Ruptured abdominal aortic aneurysm after endovascular aortic aneurysm repair.

Department of Thoracic and Cardiovascular Surgery, School of Medicine, Pusan National University, Korea.
The Korean journal of thoracic and cardiovascular surgery 02/2011; 44(1):68-71. DOI: 10.5090/kjtcs.2011.44.1.68
Source: PubMed

ABSTRACT In treating uncomplicated abdominal aortic aenurysm, endovascular aortic aneurysm repair (EVAR) has been employed as a good alternative to open repair with low perioperative morbidity and mortality. However, the aneurysm can enlarge or rupture even after EVAR as a result of device failure, endoleak, or graft migration. We experienced two cases of aneurismal rupture after EVAR, which were successfully treated by surgical extra-anatomic bypass.

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    ABSTRACT: ZusammenfassungEndoleaks vom Typ II treten nach endovaskulärer Ausschaltung eines infrarenalen Aortenaneurysmas (EVAR) mit einer Häufigkeit von bis zu 20 % auf und können sehr selten zur Aneurysmaruptur führen. Therapeutische Konsequenzen des Typ-IIEndoleaks reichen wegen seiner langfristig unklaren prognostischen Relevanz von der konservativen Therapie bis zur Konversion. Methoden: In Form einer Kasuistik wird ein weiterer Fall einer Aneurysmaruptur nach EVAR durch ein Typ-II-Endoleak beschrieben. Anhand einer Literaturanalyse wird eine Behandlungsstrategie dafür entwickelt. Ergebnisse: Eine 62-jährige Patientin wurde mit einer gedeckten Ruptur 40 Monate nach EVAR mit einem aortobiiliakalen Stentprothesensystem (Talent, World Medical) aufgenommen. Die Patientin hatte bei bekanntem Typ-II-Endoleak während der letzten zwei Jahre keine Follow-up-Untersuchung mehr wahrgenommen. Nach sofortiger Laparotomie fanden sich blutende Lumbalarterien und die A. mesenterica inferior als Ursache eines Typ-II-Endoleaks und damit der Aneurysmaruptur. Nach Explantation des Stentprothesensystems und konventionellem aortobiiliakalem Protheseninterponat ergab eine MRAKontrolle jedoch eine Dissektion der thorakalen und suprarenalen Aorta mit Minderperfusion der linken Niere. Die Patientin verstarb 44 Monate nach der Konversion an einem metastasierenden Ovarialkarzinom. Aus den Literaturdaten ergibt sich eine therapeutische Konsequenz bei großem (Nidus> 15 mm) oder persistierendem (> 6 Monate) Typ-II-Endoleak und bei Größenprogredienz des Aneurysmasackes. Diskussion: Die rechtzeitige selektive Therapie des Typ-II-Endoleaks ist zur Prophylaxe der Aneurysmaruptur nach EVAR indiziert. Bei Ruptur durch ein Typ-II-Endoleak kann alternativ zur Konversion die Nahtligatur der blutenden Arterien mit Verschluss des Aneurysmasackes und Belassen der Stentprothese erwogen werden. SummaryType II endoleaks occur in up to 20 % of patients after endovascular aortic aneurysm repair (EVAR) and may rarely cause aneurysm rupture. Because of controversial long-term prognosis there is a variety of therapeutic options ranging from conservative treatment to conversion. Methods: Another case history is presented of infrarenal aortic aneurysm rupture caused by type II endoleaks after EVAR. Based on a literature review, a treatment strategy is proposed. Results: A 62-year-old woman was admitted with contained rupture 40 months after previous EVAR with an aortobiiliac stent-graft system (Talent, World Medical). The patient had been lost to follow-up for the last two years. Immediate laparotomy was performed. The intraoperative findings revealed lumbar arteries and the inferior mesenteric artery bleeding into the aneurysm sac, thus confirming the diagnosis of type II endoleaks. However, after explantation of the stent-graft system and conventional aortobiiliac repair MRA showed a dissection of the thoracic and suprarenal aorta with impairment of left kidney perfusion. The patient died 44 months later of a spreading ovarial carcinoma. The literature analysis revealed that therapeutic consequences are indicated with large (nidus > 15 mm) or persistent (> 6 months) type II endoleaks and with growing aneurysm sac. Discussion: Aneurysm rupture can be prevented by selective and timely therapy of type II endoleaks. In case of aneurysm rupture after EVAR due to type II endoleaks oversewing of the bleeding arteries and tight closure of the aneurysm sac, thereby maintaining the stent-graft in place, should be considered as a treatment option.
