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Endovascular repair of abdominal aortic aneurysm has been shown to have a significantly lower perioperative mortality rate compared with open repair. It has been a blessing for patients at high risk who were previously denied treatment for their aortic aneurysms. It does, however, have a substantial need for re-intervention for complications. Many of these complications including endoleak, endotension, migration, post implant syndrome and conversion to open repair are unique to endovascular aneurysm repair. Others including injury to the iliac arteries, graft limb thromboses and structural failure of prostheses occur with greater frequency in endovascular repair compared with open repair. It is important, therefore, for vascular surgeons to be aware of these complications including their prevention and appropriate that patients are informed of their incidence. This review discusses the local and vascular complications of endovascular repair of abdominal aortic aneurysm with an emphasis on newer aspects.

Most aneurysms shrink after successful endovascular repair. It has been observed, however, that some aneurysms continue to enlarge despite apparent exclusion of the sac by an endograft device. Unexplained abdominal aortic aneurysm (AAA) enlargement in these circumstances appears to be associated with high pressures inside the sac, and the phenomenon has been termed endotension. This paper reviews current theories and experimental evidence regarding the possible mechanisms of causation of endotension, and early experiences with treatment.

One of the major problems of treating aortic aneurysms has been the multifocal nature of atherosclerotic disease. Co-existing cardiovascular disease in the majority of patients together with chronic obstructive airways disease, renal impairment and hostile abdomen in some, has resulted in 1/3 of patients presenting with aortic aneurysms being regarded as high risk and unfit for open repair. Endovascular repair of aortic aneurysm therefore has much to recommend it since it avoids the need for laparatomy, cross clamping of the aorta and the obligatory blood loss associated with opening of the sac. Between May 1992 and March 2003 we have used the endovascular method to repair abdominal aortic aneurysms (AAA) in 583 patients. Successful repair was achieved in 563 patients (96%). The remaining 20 patients required primary conversion to open repair at the original operation. The 30-day perioperative mortality rate was 13 of 583 (2.2%). In this paper we summarise a number of studies that we have undertaken, comparing endovascular with alternative treatment methods and comparing various types of endovascular prostheses. In addition we report the long-term outcome of endovascular AAA repair as it relates to morphological changes in the proximal neck out to 9 years from operation. We conclude that despite the continuing small incidence of device failure, endovascular is the preferred method of AAA repair in the multifocal atherosclerotic patient. This view is based on the low perioperative mortality, superior survival compared with open repair and our experience of long-term stability in the proximal neck in the majority of patients.

This paper considers the historical aspects of endovascular aneursym repair; the major findings of our Departments experience over an 812-year period and reviews recent developments in endovascular prostheses. Analysis of 400 patients undergoing primary repair of abdominal aortic aneurysm between 1992 and 2000 revealed a perioperative mortality rate of 2.7% and primary conversion rate of 5%. With sequential studies it was shown that the outcome was better with bifurcated/aorto uni iliac grafts than tube grafts; better with second generation prostheses than first generation protheses and that survival in consecutive patients treated concurrently by open repair and endoluminal repair was superior in the endoluminal group. Endoluminal AAA repair is at a critical point of its development. It is unquestioned that it can dramatically reduce the need for intensive care and length of hospital stay and more recently it has been reported that survival is improved compared with open repair. The need for lifetime surveillance, the probability of graft failure and need for re-intervention, however, negate some of the advantages. The small incidence of unpredictable rupture following endoluminal AAA repair is a timely reminder of the need for continued careful follow-up.

