Martin Rouer

Aortoiliac Elongation after Endovascular Aortic Aneurysm Repair

BACKGROUND Aortoiliac elongation after endovascular aortic aneurysm repair (EVAR) is not well studied. We sought to assess the long-term morphologic changes after EVAR and identify potentially modifiable factors associated with such a change. METHODS An institutional review board-approved retrospective review was conducted for 88 consecutive patients who underwent EVAR at a single academic center from 2003 to 2007 and who also had at least 2 follow-up computed tomography angiograms (CTAs) available for review up to 5 years after surgery. Standardized centerline aortic lengths and diameters were obtained on Aquarius iNtuition 3D workstation (TeraRecon Inc., San Mateo, CA) on postoperative and all-available follow-up CTAs. Relationships to aortic elongation were determined using Wilcoxon rank-sum test or linear regression (Stata version 12.1, College Station, TX). Changes in length over time were determined by mixed-effects analysis (SAS version 9.3, Cary, NC). RESULTS The study cohort was composed of mostly men (88%), with a mean age of (76 ± 8) and a mean follow-up of 3.2 years (range, 0.4-7.5 years). Fifty-seven percent of patients (n = 50) had devices with suprarenal fixation and 43% (n = 38) had no suprarenal fixation. Significant lengthening was observed over the study period in the aortoiliac segments, but not in the iliofemoral segments. Aortoiliac elongation over time was not associated with sex (P = 0.3), hypertension (P = 0.7), coronary artery disease (P = 0.3), diabetes (P = 0.3), or tobacco use (P = 0.4), but was associated with the use of statins (P = 0.03) and the presence of chronic obstructive pulmonary disease (P = 0.02). Significant aortic lengthening was associated with increased type I endoleaks (P = 0.03) and reinterventions (P = 0.03). Over the study period, 4 different devices were used; Zenith (Cook Medical Inc., Bloomington, IN), Talent (Medtronic, Minneapolis, MN), Aneuryx (Medtronic), and Excluder (W. L. Gore and Associates Inc., Flagstaff, AZ). After adjusting for differences in proximal landing zone, significant differences in aortic lengthening over time were observed by device type (P = 0.02). CONCLUSIONS Significant aortoiliac elongation was observed after EVAR. Such morphologic changes may impact long-term durability of EVAR, warranting further investigation into factors associated with these morphologic changes.

Axillofemoral Bypass for Kidney Transplant Protection during Open Repair of Abdominal Aortic Aneurysm

The need to treat an abdominal aortic aneurysm (AAA) in kidney transplanted patient is a rare event. To date, no method to protect the kidney during the aneurysm treatment has been identified as undeniably relevant. On the other hand, the advantage of endovascular treatment of the aneurysm (EVAR) is to avoid transplanted kidney injury. Unfortunately, EVAR is not always available leading to open repair and then aortic cross clamping. We report here 3 cases of AAA open repair in kidney transplanted patients using a temporary axillofemoral bypass to protect the renal function.

Thoracic aorta to femoral artery bypass allows secondary kidney transplantation in case of major iliac artery disease.

Iliac artery major calcifications can compromise kidney graft. First-performed prosthetic arterial bypass from the thoracic aorta to the femoral artery allows secondary kidney transplantation. Four patients were submitted to this procedure. No patient died during the postoperative period or the follow-up. The median time to receive a kidney graft after the arterial surgery was 24 months (4-52). The normalization of the sera creatinine level was 6.4 days (2-15). The median follow-up was 38 months (7-79). In our experience, using lateral side clamping of the descendant thoracic aorta during the proximal implantation of the arterial graft avoids bleeding and visceral abdominal ischemia. The secondary performed kidney graft is safe on a very available arterial conduit.