Reinhard Scharrer-Pamler

Endovascular Stent-Graft Repair of Ruptured Aortic Aneurysms

Purpose: To demonstrate the endovascular approach to the management of ruptured abdominal aortic aneurysms (AAA). Methods: From 1995 to 2001, 24 patients (21 men; mean age 69 years, range 26–92) underwent emergency endovascular treatment for ruptured AAA. The average interval between onset of symptoms and admission to the hospital was 8.0 hours; the mean time between admission and the operation was 2.3 hours. No suprarenal occluding catheter was used. The stent-graft configurations were 19 bifurcated, 4 tube, and 1 aortomonoiliac. Results: Stent-graft placement was successful in 23 (96%) cases. Failed limb extension deployment prompted conversion to open surgery in the remaining patient. One case was converted to open surgery. Mean duration of treatment was 122 minutes. Three (12.5%) patients died in-hospital. The median hospital stay was 12 days. The rate of endoleaks (all type I) was 16.7%. The overall technical success rate was 77%. The 3-year actuarial survival rate was 75%. Conclusions: Our experience shows excellent results in emergency patients with ruptured AAAs treated with endovascular surgery. In order to verify these promising results, a broader-scale clinical study must be conducted.

Endovascular Repair of Aortic Aneurysms: Treatment of Complications

Purpose: To evaluate the use of interventional procedures for treating complications following endovascular repair of aortic aneurysms. Methods: Fifty-five patients (49 men; mean age 67.5 years) underwent endoluminal stent-graft repair of traumatic (n = 4) or arteriosclerotic (n = 51) aortic aneurysms in the thoracic (n = 3) or infrarenal (n = 52) aorta. Follow-up of therapeutic success included periodic clinical examination, angiography, and spiral computed tomography. Results: Discounting the 25 (45%) cases of postimplantation syndrome that did not require treatment, there were 22 complications observed in 20 (36%) patients over a mean 10-month follow-up (range 1 to 27). There were 2 transrenal endograft maldeployments, 1 case of twisted graft limbs, 2 access site problems (1 patient), 12 endoleaks (11 patients), 1 late graft limb thrombosis, 1 symptomatic internal iliac artery occlusion, 2 myocardial infarctions, and 1 transient psychosis. Seven (13%) patients did not undergo specific therapy, while 4 (7%) required operation (2 crossover bypass grafts, 1 suture revision, and 1 graft replacement). Among 9 (16%) patients treated with interventional techniques, 7 underwent percutaneous coil embolization for 8 endoleaks (7 successfully resolved). One late stent-graft disconnection required an additional stent-graft, and 1 of the 2 malpositioned endografts was repositioned. All patients remain alive with no increase in the diameter of the aneurysm in any patient. Conclusions: Technical problems resulting from the endovascular repair of aortic aneurysms often respond to interventional treatment.

Short-term Results with Use of the Amplatz Thrombectomy Device in the Treatment of Acute Lower Limb Occlusions☆

PURPOSE To evaluate the clinical efficacy of the Amplatz device for the treatment of acute occlusions of the lower limb arteries. MATERIALS AND METHODS Forty patients with acute occlusion of the lower limb arteries (3 hours to 8 days; mean, 2 days) were treated using the Amplatz clot macerator. Acute thrombotic lower limb occlusion was due to an embolic event in 32 patients and to atherosclerotic disease in eight patients. RESULTS Complete success, with complete clearing of thrombotic material without an adjunctive procedure, was achieved in 75% (30 of 40) of the patients. Mean thrombectomy time in these patients was 75 seconds. Partial success, with incomplete clearing of the thrombus, requiring additional procedures such as local thrombolysis, angioplasty, or atherectomy, was achieved in 20% (eight of 40) of the patients. The Doppler index increased significantly (P < .001) from .45 before intervention to .96 after intervention. There were two failures (5%). No major complications occurred. CONCLUSION Mechanical thrombectomy with use of the Amplatz device is a promising approach for quick recanalization of acute peripheral thromboembolic occlusions. Further studies are needed to prove the long-term patency after mechanical thrombectomy with use of this device.

Endovascular exclusion of thoracic aortic aneurysms: mid-term results of elective treatment and in contained rupture.

