Albert G. Hakaim

Natural History of the Iliac Arteries after Endovascular Abdominal Aortic Aneurysm Repair and Suitability of Ectatic Iliac Arteries as a Distal Sealing Zone

PURPOSE To investigate the natural history of dilated common iliac arteries (CIA) exposed to pulsatile blood flow after endovascular abdominal aortic aneurysm repair (EVAR) and the suitability of ectatic iliac arteries as sealing zones using flared iliac limbs. METHODS Follow-up computed tomograms of 102 CIAs in 60 EVAR patients were investigated. Diameter changes in CIAs < or =16 mm (group 1) were compared with changes in vessels where a dilated segment >16 mm in diameter continued to be exposed to pulsatile blood flow (group 2). Within group 2, cases in which the stent terminated proximal to the dilated artery segment (2a) were compared with those that had been treated with a flared limb (2b). RESULTS The mean CIA diameter increased by 1.0+/-1.0 mm in group 1 (p<0.001 versus immediately after EVAR) and by 1.5+/-1.7 mm in group 2 (p<0.001 versus immediately after EVAR) within an average follow-up of 43.6+/-18.0 months. Diameter increase was more pronounced in dilated CIAs (p=0.048), and it was not significantly different between groups 2a and 2b (p=0.188). No late distal type I endoleak or stent-graft migration associated with CIA ectasia was observed. CONCLUSION Dilatation of the CIA is significant after EVAR, and it is more pronounced in ectatic iliac arteries. Although ectatic iliac arteries appear to be suitable sealing zones in the short term, continued follow-up is mandatory.

Impact of gender on the outcome of endovascular aortic aneurysm repair using the Zenith stent-graft: midterm results.

PURPOSE To analyze the 2-year outcomes of female patients after endovascular aortic aneurysm repair (EVAR) with the Zenith AAA Endovascular Graft. METHODS A retrospective analysis was conducted of data from the US Zenith multicenter trial and the Zenith female registry on 40 women (10.9%, study group) and 326 men (89.1%, control group) enrolled. All patients had completed their 2-year follow-up. Primary study endpoints were survival, aneurysm rupture, and conversion rate. Significance was assumed if p<0.05. RESULTS Overall rates of mortality (12.5% for women versus 13.2% for men, p = 0.94) and aneurysm rupture (2.5% for women versus 0% for men, p = 0.11) were comparable between groups. Conversion to open repair within 2 years was significantly more frequent in women compared to men (7.5% versus 0.6%, p = 0.01). The incidence of endoleaks of any type was equivalent between groups at 2 years (13.3% for women versus 6.9% for men, p = 0.30). No difference was observed in the need for secondary interventions (15% for women versus 13.5% for men, p = 0.81) or aneurysm dilatation >5 mm (10.5% for women versus 2.3% for men, p = 0.10). None of the patients developed device migration >10 mm or required intervention for migration. CONCLUSION While women underwent conversion to open repair more frequently compared to men at 2 years post EVAR, there was no difference in survival, freedom from aneurysm rupture, or need for secondary interventions between groups. As in men, the Zenith AAA Endovascular Graft provides reliable protection from aneurysm rupture and aneurysm-related death in women in a midterm follow-up.

Evaluation of Subclinical Cerebral Injury and Neuropsychologic Function in Patients Undergoing Carotid Endarterectomy

We examined subclinical alterations of cerebral function during carotid endarterectomy (CEA) and predictability of minor cerebral damage by perioperative levels of biochemical markers of brain damage (S100B and neuron-specific enolase [NSE]). Twenty consecutive patients with > or =70% asymptomatic carotid stenosis undergoing elective CEA were enrolled. Pre- and postoperative testing included magnetic resonance imaging (MRI) of the head, a standardized neurological exam, a battery of neuropsychological tests, and measurement of serum levels of S100B and NSE. There were no major ischemic strokes. In one patient, a mild weakness of the contralateral lower extremity was discovered on neurological examination; in another individual, postoperative MRI revealed two new small subcortical lesions without clinical correlate. While S100B increased significantly early after opening of the carotid clamp (p = 0.015), the NSE increase did not reach statistical significance. As a group, participants obtained a significantly higher mean overall neuropsychological score at follow-up testing (p < 0.05). In one patient, a significant decline of cognitive function was observed. This was the only individual to obtain a consistently high S100B and NSE increase. Neuropsychological testing combined with measurements of S100B and NSE may improve sensitivity when assessing subtle cerebral damage following CEA.

Endovascular repair of abdominal aortic aneurysms: where do we stand?

Endovascular repair of abdominal aortic aneurysms has evolved dramatically within the past few years. In light of the potential to reduce morbidity and mortality associated with open surgical repair, endoluminal grafting offers therapeutic options to patients who are not surgical candidates because of comorbidities. With the development of bifurcated devices, more complex aneurysms may be treated by endovascular grafting. Although successful placement of endovascular grafts requires a pronounced learning curve, including appropriate patient selection, midterm results seem consistent with those of traditional open repair of aneurysms. This review describes the current indications, minimal requirements, different devices and associated techniques, and potential complications of endoluminal repair of abdominal aortic aneurysms. Future aspects of endoluminal grafting are also discussed.

Paravertebral blockade with propofol sedation versus general anesthesia for elective endovascular abdominal aortic aneurysm repair.