    12/2010: pages 77-84;
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    ABSTRACT: It has been proposed that prior endovascular abdominal aortic aneurysm (AAA) repair (EVAR) confers protective effects in the setting of ruptured AAA (rAAA). This study was conducted to compare outcomes of rAAA repairs in patients with and without prior EVAR. A retrospective review identified 18 patients with (group 1) and 233 patients without (group 2) antecedent EVAR who presented with rAAA from January 2001 to December 2008. Patient characteristics and perioperative variables were noted and the outcomes were compared. Multiple logistic regression was used to identify factors contributing to morbidity and mortality and Kaplan-Meier analyses to estimate late survival rates. Baseline characteristics were similar between groups. Mean age was 78 years in group 1 and 74.8 years in group 2 (P=.17). Men comprised 83.3% of patients in group 1 and 77.3% in group 2 (P=.77). Hemodynamic instability at rAAA was noted with similar frequency between groups, 55.6% vs 52.6%, respectively (P=.99). Mean time from EVAR to rAAA was 4.0 years and from last follow-up computed tomography (CT) 1.2 years. The devices involved were Ancure (Guidant, Menlo Park, Calif) (9), AneuRx (Medtronic, Minneapolis, Minn) (5), Zenith (Cook Medical Inc, Bloomington, Ind) (3), and Excluder (W.L Gore, Flagstaff, Ariz) (1). Mean preoperative AAA size was 6.4 cm in group 1. All but 1 patient had an endoleak at the time of rupture. Of 14 patients with CT follow-up, only 3 patients had a known increase in size (≥5 mm) and only 3 were known to have an endoleak. Fifteen patients were treated by a single intervention, whereas 3 patients underwent multiple procedures. In group 2, open repair was performed in 218 patients and EVAR in 15. Morbidity (66.7% vs 56.7%) and in-hospital mortality (38.9% vs 36.9%) were nearly identical between groups. One-year survival rates (27.8% vs 48.2%; P=.15) were also similar. The mortality rates for EVAR for primary rAAA was 20% as compared to 38.1% for open repair for rAAAs (P=.27). rAAA remains a lethal problem in patients with and without prior EVAR alike. An existing endograft provides neither acute nor 1-year survival benefits after rAAA repairs. Prediction of patients at risk for rupture post-EVAR is difficult, as only a minority of patients had a known prior endoleak or sac enlargement.
    Journal of vascular surgery: official publication, the Society for Vascular Surgery [and] International Society for Cardiovascular Surgery, North American Chapter 11/2010; 52(5):1127-34. · 3.52 Impact Factor
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    ABSTRACT: The purpose of this study was to determine the long-term results of a 7-year follow-up of endovascular aneurysm repairs (EVARs) of abdominal aortic aneurysms (AAAs) using custom-made stent grafts (SGs). We performed a retrospective review of 17 patients (14 males, 3 females; mean age: 74.3 +/- 7.9 years; range: 53-85) undergoing EVAR of infrarenal aortic aneurysms at our institution from April 2000 to August 2006. The primary and secondary clinical success rates were 82.4% (14/17) and 100% (17/17). The initial and short-term clinical success rates were 100%. During follow-up (mean: 38.8 +/- 35.9 months; range: 0.8-90 months), 4 patients died, but there was no aneurysm-related death. In 2 patients, additional surgery was performed. The long-term clinical success rate was 83.3% (5/6). In the Kaplan-Meier curve, the 1- and 5-year survival rates were 55.0% and 45.8%, respectively. The initial and short-term clinical success rates were 100%; regarding the short-term, aneurysm-related death could be avoided. However, during long-term follow-up, aneurysm-related events did occur. Follow-up should be performed over a long period.
    Annals of thoracic and cardiovascular surgery : official journal of the Association of Thoracic and Cardiovascular Surgeons of Asia. 08/2010; 16(1):26-30.


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