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, 96 (3), 138-145

Early Experiences of Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

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Early Experiences of Endovascular Aneurysm Repair for Ruptured Abdominal Aortic Aneurysms

Dayoung Ko et al. Ann Surg Treat Res.

Abstract

Purpose: The use of endovascular aneurysm repair (EVAR) for ruptured abdominal aortic aneurysms (r-AAA) is steadily increasing. We report early experiences of EVAR for r-AAA performed in two tertiary referral centers in Korea.

Methods: We retrospectively reviewed r-AAA patients treated by EVAR from May 2013 to December 2017. An EVAR-first strategy for r-AAA was adopted whenever feasible. The demographic information, anatomic characteristics, operative details, postoperative complications with special attention to abdominal compartment syndrome (ACS), and 30-day mortality were collected and analyzed.

Results: We identified 13 patients who underwent EVAR for r-AAA. Mean age was 74.2 years and mean AAA size was 74.2 mm. Two patients underwent cardiopulmonary resuscitation at initial presentation. Bifurcated stent grafts were used in 12 out of 13 cases and physician-modified endografts with fenestrated/chimney techniques were performed in 2 cases with short neck. Successful stent graft deployment was achieved in all cases. Three patients were suspected of having ACS and 2 of them underwent laparotomy for decompression. The 30-day mortality was 7.7% (1 of 13), the only mortality being a patient that refused decompressive laparotomy for suspected ACS.

Conclusion: Despite the small numbers, the outcomes of EVAR for treatment of r-AAA were very promising, even in selected cases with unfavorable anatomy. These outcomes were achieved by a dedicated and well-trained team approach, and by use of high-end angiographic technology. Finally, ACS after EVAR is not uncommon, and requires a high index of suspicion as well as liberal use of decompressive surgery.

Keywords: Abdominal aortic aneurysm; Endovascular procedures; Rupture.

Conflict of interest statement

CONFLICTS OF INTEREST: No potential conflict of interest relevant to this article was reported.

Figures

Fig. 1
Fig. 1. (A) A case of ruptured 11.5 cm abdominal aortic aneurysm with concomitant bilateral common iliac and right internal iliac artery aneurysms. Initial angiography demonstrates a huge aneurysm with a relatively short aortic neck as shown by the location of both renal arteries (arrows). (B) The patient was treated with an aortouni-iliac device and crossover femorofemoral bypass, and an additional covered stent was inserted from the left external iliac artery into the left internal artery in a reversed U-shape configuration to allow for retrograde pelvic flow from the left femoral artery. (C) Follow-up CT reconstruction demonstrated a patent endograft with flow through the femoro-femoral graft into both the left internal iliac artery and the left lower extremity arterial system.
Fig. 2
Fig. 2. (A) A case of advanced endovascular aneurysm repair for a ruptured 7.3-cm juxtarenal abdominal aortic aneurysm where the right renal artery was 15 mm below the left renal artery, as shown in the initial angiogram. (B) A single right renal fenestration was created in a bifurcated endograft, which was reinforced with a gold marker. (C) A self-expanding covered stent was deployed into the left renal artery after cannulation through the fenestration and post-dilated with a balloon. (D) Final angiogram showed good flow through both renal arteries with no evidence of endoleak.
Fig. 3
Fig. 3. (A) A case of advanced endovascular aneurysm repair for a ruptured 4.9-cm infrarenal abdominal aortic aneurysm with short neck (neck distance 9.4 mm from the right renal artery and 11.2 mm from the left renal artery). (B) A single renal fenestration was created on an extender endograft for the right renal artery and a chimney technique was performed for the left renal artery. The left chimney technique was performed successfully and the right renal artery was also successfully cannulated throught the endograft from a left brachial approach. However, after deployment of a bifurcated endograft with suprarenal fixation system, further insertion of a covered stent into the right renal artery was unsuccessful. (C) Despite failed cannulation through the fenestration into the right renal artery, flow through both renal arteries was preserved after endograft deployment (small arrows). Final angiogram showed a minor type Ia endoleak (or possibly III) which was observed (large arrow). Eventually the patient developed abdominal compartment syndrome and underwent explorative laparotomy with stent graft explantation and definitive surgery.
Fig. 4
Fig. 4. (A) A case of a ruptured 10.7-cm left common iliac artery aneurysm treated by endovascular aneurysm repair (EVAR). (B) An EVAR procedure was performed with extension of the left limb graft to the external iliac artery. Final angiogram shows good exclusion of the aneurysm without evidence of endoleak. The patient developed abdominal compartment syndrome and therefore underwent emergent decompressive laparotomy with retroperitoneal hematoma evacuation and surgical ligation of the left internal artery. (C) Follow-up CT on postoperative day 14 demonstrates a patent graft without any evidence of endoleak.

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