The objective of this study was to evaluate the applicability of paravertebral blockade (PVB) for endovascular abdominal aortic aneurysm repair compared with general anesthesia (GA). Data from patients who underwent elective infrarenal endovascular abdominal aortic aneurysm repair between August 2001 and July 2002 using PVB or GA were retrospectively reviewed and compared with respect to risk factors, intraoperative hemodynamic characteristics, operative outcome, and complications. Ten patients underwent elective infrarenal endovascular abdominal aortic aneurysm repair under PVB, whereas 15 patients were operated on under GA. One conversion from PVB to GA was necessary for block failure. The perioperative (< 30 days) cardiovascular morbidity and overall mortality were zero in both groups. The PVB group benefited significantly with respect to the incidence of intraoperative hypotension (p < .05) and blood pressure lability (p < .01), as well as postoperative nausea (p < .01). Our preliminary results indicate that PVB is feasible and can be performed safely in a patient population with significant comorbidities.

Percutaneous Protective Coil Occlusion of the Proximal Inferior Mesenteric Artery before N-Butyl Cyanoacrylate Embolization of Type II Endoleaks after Endovascular Repair of Abdominal Aortic Aneurysms

Bowel ischemia can complicate treatment of type II endoleak with liquid or semiliquid agents such as n-butyl cyanoacrylate (NBCA) if nontarget embolization of the inferior mesenteric artery (IMA) occurs. The current report describes four cases of type II endoleak in which the IMA was the main outflow vessel and was prophylactically occluded with embolization coils before NBCA injection into the endoleak nidus. The purpose was to prevent unintentional embolization of the NBCA into IMA branches. If feasible, protective IMA coil occlusion should be considered in type II endoleaks with IMA outflow in cases of NBCA embolization.

Treatment of a mycotic descending thoracic aortic aneurysm using endovascular stent-graft placement and rifampin infusion with postoperative aspiration of the aneurysm sac

Purpose: Mycotic aortic aneurysms are rare but are associated with high morbidity and mortality due to their propensity for rupture. Traditional therapy consists of open surgical repair with resection and aortic reconstruction or extra-anatomic bypass combined with long-term antibiotic therapy. Case report: An 85-year-old male with persistent bacteremia was found to have a descending mycotic aortic aneurysm. Surgical options were discussed and endovascular treatment was recommended with stent-graft placement followed by intra-aortic rifampin infusion. This approach led to resolution of the aneurysm and eradication of bacteremia at 4-month follow-up. Conclusion: By combining traditional surgical strategies with a contemporary endovascular approach, the perioperative mortality and long-term risk of infection associated with mycotic thoracic aneurysms can potentially be decreased.

Use of proximal aortic cuffs as an adjunctive procedure during endovascular aortic aneurysm repair

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.

Long-Term Results of Endovascular Aneurysm Repair with Aortouni-iliac Custom-Made Stent Grafts

The purpose of this study was to review the outcome of endovascular abdominal aortic aneurysm repair (EVAR) using custom-made aortouni-iliac (AUI) devices with femorofemoral bypass. Between June 1999 and March 2001, 23 consecutive patients (1 female, 22 male) at high risk of open aortic aneurysm repair underwent EVAR with custom devices in an AUI configuration. The mean follow-up was 37 months (range 2–72 months), and the mean age was 76.8 years (range 67.5–88.7 years). Increased surgical risk was evidenced by 92% and 69% of patients with significant pulmonary or cardiac disease, respectively. The preoperative mean aneurysm diameter (n = 23) 62 ± 8.2 mm was significantly greater than the postoperative diameter, (n = 23) 54 ± 16.4 mm. Ten endoleaks occurred. Migration of the stent graft occurred in 9% (n = 2). Secondary interventions were necessary in 23%, whereas tertiary interventions were required in 9%. Patients at high risk of open aneurysm repair received sufficient protection from aneurysm rupture with custom-made AUI devices.

Long-term Results of Aortouniiliac Stent Grafts for the Endovascular Repair of Abdominal Aortic Aneurysms

BACKGROUND Long-term follow-up of patients with aortouniiliac (AUI) grafts is lacking in the current literature. The purpose of this study was to review the outcomes of endovascular aneurysm repair (EVAR) using commercially available AUI devices with femorofemoral bypass in patients whose aortoiliac anatomy was unfavorable for bifurcated repair. METHODS A retrospective review of 35 patients from September 2000 to February 2012, who underwent EVAR with commercially manufactured AUI devices, was performed. These comprised 35 of 372 (9.4%) patients who underwent EVAR during that period. Patient records were reviewed to determine morbidity, mortality, and survival after AUI repair. Patients were followed at 1-, 3-, 6-, and 12-month intervals with computed tomography (CT) scans during each visit. Median follow-up was 40 months (range: 2-135 months). RESULTS Median age at surgery was 76 years (range: 60-93). The median preoperative aneurysm diameter was 57 mm (range: 45-71) and the median postoperative diameter was 53 mm (range: 29-80). Two type II endoleaks occurred on 1-month CT, whereas 10 endoleaks (type I [3], II [6], and III [1]) occurred during follow-up after 1 month. Migration of the stent graft occurred in 9% (n=3). Secondary procedures were required in 26% (n=9), whereas tertiary procedures were required in 3% (n=1). One patient required treatment for thrombosis of the iliac extension and 2 required treatment for thrombosis of the femorofemoral component. Mortality over the follow-up period was 34% (n=12) with no deaths occurring within 30 days. CONCLUSIONS High-risk patients who present with aortoiliac anatomy unsuitable for bifurcated stent graft placement should be offered AUI graft placement as a potential alternative to open repair.