Fenestrated and branched endograft repair of juxtarenal aneurysms after previous open aortic reconstruction.

OBJECTIVE: Para-anastomotic aortic aneurysms and progressive aneurysmal degeneration of the aorta after previous open aortic reconstruction pose a challenging clinical scenario. Due to the proximity to the visceral arteries, endovascular exclusion is typically not an option. However, the development of fenestrated and branched endografts has provided a less invasive means of repair. We sought to evaluate our experience using fenestrated endografts in the management of juxtarenal aortic aneurysms after previous open aortic reconstruction. METHODS: This is an analysis of patients who have undergone fenestrated endovascular repair specifically for juxtarenal aneurysms in the setting of previous infrarenal open aortic surgery. Patients were treated with customized Cook (William A. Cook Australia, Ltd, Brisbane, Australia) endografts manufactured based on preoperative 3-dimensional (3-D) imaging. All patients underwent repair under the direction of a single surgeon. RESULTS: Eighteen patients were treated from March 2004 to November 2008. All patients had a previous open aortic reconstruction, and 3 patients had two prior reconstructions. The mean time since the last operation was 8.5 years (range, 1-15 years). Mean patient age was 72-years-old (range, 57-80 years). All patients were considered high risk for open surgery due to pre-existing medical co-morbidities and/or the redo nature of their surgery. The mean number of fenestrations per patient was three vessels, including proximal graft scallops. All but one operation (94%) was completed by totally endovascular means. One operation required a planned celiotomy for retrograde access to a left renal artery. Of 56 target vessels, all were successfully revascularized using a combination of: fenestrations with stents (12), or stent grafts (25), as well as graft scallops (18), and directional graft branches with a bridging stent graft (1). Mean operative time was 215 minutes (range, 135-420 minutes) and mean blood loss was 560 cc (range, 100-1500 cc). Thirty-day and 1-year mortality was 0 and 11%, respectively. Perioperative complications occurred in 2 patients. One patient developed a congestive heart failure exacerbation and myocardial infarction, and the other patient a groin wound infection. Mean follow-up time was 23 months and cumulative primary patency was 95% (53/56 vessels), with no follow-up interventions. CONCLUSION: Endovascular treatment of juxtarenal aneurysms after prior aortic reconstruction is a viable alternative to open repair with high success and low reintervention rates. These devices will broaden the available treatment modalities for these conditions, and will likely significantly decrease the complication rate of treatment in these high-risk patients.

Emergency endovascular stent grafting for thoracic aortic pathology.

Our aim was to report single-center results of emergency endovascular treatment for thoracic aortic disease. From March 1998 to January 2006, 30 acute thoracic EVAR procedures were carried out in 29 patients. One patient received two procedures in different settings. Four patients died before treatment could be initiated. The pathology of aortic lesions included atherosclerotic aneurysm (n = 13), pseudoaneurysm (n = 6), aortic rupture (n = 5), type B dissection (n = 5), aortobronchial or aortoesophageal fistula (n = 4), and intramural hematoma (n = 1). The surgical mortality rate was 21%. Three patients died as a result of technical complications, and three patients died after technically successful procedures. The mean follow-up was 31 +/- 23 months. The late mortality rate was 40% (8 of 20). Four patients died of causes unrelated to the procedure; two patients died at home without autopsy. Two patients died as a consequence of graft infections. Three late nonfatal complications occurred. Two of these resulted in additional treatment: one patient developed a mycotic aneurysm that was treated with additional stent grafting, and one patient developed a type 3 endoleak after 6 years of follow-up and was successfully treated with a bridging stent graft. Endovascular treatment for acute thoracic disease is feasible and associated with a reasonable outcome. In selected cases, it may be considered as a first option.

Is emergency endovascular aneurysm repair associated with higher secondary intervention risk at mid-term follow-up?

OBJECTIVE: The study assessed mid-term outcome of emergency endovascular repair for acute infrarenal abdominal aortic aneurysms, with special attention to secondary interventions. METHODS: Between May 1998 and August 2005, 56 patients underwent emergent endovascular repair for a ruptured abdominal aortic aneurysm (n = 34) or an acute nonruptured abdominal aortic aneurysm (n = 22). During the same period, 322 consecutive patients underwent elective endovascular aneurysm repair and were used as control group. Five types of stent grafts were used: Vanguard, Talent, Excluder, Zenith, and Quantum. Follow-up included abdominal radiograph, duplex ultrasound scanning, and computed tomographic angiography. Outcome measures included all-cause and aneurysm-related mortality, complications, and secondary interventions. RESULTS: Mortality at 30 days was 18%, 5%, and 1% in the ruptured, acute nonruptured, and elective aneurysm groups, respectively. Overall mean follow-up was 38 +/- 26 months. In the ruptured aneurysm group, survival was 67.8% +/- 8.6% at 1 year and 62.1% +/- 9.5% at 2 and 3 years. Seven secondary interventions (4 early and 3 late) were required in five patients (15%), with a cumulative risk of 9.2% +/- 5.1% at 1 year and 16.2% +/- 8.2% at 2 and 3 years. In the acute nonruptured aneurysm group, survival was 90.9% +/- 6.1% at 1 year, 84.8% +/- 8.2% at 2 years, and 76.4% +/- 10.9% at 3 years. Four secondary interventions (1 early and 3 late) were required in four patients (18%), with a cumulative risk of 9.6% +/- 6.5% at 1 and 2 years and 20.9% +/- 12.0% at 3 years. In the elective aneurysm (control) group, survival was 95.2% +/- 1.2% at 1 year, 89.9% +/- 1.8% at 2 years, and 86.2% +/- 2.1% at 3 years. A total of 51 secondary interventions (4 early, 47 late) were required in 38 patients (12%), with a cumulative risk of 4.2% +/- 1.1% at 1 year, 7.6% +/- 1.6% at 2 years, and 12.9% +/- 2.2% at 3 years. CONCLUSIONS: To our surprise, emergency endovascular aneurysm repair did not present with higher secondary intervention rate at mid-term follow-up.