Use of endostaples to secure migrated endografts and proximal cuffs after failed endovascular abdominal aortic aneurysm repair (original) (raw)
Related papers
Texas Heart Institute journal, 2010
Endovascular abdominal aortic aneurysm repair (EVAR) is an attractive alternative to open surgical repair. Distal endograft migration and type 1 endoleak are recognized to be the 2 main complications of EVAR. First-generation endografts had a stronger propensity for distal migration, modular component separation, thrombosis, and loss of structural integrity. Substantial progress has been made in recent years with 2nd- and 3rd-generation devices to prevent these complications. Some of the most common predictors of endograft failure are angulated and short infrarenal necks, large-diameter necks, and thrombus in the aneurysmal sac. The purpose of this study is to describe and review our experience in using innovative techniques and a newer generation of endografts to prevent distal migration and type 1 endoleak in patients with challenging infrarenal neck anatomy. The use of these innovative EVAR techniques and the new generation of endografts in patients with challenging infrarenal ne...
Journal of Vascular Surgery, 2002
Late onset graft or attachment site-related endoleaks may be hazardous, and early identification of patients at risk is important. We describe a patient who underwent implantation of a bifurcated stent graft 5.5 cm below the renal arteries because of a technical error with three extender cuffs implanted proximally to bridge the gap. During the 1st year, aneurysm diameter decreased from 68 to 52 mm. After 1 year, the patient had an acute endoleak develop, which originated between two of the extender cuffs and which was accompanied by severe abdominal pain and reexpansion of the aneurysm. This endoleak was treated with insertion of an additional bifurcated stent graft within the extender cuff segment. The patient has been subsequently followed for 6 months and has had no endoleak or symptoms, and aortic diameter has decreased once again to 55 mm. (J Vasc Surg 2002;35:580-3.)
Use of Proximal Aortic Cuffs as an Adjunctive Procedure during Endovascular Aortic Aneurysm Repair
Vascular, 2005
The purpose of this study was to evaluate the incidence and durability of additional proximal cuffs during endovascular abdominal aortic aneurysm repair (EVAR). A retrospective review of 90 EVAR patients was conducted. Postoperative survival, proximal sealing zone-related complications, and secondary procedures were analyzed. Additional proximal cuffs were used in 11%. Their use did not affect postoperative survival (p = .58), type I endoleak rate (4.4%; p = .19), or the need for sealing zone-related secondary procedures (6.3%; p = .38) compared with patients without cuff placement but was related to a higher cumulative graft migration rate (2.2% overall p = .02). Two patients (2.5%; p = .79) underwent conversion to open surgery, both for proximal sealing zone-related complications. Application of proximal cuffs appears to be an effective intraoperative adjunctive procedure to achieve a proximal seal during EVAR, with favorable midterm results. However, the risk of late endograft migrations may be elevated in this group.
Management of endoleak after endovascular aneurysm repair: cuffs, coils, and conversion
Journal of Vascular Surgery, 2003
The effectiveness of endovascular treatment of abdominal aortic aneurysm (AAA) may be limited by persistent perfusion of the aneurysm sac (endoleak). Endoleak that results in persistent systemic pressurization of the aneurysm or in continued AAA expansion is believed to require treatment to prevent rupture. This report describes the results of three techniques used to treat endoleak. Methods: Endovascular repair of AAA was performed in 597 patients between January 1996 and September 2002. Seventy-three endoleaks that required treatment developed in 70 patients (11.7%). These involved the graft attachment site (type I) or the graft junction site (type III) or originated from collateral side-branch vessels (type II) and were associated with an increase in aneurysm size. Endoleak type was confirmed at angiography in all cases. Average time between the initial endovascular procedure and endoleak treatment was 14.5 ؎ 5.7 months. The techniques used for endoleak treatment were deployment of an endovascular extension graft or cuff (n ؍ 44), coil embolization (n ؍ 24,) and conversion to conventional open repair (n ؍ 5). Configurations of endovascular grafts in which endoleak developed were bifurcated (n ؍ 44), aortouniiliac (n ؍ 15), and aortoaortic-tube (n ؍ 11). Mean follow-up after endoleak treatment was 24.5 ؎ 12.2 months (range, 1-60 months). Results: Endovascular extension grafts or cuffs were used to treat 41 attachment site endoleaks and 3 graft junction endoleaks, with overall technical success rate of 97%. Embolic coils were used to treat 16 retrograde side-branch endoleaks and 8 attachment site endoleaks, with overall technical success rate of 87%. Conversion to open surgery was performed in 4 patients with attachment site endoleaks and 1 patient with a graft junction site endoleak, and was successful in all cases. After endoleak treatment, aneurysm size decreased (>5 mm) in 38% of patients, stabilized in 58% of patients, and increased (>5 mm) in 4% of patients. Major morbidity occurred in 7.0%, with no perioperative deaths. Conclusions: Endovascular extension grafts, coil embolization, and conversion to open surgery each may be used to effectively repair endoleak. Selection of the treatment method used is determined by the anatomic characteristics of the endoleak and the patient's ability to tolerate conventional repair. Conversion to open repair was uniformly successful. Deployment of an extension cuff was successful when complete closure of the endoleak was achieved. Embolic coils were effective for retrograde endoleaks and provided stabilization of AAA size in selected patients with attachment site endoleaks in limited follow-up. (
Endovascular Repair for Abdominal Aortic Aneurysms: Initial Experience of an Endograft Programme
Asian Journal of Surgery, 2003
aneurysm repair has provided a less invasive therapeutic alternative to conventional open surgery. 5 With improvements in endovascular devices and greater experience, favourable early and mid-term results were reported for various commercially available devices. 6-8 As with all new procedures, there is a definite learning curve, 9 and there is always concern over their safety and efficacy, especially during the initial phase of an aortic endograft programme. The aim of this study was to evaluate the early clinical results of elective endovascular repair for abdominal aortic aneurysms during the initial phase of an aortic endograft programme and to compare them with that of conventional open surgery.
