Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation.
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PURPOSE: Local anesthesia has been shown to reduce cardiopulmonary mortality and morbidity rates in patients who undergo selected peripheral vascular procedures. The efforts to treat abdominal aortic aneurysms (AAAs) with endovascular techniques have largely been driven by the desire to reduce the mortality and morbidity rates as compared with those associated with open aneurysm repair. Early results have indicated a modest degree of success in this goal. The purpose of this study was to investigate the feasibility of endovascular repair of AAAs with local anesthesia. METHODS: During a 14-month period, 47 patients underwent endovascular repair of infrarenal AAAs with local anesthesia that was supplemented with intravenous sedation. Anesthetic monitoring was selective on the basis of comorbidities. The patient ages ranged from 48 to 93 years (average age, 74.4 +/- 9.8 years). Of the 47 patients, 55% had significant coronary artery disease, 30% had significant chronic obstructive pulmonary disease, and 13% had diabetes. The average anesthesia grade was 3.1, with 30% of the patients having an average anesthesia grade of 4. The mean aortic aneurysm diameter was 5.77 cm (range, 4.5 to 12.0 cm). All the implanted grafts were bifurcated in design. RESULTS: Endovascular repair of the infrarenal AAA was successful for all 47 patients. One patient required the conversion to general anesthesia to facilitate the repair of an injured external iliac artery via a retroperitoneal approach. The operative mortality rate was 0. No patient had a myocardial infarction or had other cardiopulmonary complications develop in the perioperative period. The average operative time was 170 minutes, and the average blood loss was 623 mL (range, 100 to 2500 mL). The fluid requirements averaged 2491 mL. Of the 47 patients, 46 (98%) tolerated oral intake and were ambulatory within 24 hours of graft implantation. The patients were discharged from the hospital an average of 2.13 days after the procedure, with 87% of the patients discharged less than 48 hours after the graft implantation. Furthermore, at least 30% of the patients could have been discharged on the first postoperative day except for study protocol requirements for computed tomographic scanning at 48 hours. CONCLUSION: This is the first reported series that describes the use of local anesthesia for the endovascular repair of infrarenal AAAs. Our preliminary results indicate that the endovascular treatment of AAAs with local anesthesia is feasible and can be performed safely in a patient population with significant comorbidities. The significant potential advantages include decreased cardiopulmonary morbidity rates, shorter hospital stays, and lower hospital costs. A definitive evaluation of the benefits of local anesthesia will necessitate a direct comparison with other anesthetic techniques. (+info)
Type B aortic dissection and thoracoabdominal aneurysm formation after endoluminal stent repair of abdominal aortic aneurysm.
(26/3358)
Endoluminal stent graft repair of abdominal and thoracic aortic aneurysms is being performed in increasing numbers. The long-term benefits of this technology remain to be seen. Reports have begun to appear regarding complications of stent graft application, such as renal failure, intestinal infarction, distal embolization, and rupture. Many of these complications have been associated with a fatal outcome. We describe a case of acute, retrograde, type B aortic dissection after application of an endoluminal stent graft for an asymptomatic infrarenal abdominal aortic aneurysm. An extent I thoracoabdominal aortic aneurysm subsequently developed and was successfully repaired. Aggressive evaluation of new back pain after such a procedure is warranted. Further analysis of the short-term complications and long-term outcome of this new technology is indicated before universal application can be recommended. (+info)
Nocturnal hypoxaemia and respiratory function after endovascular and conventional abdominal aortic aneurysm repair.
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Respiratory function, assessed by pre- and postoperative spirometry, and overnight pulse oximetry recordings, was compared prospectively in patients undergoing infrarenal abdominal aortic aneurysm repair by endovascular or conventional surgery. Episodic hypoxaemia was common in both groups before operation and up to the fifth night after operation. The frequency and severity of hypoxaemia were greater in the conventional group (P < 0.05). FEV1 and FVC decreased significantly on the third and fifth days after operation in both groups (P < 0.05); decreases in FVC were greater in patients undergoing conventional surgery. On the fifth day after operation, FVC had recovered to 86% and 64% of preoperative values in the endovascular and conventional groups, respectively (P < 0.05). Duration of surgery was greater (P < 0.05) and duration of postoperative artificial ventilation significantly less (P < 0.05) after endovascular repair. Postoperative PCA morphine consumption and duration of use were significantly greater (P < 0.05) in patients undergoing conventional abdominal aortic aneurysm surgery. (+info)
Nonsurgical reconstruction of thoracic aortic dissection by stent-graft placement.