Abstract  Purpose: The purpose is to present results of endovascular exclusion (stent‐graft treatment) of aneurysms of the descending thoracic aorta both in elective cases and in emergencies. Methods: Indications for stent‐graft treatment were dependent on multislice angio‐CT evaluation revealing a proximal neck of at least 10 mm between the left common carotid artery and the onset of aneurysm. All stent grafts were inserted in the operating room; 43 transfemoral, 2 transiliac. The stent grafts used were Corvita, Stenford, Vanguard, AneuRx, Talent, and Excluder. Deployment was achieved under fluoroscopic control, endoleaks were checked for with D S A on the operating table and postoperatively by angio‐CT. Long‐term follow‐up consisted of evaluation with angio‐CT after 6 and 12 months, and from there on once a year and with plain chest X‐rays. Follow‐up was achieved in all patients. Results: Mean follow‐up is 21 months (1–66); 30‐day mortality is 3/45, no permanent neurologic deficit. Thirty patients were treated electively, 15 with contained rupture. Left subclavian artery overstenting proved to be necessary in 12 patients for proper proximal sealing of the aneurysm, type I endoleaks were observed in 10 patients, one early conversion, 7 proximal extension cuffs, one sealed spontaneously, one still at risk. Among patients where LSA had been overstented only one wanted a transposition, all others did well without left‐hand ischemia or subclavian steal syndrome. Conclusion: Endovascular treatment is less invasive and has reasonable mortality and morbidity but is limited to well‐defined morphologies. Mid‐term results are promising but it has to be observed whether these will translate into long‐term durability. (J Card Surg 2003; 18:367‐374)

Thrombus Formation in Aortic Endografts

Purpose: To examine the incidence of intraprosthetic thrombotic deposits in aortic endografts. Methods: Transfemoral implantation of tube or bifurcated stent-grafts was performed in 82 patients (75 men; average age 67.7 years, range 25–88) for treatment of aneurysms of the abdominal (n = 73) or thoracic (n = 9) aorta in a 3.5-year period. Patients underwent 3-phase helical computed tomographic (CT) examinations at 3-month intervals. The length and cross-sectional area of any thrombotic deposits were measured from axial and 3-dimensional CT images. Results: Over a 12.1-month mean follow-up, intraluminal deposits of thrombotic material were observed in 19 (23.2%) patients, all with infrarenal endografts that were predominately of a bifurcated design. The first signs of thrombus formation occurred on average 7 months postoperatively (range 1 week to 20 months). In 16 patients, nonocclusive deposits of thrombotic material were seen in the aortic segment of the endograft; a graft limb was involved in 5 patients. Three graft limbs occluded owing to kinking; no thrombus was seen on CT scans taken prior to occlusion. In 3 cases the thrombotic deposits disappeared completely from the prosthesis lumen during follow-up. Conclusions: Based on this small experience, nearly 1 in 5 patients may experience some degree of intraluminal thrombus following endovascular treatment of aortic aneurysms. Whether the deposition of thrombus is influenced by the geometry of the aortic stent-graft or by flow conditions within the prosthetic lumen must be determined in future studies.

EMERGENT ENDOLUMINAL REPAIR OF DELAYED ABDOMINAL AORTIC RUPTURE AFTER BLUNT TRAUMA

PURPOSE To report the emergency repair of a traumatic abdominal aortic rupture using endoluminal techniques. METHODS AND RESULTS A 25-year-old female sustained multiple head, chest, and abdominal injuries in a motorcycle accident. Six days after emergency treatment (including splenectomy and repair of a superficial hepatic rupture and lacerations to the stomach, small bowel, and colon), she became hemodynamically unstable. A massive retroperitoneal hematoma had evolved from a distal aortic rupture. Owing to a hostile abdomen and possibility of bacterial contamination, a self-expanding stent-graft was inserted transfemorally to repair the aortic injury. The patient recovered uneventfully and continues in good health with a patent endograft repair 2 years after treatment. CONCLUSIONS This experience would support the efficacy of endograft implantation for emergent repair of trauma aortic injuries; however, proper facilities, an experienced interventional team, and an assortment of endografts and stents must be available.

Endovascular stenting in patients with Iliac compression syndrome. Experience in three cases.

The authors report their experience in the percutaneous treatment of the iliac compression syndrome in three women (20-53 years old) with acute iliofemoral deep venous thrombosis; in one case, there was an additional thrombus in the inferior caval vein. They were treated by percutaneous implantation of Palmaz stents in the left common iliac vein 1 day after surgical thrombectomy and construction of an arterial venous fistula. All patients showed marked improvement, as determined from venograms obtained immediately after stent implantation. The arteriovenous fistulae were closed 3 months later. At 6 months follow-up, the median clinical and color-coded duplex ultrasound indicates that all stents are patent and all patients are free of symptoms.

