Larry H. Hollier

Intraoperative rupture of an abdominal aortic aneurysm during an endovascular stent-graft procedure

PurposeTo highlight the risk of intraoperative rupture as a complication of endovascular aortic repair.Clinical featuresAn 81-yr-old man was admitted for endovascular aortic repair of a 6 cm infrarenal abdominal aortic aneurysm. After establishment of a conduction blockade using a combined spinal-epidural technique, a balloon-activated endovascular stent-graft was advanced to the proximal aneurysmal neck. Approximately four minutes after the stent-graft was deployed, the mean arterial pressure decreased to 30 mmHg and the heart rate increased to 135 bpm. While fluid and vasoactive medications were administered and the airway was secured, repeat aortography confirmed contrast extravasation into the retroperitoneal space at the junction of the proximal aortic neck and the aneurysm sac. The angioplasty deployment balloon was repositioned and inflated proximal to the presumed site of aortic rupture, thus providing aortic control until an open repair of the aorta was undertaken.ConclusionAlthough endovascular stent-graft placement may be a less invasive method than conventional open aortic reconstruction, it must be recognized that the potential for devastating consequences such as aortic rupture is present.RésuméObjectifSouligner le risque de rupture peropératoire comme complication d’une réparation aortique endovasculaire.Éléments cliniquesUn homme de 81 ans a été admis pour la réparation aortique endovasculaire d’un anévrisme infrarénal de l’aorte abdominale. Après avoir établi un bloc de conduction selon une technique rachidienne et péridurale combinée, un greffon-tuteur endovasculaire, activé par un ballonnet, a été introduit jusqu’au collet proximal de l’anévrisme. Environ quatre minutes après le déploiement du greffon-tuteur, la tension artérielle moyenne a chuté à 30 mmHg et la fréquence cardiaque a augmenté à 135 bpm. Pendant l’administration de liquide et de médicaments vasoactifs et les manoeuvres visant à assurer la liberté des voies aériennes, l’aortographie répétée a confirmé une extravasation de contraste dans l’espace rétropéritonéal à la jonction du collet aortique proximal et du sac anévrismal. Le ballonnet a été replacé et gonflé près du site présumé de la rupture aortique, permettant ainsi de préserver l’aorte jusqu’à ce qu’une réparation chirurgicale soit réalisée.ConclusionBien que la mise en place d’un greffon-tuteur endovasculaire soit moins effractif que la reconstruction aortique chirurgicale habituelle, il faut reconnaître la présence potentielle de graves conséquences, comme une rupture aortique.

Patient selection for endovascular repair of aortoiliac aneurysms.

PURPOSE This study was conducted to establish criteria to aid in the selection of patients for endovascular repair of aorto-iliac aneurysms. METHODS Characterization of pertinent factors used to determine whether a patient is eligible to undergo stent-graft repair of an aorto-iliac aneurysm. PRINCIPAL FINDINGS AND CONCLUSIONS The determinant factor that dictates whether or not one is eligible to undergo endovascular repair of aorto-iliac aneurysm is the arterial anatomy of the affected area and its surrounding vessels. Some of the initial limitations imposed in this technology have changed such as an acceptance of much shorter neck than initially conceptualized, by the use of supra-renal stent deployment. However, unsolved issues remain regarding the differentiation of thrombus and atherosclerotic plaque in the infra-renal aortic region, iliac artery disease, and the need to have an enhanced flexibility of the delivery system for proper deployment in tortuous aortic necks. The question of long-term device durability remains the most important issue that has to be taken into consideration before one chooses minimally invasive endovascular approaches.

Combined open and endovascular repair of a syphilitic aortic aneurysm

The use of endovascular stent grafts in the repair of thoracic aortic aneurysms has provided an alternative means of treatment, particularly in the high-risk patient who may not tolerate conventional open repair. The combination of conventional surgery and endovascular repair may allow for successful treatment in patients with anatomy unsuitable for repair entirely by endovascular means alone. We present the case of a patient with a syphilitic thoracic aortic aneurysm involving the aortic arch and descending thoracic aorta. He underwent a staged repair with an elephant trunk reconstruction of the aortic arch followed by endovascular repair of the descending thoracic aorta. This is the first reported case of the repair of a syphilitic aneurysm by means of endovascular techniques.

Experience with endovascular grafts in the treatment of infrarenal aortic aneurysms associated with proximal aortic dissection

BACKGROUND Chronic abdominal and thoracic aortic dissections often present with concomitant infrarenal aortic dilatation. We conducted a retrospective review of 6 patients treated with endovascular stent grafts for coexisting aortic dissection and infrarenal aneurysm. METHODS Six patients with suprarenal aortic dissections and infrarenal aortic aneurysms (AAA) had their AAAs treated with endovascular grafts. Grafts were constructed of balloon expandable Palmaz stents and expanded polytetrafluoroethylene graft. The device was inserted transfemorally and deployed under fluoroscopy. RESULTS Successfully primary AAA exclusion was achieved in 5 patients. One patient required a supplemental stent placed above the endograft and into the true lumen to seal the endoleak. No aneurysm has enlarged, and all remain thrombosed for 9 to 24 months (mean 20). One type III dissection enlarged 2 weeks after endograft insertion. One patient had uncomplicated cephalad fenestration of a dissection by the endograft. CONCLUSIONS Endovascular grafts may be used to treat coexisting AAA and aortic dissection. Attention to the site or sites of reentry of a dissection is essential to insure full aortic aneurysm exclusion. The fate of a chronic aortic dissection cephalad to an endovascularly treated AAA is unclear and will require longer follow-up.