Martin Delle

Aneurysm Sac Hygroma: A Cause of Endotension

Purpose: To describe a new pathophysiological mechanism for endotension. Case Reports: Four patients developed aneurysm sac expansion after repair of abdominal aortic aneurysms, one with a conventional polytetrafluoroethylene (PTFE) graft and the others with a variety of commercially made endografts (2 PTFE, 1 Dacron). Pressures within the sacs were nonpulsatile and approximately half the systemic blood pressure. Attenuation on computed tomography (CT) was significantly less in the sac than in the graft in 3 of the patients. A clear, highly viscous fluid was aspirated from all 4 sacs, supporting the diagnosis of aneurysm sac hygroma. Prominent local hyperfibrinolysis in the sac was combined with signs of local coagulation activation. Conclusions: A new mechanism for continued sac expansion based on aneurysm sac hygroma is proposed. Measurement of attenuation may be of diagnostic value. It is further proposed that local hyperfibrinolysis/coagulation may promote rebleeding, liquefaction, and continued expansion analogous to the chronic subdural hematoma.

Endograft therapy for diseases of the descending thoracic aorta: results in 43 high-risk patients.

Purpose: To report an initial experience with endovascular stent-graft implantation for diseases of the descending thoracic aorta in high-risk patients. Methods: Forty-three patients (28 men; mean age 67 years, range 17–82) with 16 descending thoracic aortic dissections, 14 aneurysms, 7 contained ruptures, 3 mycotic aneurysms, 2 posttraumatic pseudoaneurysms, and an aneurysm of an anomalous right subclavian artery were treated between June 1999 and July 2001. Twenty-three (53%) patients were treated emergently. Results: There were no conversions to open repair, but 3 (7%) patients died during the first 30 days (pneumonia, multiorgan failure, and acute bowel ischemia). Thirteen (30%) patients suffered 18 major complications (8 strokes, paraplegia in 3, respiratory insufficiency in 6, and 1 renal failure). Of 7 (16%) endoleaks detected in the early postoperative period, 3 required additional stents, while the other 4 were treated conservatively. Follow-up, which averaged 19 ± 6 months (median: 13; range 0–34), was 100% complete. Five (12%) patients died: 3 of aortic rupture at 34, 47, and 139 days, respectively, and 2 from heart failure at 3 and 15 months, respectively. No late migration or endoleaks have been detected in the remaining 35 patients; however, 1 (2%) patient showed progressive aortic dissection proximal to the stent-graft. In all other cases, the size of the aneurysm or the false lumen was unchanged or diminished. Conclusions: Treatment of descending thoracic aortic diseases with an endovascular approach has acceptable early mortality and morbidity in high-risk patients. In selected cases, stent-grafts may afford the best therapy.

Preserved Pelvic Circulation after Stent-Graft Treatment of Complex Aortoiliac Artery Aneurysms: A New Approach

Purpose: To describe an endovascular technique that allows stent-graft treatment of aortoiliac aneurysmal disease affecting both common iliac arteries (CIA), with maintenance of pelvic circulation on one side. Technique: For patients with aortoiliac aneurysms, both common femoral arteries (CFA) were surgically exposed. One internal iliac artery (IIA) was initially embolized with coils. A bifurcated stent-graft main body was deployed with the proximal end just below the renal arteries. On the ipsilateral side, the stent-graft limb was extended 3 cm beyond the orifice of the embolized IIA into the external iliac artery (EIA) using stent-graft limb extenders. On the contralateral side, the stent-graft limb was deployed so that the distal end was 10 to 15 mm proximal to the patent IIA orifice. Via a left brachial artery access, the IIA was catheterized, and stent-grafts were deployed from the distal end of the contralateral AAA stent-graft limb into the IIA. A femorofemoral crossover graft provided circulation to the leg ipsilateral to the IIA stent-graft, and the EIA on the same side was ligated. The technique can also be modified to treat isolated bilateral CIA aneurysms. Conclusions: By extending the distal aspect of the stent-graft into an IIA, bilateral CIA aneurysms can be excluded while preserving pelvic circulation on one side.

