Finn Farquharson

A systematic review of open versus endovascular repair of inflammatory abdominal aortic aneurysms.

INTRODUCTION Inflammatory abdominal aortic aneurysms (IAAAs) have traditionally been treated by open surgical repair (OSR). Over the last decade, endovascular aneurysm repair (EVAR) has been increasingly employed. The optimal treatment option for IAAA remains unclear. This article aims to evaluate and compare outcomes of OSR and EVAR in IAAA repair. METHODS All publications in the English language relating to IAAA were sought electronically using OVID and MEDLINE (1972-2008). Studies identifying 30-day mortality were considered. Periaortic inflammation (PAI), hydronephrosis and 1-year mortality were obtained from studies with at least 1-year computed tomography (CT) follow-up. Outcomes of OSR and EVAR were compared and analysed for statistical significance using Fishers exact test. RESULTS The results were obtained from 35 studies comprising 999 patients and 21 studies with 121 patients who underwent OSR and EVAR, respectively. One-year CT follow-up was available for 124 and 52 patients from the two groups, respectively. Thirty-day mortality after OSR was 6% (95% confidence interval (CI); 6-13) and 2% (95% CI; 0-7) after EVAR (p=0.1). At 1 year, PAI regressed in 73% (95% CI; 64-80) in the OSR group compared to 65% (95% CI; 49-77) of the EVAR group (p=0.7). Conversely, inflammation progressed in 1% and 4%, respectively (p=0.1). Forty-five patients undergoing OSR and 29 EVAR were found to have preoperative hydronephrosis. This regressed postoperatively in 69% (95% CI; 53.3-81.8) and 38% (95% CI; 20.6-57.7), respectively (p=0.01). Hydronephrosis progressed in 9% of patients after OSR and in 21% after EVAR (p=0.1). New-onset hydronephrosis developed in 6% undergoing OSR compared to 2% with EVAR (p=0.2). One-year all-cause mortality after OSR was 14% (95% CI; 6-18) compared to 2% (95% CI; 0-13) after EVAR (p=0.02). CONCLUSION Either OSR or EVAR may be considered based on patient suitability. EVAR is associated with lower 1-year mortality compared to OSR. However, OSR may be preferred in those patients who have hydronephrosis and are deemed low risk.

Contemporary Management of Aorto-iliac Aneurysms in the Endovascular Era

Up to 40% of abdominal aortic aneurysms have co-existing unilateral or bilateral iliac artery ectasia or aneurysm. These are associated with an increased risk of endoleak, morbidity and mortality following endoluminal repair. To reduce the adverse sequelae of internal iliac artery (IIA) occlusion, various open, endovascular and hybrid measures have been described to maintain perfusion to the pelvis. This review discusses the contemporary management of aorto-iliac aneurysm in the endovascular era with reference to the sequelae of IIA occlusion and the strategies to preserve IIA perfusion. Particular consideration is given to iliac bifurcation devices.

Endovascular Repair of Complex Aortic Aneurysms

Since the first published report of a fenestrated endovascular aneurysm repair, we have seen an expansion in the range of custom-made devices used to manage complex aortic aneurysms. Fenestrated devices, branched devices, and chimneys are now frequently used in many centers to repair these aneurysms. Similar to standard endovascular aneurysm repair, the advantages of less operative blood loss, decreased hospital stay, and reduced risk of morbidity and mortality hold true for endovascular repair of complex aneurysms as well. This is contrasted by the requirement for long-term surveillance and increased incidence of secondary interventions.

Abdominal aortic aneurysm repair: The carotid approach.

We present the case of a 61-year-old man with a 5.8 cm infrarenal aortic aneurysm with extensive iliac disease that did not permit conventional EVAR, who was also judged to be too high risk for open surgery. Despite these factors, the aneurysm was still successfully repaired using endovascular means and an alternative access technique. This involved a specially commissioned Zenith aorto-uniliac endograft reverse mounted onto a TX2 delivery device, delivered via the carotid artery.