Journal of Vascular Surgery, 2003
Objectives: The purpose of this study was to review our experience with delayed open conversion (>30 days) following endovascular aortoiliac aneurysm repair (EVAR) and to introduce the concept and advantages of endograft retention in this setting. Methods: From January 1992 to January 2003, a total of 386 EVARs using a variety of endografts were successfully deployed. Eleven (2.8%) patients required delayed conversion to open repair at an average of 30 months (range, 10-64). Data from all patients undergoing both EVAR and open conversion were prospectively collected. Results: EVARs were performed using grafts made by Talent (4), Vanguard (2,) AneuRx (1), and Surgeon (4). Conversion to open repair (9 transabdominal, 1 retroperitoneal, 1 transabdominal plus thoracotomy) was performed for aneurysm rupture in 7 patients (4 type 1 endoleak, 2 type 2 endoleak, 1 aortoenteric fistula) and aneurysm enlargement in 4 patients (1 type 1 endoleak, 1 type 2 endoleak, 1 type 3 endoleak, 1 endotension). Patients with aneurysm rupture were treated on an emergent basis. Complete removal of the endograft with supraceliac cross-clamping was performed in two cases. One patient (rupture) did not survive the operation, and one patient (aortoenteric fistula) died 2 weeks postoperatively. In the remaining nine cases, the endograft was either completely (1) or partially (6) removed, or left in situ (2). Supraceliac balloon control (2), supraceliac clamping (1), suprarenal clamping (1), or infrarenal clamping (5) was used in these cases. All nine of these patients survived the operation. In one procedure in which the endograft was left intact (endotension), repair was accomplished by exposing the endograft and by placing a standard tube graft over it as a sleeve. In the second procedure in which the graft was left in situ (rupture), the graft was well incorporated, and bleeding lumbar arteries were oversewn and the sac was closed tightly over the endograft. In the remaining 7 cases, the endograft was transected and the proximal portion only (6) or the proximal and distal portions (1) were excised. All surviving patients continue to do well and remain without complications associated with the endograft remnant at a mean follow-up of 22 months (range, 3-56) from the time of open conversion and 46 months (range, 10-73) from the time of original EVAR. Conclusions: Open repair in the setting of a long-standing endograft offers several unique technical challenges but can be successfully accomplished in most patients. Preservation of all or part of the endograft is possible in many patients. This technique simplifies the operative approach and is preferred over complete endograft removal if possible.
Midterm durability of abdominal aortic aneurysm endograft repair: A word of caution
Journal of Vascular Surgery, 2001
Purpose: Endograft technology for abdominal aortic aneurysm (AAA) repair is being applied more liberally. There is little information about the midterm performance of these grafts. This study is focused on follow-up interventions after endograft repair for AAA. Methods: Prospective follow-up analysis of a consecutive patient series (n = 173 patients) at a single center who underwent endovascular AAA repair up to 50 months after operation. Seventeen percent of the patients were regarded unfit for open surgery. Four types of commercially available grafts were used. The Society for Vascular Surgery/International Society for Cardiovascular Surgery guidelines were applied for endograft implantation and data preparation. Results: In two patients, the procedure was converted to open surgery. In one procedure, emergency repair for iliac artery rupture was performed. The 30-day mortality rate was 2.8% (n = 5 patients). An early second procedure to correct type I endoleaks was necessary in 8 cases (4.6%; 3-10 days). The following midterm results were obtained: median follow-up of the 166 remaining patients was 18 months (range, 1-50 months); 50 additional procedures were necessary in 37 patients (22.3%) for the treatment of leaks (n = 45 interventions) or to maintain graft patency (n = 5 grafts; four patients with concomitant graft segment disconnection); and 46% of the reinterventions were performed within the first year of followup and 74% of the reinterventions were performed within the second year of follow-up. One patient died after emergency surgery for rupture as the result of a secondary endoleak at 1 year. Although seven interventions (14%) were performed for type II endoleak, no serious complications were related to patent sidebranches. There was no statistically significant difference between the need for maintenance in different graft configurations (tubular, bifurcated, aorto-uniiliac), or number of graft segments . New generation grafts (after 1996) performed better than early generation grafts (P = 0.04, chi-squared test) with regard to endoleak development. Conclusion: Endograft repair for AAA is safe but, with current technology, not as durable as open repair. Our data suggest that the use of endograft repair for AAA is becoming safer as endograft design improves. Nevertheless in 26.6% of the patients, there is need for reintervention within midterm follow-up. Close follow-up is crucial because late leaks may develop after more than 2 years after the initial procedure. Endoluminal repair should therefore be applied with caution, strict indication, and only if a tight follow-up is warranted. These findings may also affect health care reimbursement policies. J Vasc Surg 2001;33:S46-54.) JOURNAL OF VASCULAR SURGERY Volume 33, Number 2 * Rutherford R, Flannigan D, Gupta S, et al. Suggested standards for reports dealing with lower extremity ischemia. J Vasc Surg 1986;4:80-94.
