Original Scientific Articles
Endovascular graft repair of ruptured aortoiliac aneurysms1,

Presented at the American College of Surgeons 84th Annual Clinical Congress, Orlando, FL, October 1998.
https://doi.org/10.1016/S1072-7515(99)00051-4Get rights and content

Abstract

Background: The feasibility of endovascular graft (EVG) repair of ruptured aortoiliac aneurysms (AIAs) has yet to be demonstrated. There are inherent limitations in EVG repair, including the need for preoperative measurements of the aneurysmal and adjacent arterial anatomy to determine the appropriate size and type of graft and the inherent delay to obtain proximal occlusion. We developed an EVG system with broad versatility that largely eliminates these problems.

Study Design: Between 1993 and 1998, within an experience of 134 endovascular AIA repairs, 12 ruptured AIAs were treated using EVGs that facilitated intraoperative customization and eliminated the need for preoperative measurements. The EVGs consisted of either a Palmaz stent and a PTFE graft deployed by a compliant balloon (n = 9) or a self-expanding covered stent graft (n = 3). Both grafts were cut to the appropriate length intraoperatively. The mean age of the patients was 72 years (range 40 to 86 years). The mean size of the aneurysms was 7.6 cm (range 3 to 16 cm). Preoperative symptoms were present in all patients and included abdominal or back pain (n = 9), syncope (n = 4), and external bleeding (n = 2). All patients were high surgical risks because of comorbid disease (n = 10) or previous abdominal operations (n = 6), and nine experienced hypotension.

Results: All EVGs were inserted successfully and excluded the aneurysms from the circulation. The mean operating time was 263 minutes, the mean blood loss was 715 mL, and the mean length of hospital stay was 6.5 days. There were two deaths (16%), one from the preexisting acute myocardial infarction and one from multiple organ failure. There were three minor complications (25%). Two patients required evacuation of an intraabdominal hematoma from the initial rupture. All but one of the grafts was functioning at a mean followup of 18 months.

Conclusions: This study demonstrates the feasibility of EVG repair for ruptured AIAs using a graft that can be customized intraoperatively for each patient. Such repairs currently are valuable in patients with ruptured AIAs and serious comorbidities and may be applicable in other circumstances as well.

Section snippets

Patients

Between 1993 and 1998, 47 ruptured AIAs were treated at the Montefiore Medical Center, of which 12 were treated using one of two types of EVGs. Nine of these patients were male and three were female. Ages ranged from 40 to 86 years (mean 72 years). The types and locations of the aneurysms included six AAAs (four true, two false) and six iliac artery aneurysms (two true, four false)(Table 1). Spiral CT scan was performed in each patient. All 12 patients were deemed prohibitively high risk for

Results

The interval between the onset of symptoms and initiation of the procedure and other operative data are shown in Table 2. Although nine patients showed signs of hypotension during the preoperative period, four patients became hemodynamically stable either with or without fluid resuscitation and were able to tolerate the relatively long interval between symptom onset and operation. In those patients who required relatively rapid arterial control because of sustained hemodynamic instability,

Discussion

During the last 4 decades, important advances have been made in the treatment of ruptured AAAs or iliac artery aneurysms.2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17 Despite these efforts, operative mortality rates have remained high. Most of these advances in the management of ruptured aneurysms have focused on the nonsurgical aspects of care, with little change in the surgical treatment methods. We evaluated the feasibility and safety of EVG repair in the treatment of ruptured AAAs

References (32)

Cited by (144)

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    Open surgical repair with synthetic graft interposition used to be the standard of care in this clinical situation. Endovascular aneurysm repair (EVAR) has become the most performed procedure for rAAA due to lower mortality compared to open repair.1 The procedure has been independently associated with a lower mortality risk than open surgical repair in AAA patients with rupture.2,3

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    A meta-analysis of the last 50 years experience demonstrated that open surgical repair (OSR) continues to be related with high mortality7 despite the evolution of anesthesia and intensive care.8,9 Since the 90s, when the use of endovascular repair (EVAR) was first reported for rAAA treatment,10–12 there has been conflicting evidence on EVAR advantages over OSR-regarding mortality rates.13–16 Unlike some reports that have shown reduced mortality with EVAR,17,18 randomized studies which were expected to provide a more solid evidence failed to show similar results.19–22

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  • Clinical application and early outcomes of the aortouni-iliac configuration for endovascular aneurysm repair

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    The favorable results reported from this retrospective review suggest that the AUI configuration is a valid option for patients with complex aortoiliac anatomy and may be preferable to open repair when a BIF graft cannot be deployed. In addition, the technical ease of deploying a one-sided device compared with a complicated BIF modular approach should not be underemphasized, especially in urgent clinical scenarios including ruptured aneurysms.17 As with all EVAR patients, follow-up is essential to monitor graft complications.

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Supported by grants from the U.S. Public Health Service (HL 02990-04), the James Hilton Manning and Emma Austin Manning Foundation, the Anne S Brown Trust, and Jikei University International Research Grant.

1

No competing interests declared.

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