Purpose: The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysm (AAA) treated concurrently by means of open repair (OR) and endoluminal repair (ER) with second-generation prostheses by the same surgeons during a defined interval., Methods: Between May 1995 and December 1998 second-generation (low profile, fully supported, modular) endoprostheses were implanted in 148 patients. These patients, together with 135 patients treated concurrently with OR during the same period, comprised the study group of 283 patients. Patient selection was based on aneurysm morphology. Those patients who were anatomically suitable for ER were treated with this method. The ER and OR groups were similar with regard to age, sex, and size of AAA. The ER group contained high-risk patients considered unfit for OR (n = 46), and the OR group contained high-risk patients who were anatomically unsuitable for ER (n = 19). Outcome criteria in both groups were survival and successful aneurysm repair. Success in the ER group was defined as exclusion of the aneurysm sac and stability or reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, regardless of whether they were subsequently corrected with secondary endovascular intervention. Data were analyzed with the life table method. The minimum period of follow-up for all patients was 18 months., Results: The perioperative mortality rate was 5.9% in the OR group and 2.7% in the ER group (not significant). There was a statistically significant difference between the survival curves of the two groups in favor of the ER group when analyzed with the log-rank test (P =.004). The Kaplan-Meier curve for graft failure for the ER group revealed a 3-year graft success probability of 82%. Survival probability with successful repair in the OR group at 3 years was 85%., Conclusions: A concurrent comparison of ER with second-generation prostheses versus OR demonstrated a significant difference in survival in favor of the ER group. The probability of survival with successful repair at 3 years was similar in both groups.

Purpose: The outcome of endoluminal repair of abdominal aortic aneurysms with two generations of prostheses was analyzed and compared., Methods: Between May 1992 and December 1998, 266 patients underwent elective endoluminal repair of an AAA. First-generation prostheses were used in 118 patients (group I), and second-generation prostheses were used in 148 patients (group II). The two groups were similar in age, sex, and size of AAA. The proportion of patients with comorbidities was higher in group I than in group II, but not significantly. First-generation devices were characterized by large (24F internal diameter) delivery systems, one-piece construction, and a lack of metallic support throughout their length. Second-generation devices had smaller (21F or smaller internal diameter) delivery systems, modular construction, and a metallic frame throughout the length of the prostheses. The major end-point criteria were survival and successful endoluminal repair. Success was defined as the exclusion of the aneurysm sac from the circulation, with stability or the reduction in AAA maximum transverse diameter. Persistent endoleaks were classified as failures, irrespective of whether they were subsequently corrected by means of secondary endovascular intervention. The minimum follow-up period was 5 months for each of the 266 patients. Analysis was performed by means of the life-table method., Results: Perioperative mortality was not significantly different between group I (4.2%) and group II (2.7%). There was a statistically significant difference between the survival curves of the two generations, which favored group II (P =.012). There was a significant (P <.001) difference between the two generations of patients in their conditional probability of graft failure when the competing risk of all-cause mortality was considered. Second-generation patients were at a lower risk of graft failure than first-generation patients. The probability of failure, expressed as a proportion of grafts failing at 2 years, was 0.15 for patients with second-generation prostheses and 0.33 for patients with first-generation prostheses., Conclusion: Endoluminal AAA repair is a safe procedure, whether first- or second-generation prostheses are used. Survival and probability of graft success were significantly higher with second-generation prostheses than with first-generation prostheses. This improvement in outcome resulted from a combination of increasing clinical experience and advances in technology. A more accurate evaluation of the role of the endoluminal method in AAA repair would be achieved by studying patients in whom second-generation devices were used, rather than longer term studies in which first- and second-generation devices were used.

Aim: the aim of this study was to analyse the effect of supplementary endovascular intervention on the outcome of primary endoluminal repair of abdominal aortic aneurysm (AAA)., Methods: between May 1992 and December 1998, 266 patients underwent endoluminal repair of AAA. Minimum period of follow-up was 6 months. Those patients in whom the endoprosthesis could not be deployed were converted to open repair at the primary operation. Patients developing an early endoleak, within 31 days, were treated by a period of observation and secondary endovascular intervention in persistent cases. Patients developing a late endoleak were treated similarly, without a period of observation. Outcome was analysed by the life-table method. Primary success was defined as exclusion of the aneurysm from the circulation resulting from the original operation. Assisted success occurred when aneurysms with endoleaks became excluded from the circulation as a result of supplementary endovascular intervention., Results: endoluminal repair failed in 17 patients requiring conversion to open repair at the original operation. Supplementary endovascular intervention was undertaken in 26 patients, with early endoleaks (n=6) and late endoleaks (n=20). Interventions involved deployment of secondary endoluminal grafts within the primary grafts (n=22), and coil embolisation (n=4). Successful exclusion of the aneurysm sac was achieved in 22 of 26 (85%) patients undergoing supplementary endovascular procedures. Conditional cumulative incidence of primary graft failure and secondary graft failure in the presence of all-cause mortality at 6 years was 47% and 25% respectively., Conclusions: supplementary endovascular intervention is an important adjunct to endoluminal AAA repair with the potential to improve outcome and avoid conversion to open repair. Successful supplementary endovascular intervention was achieved in 85% of patients in whom it was attempted. Life-table analysis showed these supplementary procedures to be durable in the long term., (Copyright 2000 Harcourt Publishers Ltd.)

