[Show abstract][Hide abstract]ABSTRACT: Repair of thoracovisceral aortic aneurysms (TVAA) after previous open repair of an infrarenal abdominal aortic aneurysm (AAA) poses significant challenges. We sought to better characterize such recurrent aneurysms and to evaluate their operative outcome.
We reviewed the records and radiographs of 49 patients who underwent repair of TVAAs between 1988 and 2002 after previous repair of an AAA. Visceral artery reconstructions were completed with combinations of beveled anastomoses, inclusion patches, and side arm grafts. In 14 patients visceral endarterectomy was required to treat associated occlusive disease. Sixteen patients had cerebrospinal fluid drainage, and 10 patients had distal perfusion during cross-clamping.
Patient mean age was 72 years, and 80% were men. Fifty-one percent of patients had symptomatic disease, and average TVAA diameter was 6.2 cm. Mean time between AAA and TVAA repair was 77 months. Twenty-six percent of aneurysms were restricted to the lower visceral aortic segment, 35% extended to the diaphragm, another 35% extended to the distal or middle thoracic aorta, and 4% involved the entire remaining visceral and thoracic aorta. The 30-day operative mortality rate was 4.1% in patients with nonruptured aneurysms and 50% in patients with ruptured aneurysms, for an overall mortality rate of 8.2%. Fifteen patients (30.6%) had major morbidity, including paresis in two patients and dialysis-dependent renal failure in five patients. At late follow-up, three patients required further aortic operations to treat additional aneurysms, and four patients had fatal aortic ruptures. Two-year and 5-year cumulative survival rates were 61% (+/-7.5%) and 37% (+/-7.8%), respectively. At univariate analysis, operative blood loss was the sole significant predictor of major morbidity (P <.023), and rupture (P <.030, P <.0001) and aneurysm extent (P <.0007, P <.0001) correlated with both operative death and long-term survival. Only aneurysm extent (P <.010, relative risk 37.3) remained a significant predictor of long-term survival at multivariate analysis.
Elective repair of TVAAs after previous AAA repair can be performed with an acceptable level of operative mortality, though with considerable operative morbidity. Limited long-term survival mandates careful patient selection, and the high mortality associated with ruptured TVAA underscores the need for post-AAA surveillance.
Full-text Article · Jun 2004 · Journal of Vascular Surgery
[Show abstract][Hide abstract]ABSTRACT: Endoluminal repair of an infrarenal saccular aortic aneurysm was undertaken with a modular endovascular stent graft in a 74-year-old man. After deployment of the main body and right iliac limb of the graft, an attempt was made to gain guide wire access to the open short left limb of the graft for placement of the left iliac prosthesis. Attempts to gain access to the left limb graft from the left femoral artery area were unsuccessful. Since we were unable to pass the wire into the iliac system or snare it from below, can nulation from the left brachial artery was attempted. This resulted in the guide wire coiling up within the aneurysm. Eventual conversion to an open procedure confirmed that the short open left limb of the modular graft had deployed such that the opening was completely impacted against the inferior wall of the saccular aneurysm, preventing successful passage of a guide wire. The distance from the aortic neck to the base of the aneurysm is generally not considered an important parameter when designing an endoluminal graft. However, this case documents the importance of this dimension when design ing grafts for saccular aneurysms where access to the open short limb may be limited.
Article · Mar 2002 · Perspectives in Vascular Surgery and Endovascular Therapy