(28/3358)
BACKGROUND: The treatment of thoracic aortic dissection is guided by prognostic and anatomical information. Proximal dissection requires surgery, but the appropriate treatment of distal thoracic aortic dissection has not been determined, because surgery has failed to improve the prognosis. METHODS: We prospectively evaluated the safety and efficacy of elective transluminal endovascular stent-graft insertion in 12 consecutive patients with descending (type B) aortic dissection and compared the results with surgery in 12 matched controls. In all 24 patients, aortic dissection was diagnosed by magnetic resonance angiography. In each group, the dissection involved the aortic arch in 3 patients and the descending thoracic aorta in all 12 patients. With the patient under general anesthesia, either surgical resection was undertaken or a custom-designed endovascular stent-graft was placed by unilateral arteriotomy. RESULTS: Stent-graft placement resulted in no morbidity or mortality, whereas surgery for type B dissection was associated with four deaths (33 percent, P=0.09) and five serious adverse events (42 percent, P=0.04) within 12 months. Transluminal placement of the stent-graft prosthesis was successful in all patients, with no leakage; full expansion of the stents was ensured by balloon inflation at 2 to 3 atm. Sealing of the entry tear was monitored during the procedure by transesophageal ultrasonography and angiography, and thrombosis of the false lumen was confirmed in all 12 patients after a mean of three months by magnetic resonance imaging. There were no deaths or instances of paraplegia, stroke, embolization, side-branch occlusion, or infection in the stent-graft group; nine patients had postimplantation syndrome, with transient elevation of C-reactive protein levels and body temperature plus mild leukocytosis. All the patients who received stent-grafts recovered, as did seven patients who underwent surgery for type B dissection (58 percent) (P=0.04). CONCLUSIONS: These preliminary observations suggest that elective, nonsurgical insertion of an endovascular stent-graft is safe and efficacious in selected patients who have thoracic aortic dissection and for whom surgery is indicated. Endoluminal repair may be useful for interventional reconstruction of thoracic aortic dissection. (+info)
The morbidity of secondary vascular access. A lifetime of intervention.
(29/3358)
OBJECTIVES: to examine the outcome and incidence of access-related procedures in patients who dialyse via PTFE secondary access grafts. DESIGN: retrospective case note study. RESULTS: recipients of secondary access procedures face a lifetime of haemodialysis access interventions. In total, 639 access-related procedures were performed on the 72 patients studied. At the end of the study five patients were wholly reliant on central venous catheters for dialysis access. Patients with secondary access grafts have little hope of transplantation; only six of 72 patients received a transplant after a secondary access procedure. CONCLUSION: the increasing number of patients coming to synthetic access-graft procedures and the morbidity of such procedures mean that surgeons should adopt strategies to minimise the use of grafts and limit the number of interventions performed. Careful planning will also reduce the number of central line placements and help to reduce the morbidity associated with long-term haemodialysis. Increasing resources will be required to meet the rising demand for secondary access provision. (+info)
Isolated inferior mesenteric artery revascularization for chronic visceral ischemia.
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PURPOSE: Complete visceral artery revascularization is recommended for the treatment of chronic visceral ischemia. However, in rare cases, it may not be possible to revascularize either the celiac or superior mesenteric (SMA) arteries. We have managed a series of patients with isolated revascularization of the inferior mesenteric artery (IMA) and now report our experience gained over a period of three decades. METHODS: Records were reviewed from 11 patients with chronic visceral ischemia who underwent isolated IMA revascularization (n = 8) or who, because of failure of concomitant celiac or SMA repairs, were functionally left with an isolated IMA revascularization (n = 3). All the patients had symptomatic chronic visceral ischemia documented with arteriography. Five patients had recurrent visceral ischemia after failed visceral revascularization, and two patients had undergone resection of ischemic bowel. The celiac or the SMA was unsuitable for revascularization in five cases, and extensive adhesions precluded safe exposure of the celiac or the SMA in five cases. IMA revascularization techniques included: bypass grafting (n = 4), transaortic endarterectomy (n = 4), reimplantation (n = 2), and patch angioplasty (n = 1). RESULTS: There was one perioperative death, and the remaining 10 patients had cured or improved conditions at discharge. One IMA repair thrombosed acutely but was successfully revascularized at reoperation. The median follow-up period was 6 years (range, 1 month to 13 years). Two patients had recurrent symptoms develop despite patent IMA repairs and required subsequent visceral revascularization; interruption of collateral circulation by prior bowel resection may have contributed to recurrence in both patients. Objective follow-up examination with arteriography or duplex scanning was available for eight patients at least 1 year after IMA revascularization, and all underwent patent IMA repairs. There were no late deaths as a result of bowel infarction. CONCLUSION: Isolated IMA revascularization may be useful when revascularization of other major visceral arteries cannot be performed and a well-developed, intact IMA collateral circulation is present. In this select subset of patients with chronic visceral ischemia, isolated IMA revascularization can achieve relief of symptoms and may be a lifesaving procedure. (+info)
An assessment of the current applicability of the EVT endovascular graft for treatment of patients with an infrarenal abdominal aortic aneurysm.