Purpose: To present and analyze several cases that illustrate persistent sac pressurization following endovascular abdominal aortic aneurysm (AAA) repair., Methods and Results: Four patients with successful endovascular AAA exclusion presented in follow-up with an expanding aneurysm. Two had initial sac diameter decrease, but by 18 and 24 months, respectively, the AAA had enlarged and become pulsatile. There was no endoleak evident, but the proximal attachment stents had mig rated distally in both cases. One patient developed endoleak with aneurysm expansion at 6 months; contained rupture occurred at 12 months. The last case had slowly evolving aneurysm expansion over 36 months but no endoleak. All endografts were removed and successfully replaced with conventional grafts. Intrasac thrombus was implicated as the means of pressure transmission that precipitated AAA expansion in these cases., Conclusions: Excluded AAAs can increase in size owing to persistent or recurrent pressurization (endotension) of the sac even when there is no evidence of endoleak. One proposed mechanism is pressure transmission via thrombus that lines the attachment site. Endotension may also represent an indiscernible, very low flow endoleak that allows blood to clot at the source of leakage.

Aim: to compare the outcome of patients whose abdominal aortic aneurysm (AAA) ruptured following endoluminal repair with those whose AAA ruptured prior to treatment., Patients: over a 4-year period 434 patients underwent treatment for AAA with conventional open (n=253) and endoluminal repair (n=181). Of those having open repair, 216 patients had elective operations while 41 had operations for ruptured AAA. Four patients with ruptured AAA had undergone endoluminal repair previously (Group I) while the remaining 37 patients ruptured de novo (Group II). The patients in both groups were similar in age and sex but differed clinically. All four patients in Group I had major medical co-morbidities versus 56% in Group II (p<0.05). All patients in group I had a known endoleak following endoluminal repair. All patients underwent open repair., Results: the proportion of patients presenting with hypotension in Group I (1/4) was significantly less than in Group II (30/37). The difference in 30-day mortality for Group I (0%) compared with that for Group II (43%) was significant. The four patients in Group I remain alive and well at follow-up 22 months after operation. The outcome for Group I was better than Group II despite the higher incidence of medical co-morbidities., Conclusion: endoluminal AAA repair complicated by a persistent endoleak does not protect from rupture, which may not be accompanied by such major haemodynamic changes and high mortality as rupture de novo. Further long-term results in more patients are required to confirm this intermediate level of protection., (Copyright 1999 Harcourt Publishers Ltd.)

Conversion from endoluminal to open repair of abdominal aortic aneurysms (AAA) may be primary, at the original operation or secondary, at a subsequent operation. The indications for primary conversion include aortic rupture and migration of an endograft resulting in obstructed blood flow and irreversible twisting of an endograft. The indications for secondary conversion include persistent endoleak, sealed endoleak with continued AAA expansion, apparently successful AAA repair, with continued expansion and the presence of an infected endograft. The technique of conversion varies from standard repair through modified standard repair to supraceliac control, depending on the cause of failure leading to conversion. All conversion procedures expose the patient to an increased risk and are best avoided by careful case selection, accurate sizing, and good procedural technique.

Objective: The purpose of this paper is to briefly review the historical aspects and outcome of endoluminal abdominal aortic aneurysm (AAA) repair and summarise two studies presented at the 1997 and 1998 meetings of the Society for Vascular Surgery., Patients: Between May 1992 and September 1998 the endoluminal method was used to repair arterial aneurysms in 304 patients at the Royal Prince Alfred Hospital, Sydney, a tertiary referral teaching hospital. The study focuses on 243 patients with true AAA who underwent primary repair. There were 17 females and 226 males with a mean age of 72 years. Co-morbidities leading to rejection for conventional open repair were present in 83 patients. The criteria for inclusion included a segment of thrombus-free aorta between the lowermost renal artery and the commencement of the aneurysm of 1.5 cm or greater and iliac arteries that allowed access to the aorta from the groin. The technique involved the delivery of an endograft into the abdominal aorta by means of a sheath inserted through the femoral or iliac artery. Laparotomy associated with conventional open repair was avoided. Outcome measures included clinical examination and contrast-enhanced computed tomography (CT) within 10 days, at 6, 12, 18 months after operation and then annually thereafter., Results: Endografts were successfully deployed in 226 patients. In the remaining 17 patients endoluminal repair was converted to open repair. There were 8 deaths within 30 days of operation giving a perioperative mortality rate of 3.3%. The two studies presented to the Society for Vascular Surgery concern: (i) a concurrent comparison of the endoluminal versus open methods of treating AAA; and (ii) a comparison of adverse events following endoluminal repair of AAA during two consecutive periods of time.