Cardiovascular Surgery, 1998
The incidence and indications for conversion from endoluminal to open repair of abdominal aortic aneurysms are changing. This paper is based on a S-year experience in which endoluminal repair of abdominal aortic aneurysms was undertaken in IS6 patients. Primary conversion at the original operation was required in 14 patients and secondary conversion at a subsequent operation was required in 9 patients. The reasons for primary conversion were access problems (n = 2). balloon related problems (n = Z), endograft migration (n = 4), endograft thrombosis (n = 1) and failed deployment of a bifurcated endograf? (n = 5). Twelve of 14 primary conversions occurred in the first half of the study period, in which 59 endoluminal abdominal aortic aneurysms repairs were undertaken. Improvements in technology and interventional techniques for overcoming obstacles. as well as increasing experience, has resulted in primary conversion being limited to two patients in the most recent ZS-year period in which 97 endoluminal repairs were undertaken.
Infrarenal endograft clamping in late open conversions after endovascular abdominal aneurysm repair
Journal of Vascular Surgery, 2017
Objective: The aim of this study was to report the technical aspects and outcomes of late open conversion (LOC) after endovascular aneurysm repair (EVAR) in a single center by using exclusively infrarenal clamping of the endograft as an alternative to suprarenal or supraceliac aortic clamping. Methods: A retrospective analysis of EVAR requiring late explantation (>30 days) from January 1996 to October 2016 was performed. Patients' demographics, type of endograft, duration of implantation, reason for removal, extent of stent graft removal, type of reconstruction, 30-day mortality, postoperative complications, and long-term survival were obtained for analysis. Results: During the study period, 28 patients required LOC. The mean age at conversion was 75.11 6 6.65 years; 26 of 28 (92.86%) were male. Grafts were excised after a median of 41.4 months (range, 5.97-112.67 months), with 21 of 28 explantations (75%) performed electively. Multiple types of EVAR devices have been explanted; suprarenal fixation was present in 75% of the cases. The indication for LOC was the presence of an endoleak in 27 cases (20 type I, 4 type II associated with aneurysm growth, 3 type III, and 3 endotensions; in 3 cases, multiple types of endoleak were present) and graft thrombosis in 1 case. All patients underwent a transperitoneal approach with infrarenal clamping. No patient required revascularization of visceral or renal vessels. Complete removal of the stent graft was performed in 8 of 28 cases, partial removal in the remaining 20 cases (with conservation of the proximal portion in 16 of 20 cases). Technical success was 100%. Overall 30-day mortality was 7.14% (2/28). The 30-day mortality was 9.5% in elective patients and 0% in the urgent setting; this difference was not statistically significant (P ¼ .56). Postoperative kidney injury rate was 7.7% (2/26). Mean follow-up was 47.37 6 55.67 months (range, 0.23-175.07 months). The estimated 5-year survival rate was 78%. No aneurysm-related death or additional procedure occurred during follow-up. Conclusions: LOC after EVAR using infrarenal clamping of the endograft is a feasible and effective technique, with satisfactory postoperative mortality and morbidity. This method allows simplification of the surgical technique and may avoid renal and visceral complications related to suprarenal or supraceliac clamping.
Annals of vascular surgery, 2004
The development of an ideal aortic stent graft continues to progress. New devices and techniques are expanding the use of endovascular repair in the treatment of abdominal aortic aneurysms (AAA). We present data with intraoperative composite endograft (CEG) techniques evaluating immediate and short-term compatibility of components and patients outcome. Twenty-five of 66 patients (38%) received intraoperative CEGs for AAA treatment. A total of 50 components were used to treat type I endoleaks, prevent graft limb kinking or treat associated iliac aneurysm. Nine of the components were used to manage type I proximal endoleaks. Forty-one components were used at the iliac limb for distal type I endoleak, hostile iliac anatomy, or graft limb support or to treat an associated iliac aneurysm. Two patients were left with a type I endoleaks at the iliac attachment site on completion of graft placement. With a mean follow-up of 11 months. Two of 25 patients had a type II endoleak at 6 months. O...