Arteriovenous fistula failure: Is there a role for accessory draining vein embolization?

Purpose Arterio-venous fistulae (AVFs) are accepted as the best form of haemodialysis vascular access (VA) but are plagued by high primary failure. Accessory drainage veins (ADVs) may account for up to 40% of these failures. Furthermore, they may also lead to low flow in ‘mature’ AVFs. Methods We analysed the results of 42 patients who underwent endovascular coiling of ADVs at our centre over a 4-year period. Results Indications were failure to mature in 34%, low flow or cannulation difficulty in 56% and thrombosis in 10% of cases. 95% procedures involved a combination of angioplasty and coiling with only 5% patients having coiling of ADV alone. Forearm AVFs constituted the majority of the cases as opposed to upper arm AVFs (74% vs. 26% respectively). Primary patency at 3, 6, 12, 18 and 24 months was 90%, 87%, 76%, 70% and 55% respectively. Successful dialysis was achieved in 10 of the 14 fistulae that had hitherto failed to mature. Coil migration was observed in 1 patient, which led to fistula occlusion. Conclusion Coil embolisation of ADVs is an effective treatment option for dysfunctional fistulae that can be performed at the same time as angioplasty.

Treatment of aortoiliac aneurysms with the iliac bifurcated device for preservation of internal iliac artery flow.

Introduction: The iliac bifurcated device (IBD) is an innovative endovascular device for aortoiliac aneurysm repair. The objective of this study is to provide further evidence on the efficacy and safety of the device. Study Design: Case series study with retrospective analysis of prospectively collected nonrandomized data. Methods: Between 2007 and 2010, all consecutive IBD placements were analyzed. The main outcomes included (1) technical failure; (2) morbidity and mortality; and (3) late outcomes. Prospective follow-up was performed by interval computed tomography scanning. Results: In all, 27 consecutive patients had elective placement of 28 IBDs. Mean operating time was 251.1 ± 65.4 minutes, mean fluoroscopy time was 63.9 ± 27.2 minutes, and mean contrast volume used was 186.2 ± 106.7 mL. Periprocedural type I endoleak occurred in 2 patients. No aneurysm-related adverse events were recorded. Conclusion: We demonstrate that IBDs can be used in patients with aortoiliac aneurysms and are associated with satisfactory medium-term results as expressed by high patency and low reintervention rates.

Bifurcated abdominal aortic endograft deployment via the carotid artery.

BACKGROUND We report the use of the common carotid artery as an alternate access in endovascular therapy. METHODS/RESULTS A 77-year-old man with an enlarging abdominal aortic aneurysm in whom previous attempts at standard endovascular repair had failed because of difficult iliac access underwent endovascular repair via the left common carotid artery. A custom-made Zenith infrarenal bifurcated stent graft was reverse-loaded on a thoracic distal delivery device and deployed in a caudal-to-cranial fashion. The patient made an uneventful recovery without any complications. Computed tomography confirmed exclusion of the aneurysm. CONCLUSION This case report highlights the role of the common carotid artery as an access vessel for stent-graft deployment when standard access via the femoral and iliac routes is unachievable.

Endovascular Repair of Aorto-Bi-Iliac Aneurysm

Iliac bifurcated devices (IBDs) are used in the endovascular treatment of aorto-iliac and common iliac artery aneurysms to preserve the flow to at least one internal iliac artery thereby decreasing the risk of pelvic ischemic complications. We report the use of IBDs in preserving both the internal iliac arteries.

Rupture of an Abdominal Aortic Aneurysm Post EVAR: A Rare Presentation of Retroperitoneal Liposarcoma

Endoleak is the classical cause of rupture of aneurysms previously treated by endovascular means. We report a rare case of a retroperitoneal liposarcoma (LIS) invading an abdominal aortic aneurysm (AAA), previously treated by endovascular repair (EVAR), causing rupture. Furthermore, a brief discussion of the diagnostic challenges posed by retroperitoneal tumors is presented with a closing note on their management.