Purpose: To evaluate the incidence and extent of length changes during implantation of endovascular grafts in a prospective study of patients undergoing endovascular abdominal aortic aneurysm (AAA) repair., Methods: Data regarding the occurrence of intraoperative technical difficulties and device complications were recorded prospectively for the Vanguard or AneuRx self-expanding, bifurcated endovascular grafts in 64 patients (56 males; mean age 75 years). Graft length was measured in the sheath system before deployment and again immediately after deployment by fluoroscopic comparison to a graduated marking catheter., Results: Graft shortening > or = 15 mm was documented in 22 (56%) of 39 Vanguard cases and 11 (44%) of 25 AneuRx endografts. Additional extension grafts were required to correct endoleak caused by inadequate graft length in 9 (14%) patients, but no conversion to open repair was necessary., Conclusions: There appears to be a high incidence of intraprocedural graft shortening with 2 current designs of self-expanding endoluminal grafts.

Purpose: The aim of this study was to document the incidence rate of adverse events after endoluminal repair of abdominal aortic aneurysms (AAAs) during two successive periods of time., Methods: One hundred ninety patients (175 men, 15 women; mean age, 72 years) underwent endoluminal repair of AAAs in a 5(1/2)-year period. Adverse events were documented prospectively for all the patients throughout this interval. An adverse event was defined as any of the following events: a death within 30 days, a conversion to open repair, the need for further intervention (either open or endovascular), the need for hemodialysis, a failure to cure the AAA, and wound complications. The patients were divided into two groups those who underwent operation in the initial 3-year period (group I; n = 75) and those who underwent operation in the subsequent 2(1/2)-year period (group II; n = 115). The results were analyzed for total adverse events for both periods of time and for difference in incidence rates within categories of adverse events between the two groups., Results: Eight patients (4.2%) died in the perioperative period. The endoluminal repair failed in 17 patients (8.9%), which necessitated a primary conversion to open repair at the original operation. In 88 patients, 110 adverse events occurred. There was no significant difference in the incidence rates of adverse events in patients in group I (37/75) and group II (51/115). Apart from primary conversion (P =.007), there was no significant difference in the incidence rates of adverse events between group I and group II within the following categories: perioperative (within 30 days) deaths, primary conversion, secondary conversion, supplementary endoluminal repair, intervention for lower limb ischemia, hemodialysis necessitated, failure to cure the AAA as a result of persistent endoleak, and wound complications., Conclusion: Despite improvements in technology and increasing experience, adverse events continue to occur in a relatively high proportion of patients (45%) who undergo endoluminal repair of AAA. Reporting the incidence rates of adverse events provides a more accurate picture of the morbidity rates of the endoluminal method rather than simply listing the procedures as successes or failures. The similarity in the incidence rates of adverse events in patients in group I and group II suggests that there are inherent risks in the endoluminal method rather than iatrogenic complications that occur during the learning curve with a new technique.

In this document the authors continue to refine their seminal categorization of endoleak, a major complication of endovascular aneurysm repair. In addition to type I (related to the graft device itself) and type II (retrograde flow from collateral branches) endoleak, they propose two new categories: endoleak due to fabric tears, graft disconnection, or disintegration would be classified type III, and flow through the graft presumed to be associated with graft wall "porosity" would be categorized as type IV endoleak.