Verschluss der A. iliaca interna bei stentgestützter Ausschaltung infrarenaler Aortenaneurysmen

ZusammenfassungZielsetzung. Ziel dieser retrospektiven Studie war es, die Morbidität der Patienten zu erfassen, bei denen uni- oder bilateral ein Verschluss der A. iliaca interna herbeigeführt wurde, um ein Aortenaneurysma mit Hilfe des Endograftverfahrens auszuschalten. Patienten und Methoden. Bei 27 von 174 Patienten, die im Zeitraum von 7/1995—1/2001 wegen eines Aortenaneurysmas mit Hilfe des Endograftverfahren operiert worden waren, wurden 31 Aa. iliacae internae verschlossen (4 Patienten mit beidseitigem A.-iliaca-interna-Verschluss). Ergebnisse. 8 der 27 Patienten (31%) gaben keine Beschwerden an. 13 Patienten (48%) wiesen Symptome von motorischen und sensiblen Defiziten der unteren Extremität sowie Claudicatio glutealis, Gutealatrophie und neu aufgetretene sexuelle Dysfunktion auf.Lebensbedrohliche Komplikationen, wie z. B. Nekrosen des kleinen Beckens und Kolonischämie, traten auch bei beidseitigem Verschluss der A. iliaca interna nicht auf. Zusammenfassung. Die häufigsten Beschwerden, die bereits bei Verschluss einer A. iliaca interna auftreten, sind die Claudicatio glutaealis bzw. motorisch sensible Defizite der unteren Extremität. Lebensbedrohliche Komplikationen im Sinne von Beckennekrosen traten nicht auf, sodass die endovaskuläre Aufgabe einer bzw. beider Aa. iliacae internae bei Risikopatienten von uns in Kauf genommen wurde.AbstractObjective. Objective of this retrospective study was to evaluate morbidity in patients experiencing either uni- or bilateral occlusion of the internal iliac artery secondary to endograft treatment of infrarenal aneurysms of the abdominal aorta. Patients and Methods. In a group of 174 patients undergoing endograft treatment for infrarenal aneurysms of the abdominal aorta between July 1995 and January 2001, occlusion of a total of 31 internal iliac arteries occurred in 27 patients (unilateral occlusion in 23 patients and bilateral occlusion in four patients). Results. Eight of 27 patients (31%) reported no complaints. Thirteen patients (48%) exhibited motor and sensory deficits of the lower extremity, gluteal claudication, gluteal atrophy and new onset of sexual dysfunction.Life-threatening complications, such as necroses of the lesser pelvis and colon ischemia, did not occur, even in patients with bilateral occlusion of the internal iliac arteries. Discussion. The most common complaints in patients with only unilateral occlusion of an internal iliac artery included gluteal claudication, and motor and sensory deficits of the lower extremity. Life-threatening complications such as pelvic necroses did not occur. Hence, the benefits of endovascular treatment of aneurysms in high-risk patients outweigh the detrimental effects of potential occlusion of one or both internal iliac arteries.

Endovaskuläre Ausschaltung thorakaler Aortenaneurysmen, Dissektionen und Rupturen