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OBJECTIVE: To determine the percentage of elective abdominal aortic aneurysms (AAAs)/aortoiliac aneurysms that currently can be repaired with endovascular grafts (EVGs), the reasons for rejection of EVGs, and the future role of EVG in the treatment of AAA. METHODS: From January 1997 to May 1998, patients at three hospitals (a university hospital, a university-affiliated teaching hospital, and a Veterans Administration hospital with university faculty and residents) were evaluated for EVGs as part of a national clinical trial with grafts manufactured by Endovascular Technologies (EVT, Menlo Park, Calif). All patients at two hospitals and patients treated by the participating surgeons at the third hospital were screened for EVG. Patients with AAAs that were ruptured, symptomatic, or involved renal or mesenteric arteries and patients who declined treatment were excluded from the study. Evaluation included clinical examination, computed tomography scan, and selective arteriography. The decision to proceed with EVG was made by the vascular surgeon, with input and concurrence of medical personnel from a company with extensive experience in endograft repair. The main outcome measures were the determination of the percentage of elective AAAs currently being treated with an EVG and the reasons for exclusion of patients from EVG placement. RESULTS: A total of 162 patients underwent elective treatment of an AAA, 22 (14%) with an EVG (14 bifurcated, eight tube) and 140 (86%) with traditional resection. Indications for not proceeding with an EVG included insufficient proximal cuff in 29 patients (21%), distal common iliac aneurysm or insufficient distal iliac neck in 29 patients (21%), proximal neck too large for an EVG in 24 patients (17%), symptomatic iliac stenosis in 23 patients (16%), iliac stenosis precluding introducer passage in 17 patients (12%), patient preference in 11 patients (8%), and calcification, kink, or extensive thrombus involving the proximal neck precluding safe graft attachment in seven patients (5%). Of the 22 patients treated with an EVG, three were converted to open resection, because of iliac stenosis in two patients and premature stent deployment in one patient (initial technical success rate, 86%). CONCLUSION: Based on currently available technology, 80% of patients were not candidates for an EVG because of proximal calcification, short aortic or distal cuff, coexisting distal iliac aneurysm, and stenotic iliac disease. Even with the use of adjunctive procedures, most patients still require open repair. Significant changes in design will be necessary to apply these devices to most patients with an AAA. (+info)
In situ replacement of infected aortic grafts with rifampicin-bonded prostheses: the Leicester experience (1992 to 1998)
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PURPOSE: Prosthetic graft infection after aortic aneurysm surgery is a life-threatening complication. Treatment options include total graft excision and extra-anatomic bypass grafting or in situ replacement of the graft. The latter option is gaining increasing popularity, but the long-term outcome remains uncertain, particularly in light of the increasing prevalence of methicillin-resistant Staphylococcus aureus (MRSA). We performed a prospective nonrandomized study to assess the outcome after graft excision and in situ replacement with a rifampicin-bonded prosthesis for the treatment of major aortic graft infection. METHODS: In a 6-year period from January 1992 to December 1997, 11 patients (eight men, three women) with major aortic graft infection underwent total graft excision and in situ replacement with a rifampicin-bonded prosthesis. The median age of the patients was 66 years (range, 49 to 78 years). Four patients had a hemorrhage from an aortoenteric fistula, three had a retroperitoneal abscess, two had graft occlusion, one had a perigraft collection shown by means of computed tomography, and one had a ruptured suprarenal false aneurysm. Organisms were cultured from 10 patients. RESULTS: MRSA was isolated in two patients, both of whom had originally undergone repair of a ruptured abdominal aortic aneurysm. Two patients died (18.2%) within 30 days, and three patients (27.6%) had nonfatal complications (peritoneal candidiasis, transient renal impairment, and profound anorexia). Two patients died late in the follow-up period. Seven patients remain alive and clinically free of infection. CONCLUSION: The long-term results after total graft excision and in situ replacement with a rifampicin-bonded prosthesis appear to be favorable. However, MRSA aortic graft infection appears to be associated with a poor prognosis. (+info)