Objectives: To evaluate the effects on the aortic wall of balloon dilatation as utilised in deployment of stent-graft devices during endoluminal repair of infrarenal abdominal aortic aneurysm., Methods: Large dilatation balloons were expanded within the aorta of 41 cadavers. Testing was done to evaluate the effect of differing degrees of balloon oversizing, at pressures in the range of 0.15-2.5 atm. The aorta was then open for macroscopic inspection., Results: In group 1 (mild atherosclerosis) no macroscopic abnormalities were detected with up to 6 mm oversized balloon. In group 2 (moderate atherosclerosis) fracture of atherosclerotic plaque occurred in seven of 14 aortas (50%) with 2.5 mm-4mm oversized balloon. In group 3 (severe atherosclerosis) fracture of atherosclerotic plaque occurred in six of seven (85%) with 2.5 mm to 4 mm oversized balloon and rupture of the aorta occurred at 6 mm oversizing., Conclusions: This study suggests that balloon overdilatation of the aorta by 2 mm, at pressures less than 2 atmospheres, allows safe deployment even in the presence of severe atheroma. Larger amounts of overdilatation are relatively safe in mildly atherosclerotic aorta. Aortic rupture is unlikely with overdilatation up to 6 mm, especially in less calcified vessels.

Aim: The aim of this study was to determine the influence of graft configuration on the outcome of endoluminal repair of abdominal aortic aneurysm (AAA)., Methods: The 5-year study period extended from May 1992 to May 1997 and included analysis of patients undergoing endoluminal AAA repair in the first 4.5-year period with a minimum follow-up period of 6 months. Between May 1992 and November 1996 136 patients underwent endoluminal AAA repair. Two patients who had endoluminal repair of anastomotic AAA and six patients who had secondary endoluminal repair of AAA were excluded, leaving 128 patients in the study group. There were 117 males and 11 females with a mean age for the group of 71 years. The configuration of the grafts was tubular aortic (T) (n = 50), tapered aortoiliac/femoral (AI) (n = 24) and bifurcated (B) (n = 54). Patient characteristics and co-morbidities were similar in the three groups. The procedures were performed in the operating room under radiographic control. Follow-up was complete and consisted of regular physical examination and contrast enhanced computed tomography. Outcome measures were perioperative mortality rate, need for conversion to open repair, presence of early and late endoleaks, successful exclusion of AAA from the circulation, and survival. Data were analysed by the life table method., Results: There was no significant difference in perioperative mortality for T (4%), AI (4%) and B (5.5%) configuration of endograft. Outcome for T, AI, and B configurations was respectively: primary conversion (%) 8, 12, 13; early endoleaks (n =) 5, 0, 1; late endoleaks (n =) 7, 0, 1. The overall incidence of failed procedures throughout the study period was higher in tube grafts compared with non-tube (aortoiliac and bifurcated) grafts (p < 0.05). Kaplan-Meier curves demonstrated a success probability at 40 months of 50% for tube grafts and 80% for non-tube grafts. However, a comparison of the time to procedure failure between tube versus non-tube after adjusting for competing risks (death without prior graft failure) was non-significant (p = 0.14)., Conclusions: The poor mid-term outcome for tube prostheses requires a reassessment of the criteria for selecting this configuration. It would be unwise to abandon the use of tube prostheses entirely in endoluminal repair. With increasing information on mid and long-term outcome of endoluminal AAA repair it is likely that there will be an increasing acceptance of treating smaller AAA while they are still suitable for treatment by the endoluminal method and most likely with tube grafts. A tightening of the criteria for using tube prostheses would seem sensible. In particular, the minimum length of distal neck required for endoluminal tube graft repair should be increased to the 2-2.5 cm range.

Background: The development of devices designed for the endoluminal repair of abdominal aortic aneurysm has led to the emergence of new endovascular techniques., Methods: Articles and case reports obtained from a Medline search of the English language literature from 1989 to 1997 are reviewed. This search was carried out using the MeSH heading 'aortic aneurysm, abdominal' and the keywords 'endovascular' and 'endoluminal'., Results: Reported mortality and complication rates for endoluminal aneurysm repair are similar to those following conventional repair, with the exception of continued perfusion of the aneurysm sac which remains a major problem following endoluminal repair., Conclusion: Successful endoluminal aneurysm exclusion is associated with reduced aneurysm diameter. However, longer term results of endoluminal repair, in particular of sealed endoleaks, are required before randomized controlled trials of endoluminal versus conventional repair can be undertaken.