Endovascular Treatment of Type B Thoracic Aortic Dissections

Abstract  Purpose: To evaluate the initial experience of endovascular repair of aortic dissections from a single center. Materials and Methods: From June 1999 to March 2002, endovascular stent grafting was performed in 20 high‐risk patients (16 to 80 years). Eighteen patients had a type B dissection (14 acute and 4 chronic). Two patients had chronic type A dissection. Preoperative work‐up included CT and MRI to evaluate the extent of the dissection, the relation to the left subclavian artery, the size of false and true lumen, and branch complications. Results: Stent‐graft deployment was technically successful in all cases. None was converted to open repair. Three patients died within 30 days, i.e., a 15% mortality rate. Four patients (20%) had a perioperative stroke. Paraplegia was observed in one case. No migration of the stent grafts or endoleaks was observed during the mean follow‐up period of 13 months. In all but two patient thrombosis of the false lumen was noted. Conclusions: Endovascular treatment of thoracic dissections is feasible. Early results are encouraging. While endovascular repair with stent‐grafts is progressing rapidly as a viable strategy for aortic dissections in selected patients careful investigations must continue to focus on its safety. Randomized controlled trials are urgently needed. (J Card Surg 2003;18:539‐544)

Management of Aneurysm Sac Hygroma

Purpose: To document the management strategies and outcome of patients diagnosed with sac hygroma following open or endovascular abdominal aortic aneurysm (AAA) repair. Methods: Seven men (median 68 years, range 43–79) with previous open (n=3) or endovascular (n=4) AAA repairs and increasing aneurysm diameters documented on spiral computed tomography (CT) were diagnosed with sac hygroma based on the lack of a demonstrable endoleak on CT imaging; the presence of a gelatinous, clear fluid in the sac; and a nonpulsatile sac pressure that was about one third of the systemic blood pressure. The patients were followed at regular intervals with spiral CT and percutaneous CT-guided translumbar intrasac pressure measurements. Surgical interventions were performed for sac diameter increase >5 mm or expansion-related pain. Blood samples and fluid aspirated from the sac were analyzed to detect activation of the coagulation and fibrinolytic systems. Results: Over a median 21.5-month follow-up, open fenestration with resection of the aneurysm wall or open tight wrapping of the wall around the graft in 4 patients did not prevent hygroma reoccurrence, nor did repeated punctures with aspiration of fluid in the other 3 patients. Aneurysm diameters remained unchanged during the observation period. Conclusions: Only symptomatic hygromas need be treated, but the treatment of choice remains to be established, since puncture, fenestration, or resection of the sac do not seem to be adequate.

Treatment of descending thoracic aneurysms by endovascular stent grafting.

Abstract  Purpose: Endovascular stent‐graft treatment for true aneurysms of the descending thoracic aorta is a valid and effective alternative to conventional surgery. A review of our experience with 21 consecutive patients is reported and technical considerations are discussed. Methods: Twenty‐one patients (mean age 73 years) with true aneurysms of the descending thoracic aorta (n = 14) or contained rupture (n = 7) were treated between October 1999 and July 2001. Seven patients (33%) underwent emergency endovascular procedure. Postoperatively, the patients were followed with CT scans at 1, 3, 6, and 12 months. Follow‐up, which averaged 17 months, was 100% complete. Thirty‐day results: No conversions to open repair were necessary. Two patients died (10%), one of acute intestinal ischemia and the other because of multiorgan failure. Four patients showed endoleaks immediately after stenting. Two patients required new endovascular stentgrafts, while the remaining two were treated conservatively. Besides endoleaks, eight major complications occurred in six patients (two stroke, two paraplegia, two respiratory insufficiency, and one renal failure). Mid‐term results: Three more patients died during the follow‐up period. One patient died of heart failure after a complicated postoperative course, 91 days after stenting. The second patient died because of aortic rupture, 139 days after stenting. The third patient died of heart failure, 15 months after the endovascular procedure. The remaining 16 patients are alive and have been regularly controlled by CT scans. No late migration or endoleaks have been detected. In all the survivors, the size of the aneurysm was unchanged or diminished. Conclusions: Treatment of descending thoracic aortic aneurysms by endovascular stentgraft devices has good early and mid‐term results. More accurate selection of patients may further reduce mortality and morbidity.

Transhepatic Placement of an Enteral Stent to Treat Jaundice in a Tumor Recurrence Obstructed Afferent Loop after a Whipple Procedure

Tumour recurrence that obstructs the afferent limb, blocking outflow of bile and pancreatic juice, constitutes a major clinical problem after a Whipple procedure. The endoscopic route is often not a possible alternative. Surgery may be difficult and perhaps dangerous to the often very sick patient and decompression with fine bore catheters may lead to cholangitis. External drainage is inconvenient to the patient. The present case describes a less invasive method to provide adequate drainage of the obstructed jejunal limb by insertion of a 22-mm enteral Wallstent transhepatically. The patient became and stayed anicteric during 7 months’ follow-up.