3%). Duration of ileus (2 vs 3 days, P < .05), return to normal diet (4 vs 8 days, P < .0001), day of ambulation (3 vs 4 days, P < .05) and dose of narcotics (3.5 mg vs 28.5 mg, P < .05) were significantly lower in group I. Median length of intensive care unit stay was similar between the two groups (48 hours). Median hospital stay was lower in group I but without significant differences with group II (9 vs 11 days, NS). CONCLUSION: This case-control study provides preliminary results that short-term outcomes of total laparoscopic AAA repair are comparable with those of open surgery. Peroperative data demonstrate that laparoscopy is more technically demanding than open repair. However, the technical challenge of laparoscopy does not worsen the postoperative course.

Total videoscopic bypass graft implantation on the ascending aorta for lower limb revascularization.

An extra-anatomic bypass initiating from the ascending aorta, namely the ventral aorta, is a possible alternative for lower limb revascularization. However, acceptance of this technique is limited by the need of a median sternotomy and clamping of the ascending aorta. We report a new technique for the ventral aorta using a total videoscopic approach of the ascending aorta, which avoids the need for a median sternotomy. We discuss the advantages and perspectives of this new approach.

Total videoscopic treatment of a type IV thoracoabdominal aneurysm.

We performed a total videoscopic type IV thoracoabdominal aortic aneurysm repair. The postoperative course was uneventful, and the patient did well 10 months later. To our knowledge, a total videoscopic thoracoabdominal aortic aneurysm repair has not been previously described.

Total laparoscopic bypass for aortoiliac occlusive lesions: 93-case experience.

OBJECTIVES: We describe our experience with a new technique of total laparoscopic bypass surgery to treat aortoiliac occlusive lesions. MATERIAL AND METHODS: From November 2000 to December 2003, 93 total laparoscopic bypass procedures were performed to treat TASC (TransAtlantic Inter-Society Consensus document) grade C or D aortoiliac occlusive lesions. We also reimplanted 2 inferior mesenteric arteries, and performed 3 prosthesis-superior mesenteric bypasses and 2 suprarenal aorta endarterectomies. Our technique includes a sloping right lateral decubitus installation, which enables a simple transperitoneal left retrocolic or retrorenal approach to the infrarenal abdominal aorta. In patients with a hostile abdomen a retroperitoneal videoscopic approach was used. Aorta-prosthesis laparoscopic anastomoses are performed simply, which averts any trauma to the suture material. RESULTS: Patients included 76 men and 17 women, with median patient age 61 years (range, 38-79 years). The approach to the aorta was always possible, in particular, in obese patients. It enabled stable aortic exposure during performance of the laparoscopic aorta-prosthesis anastomosis. Median operative time was 240 minutes (range, 150-450 minutes). Median aortic clamping time measured to unclamping of the first prosthetic limb was 67.5 minutes (range, 30-135 minutes). Median duration of aorta-prosthesis anastomosis was 30 minutes (range, 12-90 minutes). The longest durations were mainly observed during the learning curve. Thirty-day postoperative mortality was 4% (4 of 93 patients). Two patients died of myocardial infarction. One patient with American Society of Anesthesiologists grade 4 disease operated on to treat critical ischemia died of multiple organ system failure, and 1 patient died of colonic ischemia. Major nonlethal postoperative complications were observed in 4 patients, and included lung atelectasia in 2 patients, graft infection in 1 patient operated on emergently to treat aortic occlusion, and secondary spleen rupture at day 5 in 1 patient. Median hospital stay was 7 days (range, 2-57 days). With a mean follow-up of 19 months (range, 1-37 months), complete recovery was observed in 89 patients, and all grafts were patent. One patient had kinking of a prosthetic limb at the groin, and in 1 patient Staphylococcus epidermidis graft infection developed, which was treated with in situ replacement with a rifampin-bonded graft. CONCLUSION: Total laparoscopic aortic bypass is feasible. In patients with TASC C and D aortoiliac occlusive lesions, short-term outcomes are comparable to those with conventional aortic bypass. After the initial learning curve, laparoscopic technique may reduce the operative trauma of aortic bypass.

Total laparoscopic infrarenal aortic aneurysm repair: preliminary results.

OBJECTIVES: We describe our initial experience of total laparoscopic abdominal aortic aneurysm (AAA) repair. MATERIAL AND METHODS: Between February 2002 and September 2003, we performed 30 total laparoscopic AAA repairs in 27 men and 3 women. Median age was 71.5 years (range, 46-85 years). Median aneurysm size was 51.5 mm (range, 30-79 mm). American Society of Anesthesiologists class of patients was II, III and IV in 10, 19, and 1 cases, respectively. We performed total laparoscopic endoaneurysmorrhaphy and aneurysm exclusion in 27 and 3 patients, respectively. We used the laparoscopic transperitoneal left retrocolic approach in 27 patients. We operated on 2 patients via a tranperitoneal left retrorenal approach and 1 patient via a retroperitoneoscopic approach. RESULTS: We implanted tube grafts and bifurcated grafts in 11 and 19 patients, respectively. Two minilaparotomies were performed. In 1 case, exposure via a retroperitoneal approach was difficult and, in another case, distal aorta was extremely calcified. Median operative time was 290 minutes (range, 160-420 minutes). Median aortic clamping time was 78 minutes (range, 35-230 minutes). Median blood loss was 1680 cc (range, 300-6900 cc). In our early experience, 2 patients died of myocardial infarction. Ten major nonlethal postoperative complications were observed in 8 patients: 4 transcient renal insufficiencies, 2 cases of lung atelectasis, 1 bowel obstruction, 1 spleen rupture, 1 external iliac artery dissection, and 1 iliac hematoma. Others patients had an excellent recovery with rapid return to general diet and ambulation. Median hospital stay was 9 days (range, 8-37 days). With a median follow-up of 12 months (range, 0.5-20 months), patients had a complete recovery and all grafts were patent. CONCLUSION: These preliminary results show that total laparoscopic AAA repair is feasible and worthwhile for patients once the learning curve is overcome. However, prior training and experience in laparoscopic aortic surgery are needed to perform total laparoscopic AAA repair. Despite these encouraging results, a greater experience and further evaluation are required to ensure the real benefit of this technique compared with open AAA repair.

Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery.

We performed a total laparoscopic reimplantation of the inferior mesenteric artery (IMA) during laparoscopic infrarenal aortic aneurysm repair. The postoperative course was uneventful, and angiograms showed a patent IMA after reimplantation. To our knowledge, total laparoscopic reimplantation of the IMA in human beings has not previously been described.