ZusammenfassungIm Rahmen einer prospektiven, nicht randomisierten Studie wurde die funktionelle stentgestützte Ausschaltung von Aneurysmen, Dissektionen und traumatischen Rupturen im Bereich der Aorta descendens untersucht. Im Zeitraum von 1995 bis 2000 erwiesen sich 52 (46,4%) von 112 Patienten mit thorakalen Aortenläsionen und hohem Risiko für einen offenen chirurgischen Eingriff anatomisch und pathomorphologisch geeignet für eine stentgestützte Rekonstruktion. 16 (30,8%) Patienten wurden notfallmäßig im Stadium der Ruptur versorgt, bei 36 (69,2%) Patienten erfolgte der Eingriff elektiv.Die 30-Tage-Letalität betrug 5,7%. In 2 Fallen musste eine Konversion zur konventionell offenen Operation erfolgen. Zwei Patienten entwickelten postoperativ eine beinbetonte passagere Parese. Ein permanentes neurologisches Defizit fand sich bei keinem der 52 Patienten. Die primäre Endoleakrate betrug 9,6% (5 Patienten). Bei insgesamt 10 (19,2%) Patienten war ein zusätzlicher chirurgischer Eingriff erforderlich, in 7 Fällen im Bereich der Zugangsgefäße. In 3 Fällen war eine Revaskularisation der linksseitigen A. subclavia bzw. linksseitigen A. carotis communis erforderlich. Renale, kardiale und pulmonale Komplikationen traten bei 12 (23,0%) Patienten auf.Die mittlere Nachbeobachtungszeit betrug 19 Monate (1–66 Monate). 4 Patienten verstarben im Nachbeobachtungszeitraum an kardiopulmonalen Ereignissen. Ein Patient starb an den Folgen eines chronischen Pleuraempyems nach sekundärer Ausräumung eines Hämatothorax. Eine sekundäre Konversion musste in einem Fall bei Rezidiv einer aortobronchialen Fistel erfolgen; ein sekundäres Endoleak trat bei einem (1,9%) Patienten auf.Unsere Ergebnisse zeigen, dass eine stentgestützte Rekonstruktion im thorakalen Aortenabschnitt technisch durchführbar und mit einer ausreichenden Sicherheit begleitet ist. Das Verfahren eignet sich für elektive und Notfallpatienten ebenso wie für Hochrisikopatienten mit schwerwiegenden kardiopulmonalen Begleiterkrankungen. Als Ergebnis resultiert im Vergleich zum offenen Verfahren eine niedrigere Sterblichkeit und Paraplegierate, insbesondere wenn der Eingriff bei rupturierten Aortenerkrankungen durchgeführt werden muss.AbstractIn a prospective nonrandomized study, endovascular repair was evaluated for the treatment of descending aortic aneurysms, dissections, and ruptures.Over a 5-year period (1995–2000), endografts were placed into 52 patients at high risk for conventional surgical repair: 16 (30.8%) procedures were conducted as emergencies and 36 (69.2%) electively.The overall 30-day mortality rate was 5.7%. There were two conversions to open repair. Temporary neurologic deficits developed in two patients; no patient suffered permanent paraplegia. Five (9.6%) endoleaks required treatment. Ten (19.2%) cases required secondary surgical procedures (femoral and iliac access complications in seven patients and revascularization of the left subclavian artery and left carotid artery in three cases). Median follow-up was 19 months (1–66 months).In the follow-up period, four patients died due to cardiopulmonary complications, one single patient due to a fatal pleura empyema. A secondary conversion to open repair was necessary in one (1.9%) patient due to a recurrent aortobronchial fistula. Conclusion. The treatment of descending thoracic aortic aneurysms, dissections, and ruptures with an endovascular approach is feasible and safe and may offer the best means of therapy in high-risk patients and in emergencies.Thoracic endografting is followed by a low rate of mortality and paraplegia; procedure-related complications can be reduced best by precise patient selection.

Percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease using a transluminal endatherectomy catheter (TEC) : Initial results and angiographic follow-up

PurposeTo evaluate the clinical results of percutaneous transluminal rotational atherectomy in the treatment of peripheral vascular disease.MethodsRotational atherectomy was performed in 39 patients aged 39–87 years (mean 66.6 years). A total of 71 lesions (43 stenoses and 28 occlusions) were treated in 40 limbs. Additional balloon angioplasty was required in 54% of lesions. Fifteen patients (37.5%) presented in Fontaine stage II, 10 patients (25%) in Fontaine stage III and 15 patients (37.5%) in Fontaine stage IV. Rotational atherectomy at 750 rpm was carried out over a 0.014-inch guidewire with continuous aspiration into a vacuum, bottle. Follow-up angiography and color flow Doppler examinations were performed in 22 patients (23 limbs) after a mean period of 6 months (range 2–14 months)ResultsThere was one primary technical failure. In 36 of 40 lesions there was a good angiographic result with residual stenoses in less than 30%. In 70 lesions treated by rotational atherectomy, however, 54% showed residual stenoses of 30%–50% and these cases required additional balloon angioplasty. The mean ankle-brachial index improved significantly (p<0.001), from 0.49 before the procedure to 1.01 after the procedure. A single distal embolus, related to primary recanalization, occurred and there were two large inguinal hematomas. Cumulative clinical patency after 6 months was 83.8% and cumulative angiographic patency after 6 months was 79.1%.ConclusionPercutaneous rotational atherectomy is a promising approach for the treatment of chronic peripheral vascular disease. Further prospective, randomized studies are necessary to compare percutaneous transluminal angioplasty with this new technical approach.