The incidence and indications for conversion from endoluminal to open repair of abdominal aortic aneurysms are changing. This paper is based on a 5-year experience in which endoluminal repair of abdominal aortic aneurysms was undertaken in 156 patients. Primary conversion at the original operation was required in 14 patients and secondary conversion at a subsequent operation was required in 9 patients. The reasons for primary conversion were access problems (n = 2), balloon related problems (n = 2), endograft migration (n = 4), endograft thrombosis (n = 1) and failed deployment of a bifurcated endograft (n = 5). Twelve of 14 primary conversions occurred in the first half of the study period, in which 59 endoluminal abdominal aortic aneurysms repairs were undertaken. Improvements in technology and interventional techniques for overcoming obstacles, as well as increasing experience, has resulted in primary conversion being limited to two patients in the most recent 2.5-year period in which 97 endoluminal repairs were undertaken. The reasons for secondary conversion were renal arteries covered by the endograft (n = 2), increasing abdominal aortic aneurysm diameter in the absence of endoleak (n = 1) and persistent endoleak (n = 6). The latter group comprised three patients with intact aneurysms and three with known endoleaks who presented with ruptured aneurysms. The current indications for primary conversion include: (i) rupture of the aorta; (ii) complete migration of the endograft resulting in obstruction of the iliac arteries; and (iii) irreversible twisting of a non-modular bifurcated endograft. The current indications for secondary conversion include: (i) persistent endoleak; (ii) sealed endoleak with continued abdominal aortic aneurysms expansion; (iii) apparently successful endoluminal repair without evidence of endoleak but continued abdominal aortic aneurysms expansion; and (iv) infected endograft.

Purpose: The aim of this study was to compare the outcome of consecutive patients with abdominal aortic aneurysm (AAA) treated concurrently by open operation and endoluminal intervention by the same surgeons during a defined interval., Methods: Between May 1992 and May 1996, 362 consecutive patients with AAA underwent repair. Fifty-three patients who underwent open operations for ruptured AAA plus two patients who underwent endoluminal repair of false AAA and four patients who underwent secondary endoluminal repair of AAA were excluded, leaving 303 patients who underwent elective repair of true AAA in the study. The elective operations were conventional open repair (OR) in 195 patients (151 men, 44 women; mean age, 69 years) and endoluminal repair (ER) in 108 patients (100 men, 8 women; mean age, 70 years). The decision to perform ERwas based on comorbidities that precluded open repair (n = 48) and patient choice (n = 60). Graft configuration in the open repair group was tubular (n = 180) and bifurcated (n = 15), and in the ER group tubular (n = 48), aortoiliac/femoral (n = 25), and bifurcated (n = 35). All procedures were performed in the operating department, and radiographic guidance was used in the ER group. Follow-up was by interview, examination, and telephone. In addition, contrast-enhanced computed tomography was performed within the first 10 days after operation, 6 months and 12 months after operation, and then annually thereafter in the ER group. Outcome measures were successful exclusion of the aneurysm sac from the general circulation and survival. Data were analyzed by the life table method. Other outcome measures were length of hospital stay, length of intensive care unit stay, and operative blood loss., Results: No significant difference was found between the perioperative mortality rate for OR (11 deaths [5.6%] in 195 patients) and ER (six deaths [5.6%] in 108 patients). Three of the six deaths in the latter group occurred in patients with successful ER, and three occurred in 18 patients with failed ER who were converted to OR. Similarly, no significant difference was seen in the survival rate between the endoluminal and open repair groups when analyzed by the log-rank test (p = 0.14). The rate of graft failure, however, was significantly higher in the ER group than in the OR group (Fisher's exact test, p < 0.001). Success in the ER group was defined as continuing graft function without endoleak or conversion to open repair. Kaplan-Meier curve for graft failure times for the endoluminal group revealed a 3-year graft success probability of 70%., Conclusions: This study suggests that ER is safe, sharing the same perioperative mortality risk as OR despite 44% of the ER group being rejected as unfit for OR. Conventional open repair is the most reliable method of successfully managing AAA. The endoluminal method, however, results in shorter length of hospital stay, shorter length of intensive care unit stay, and less blood loss than the open method. Patients who opt for the endoluminal method of repair should be made aware that the minimally invasive technique carries the disadvantage of a higher failure rate.

The purpose of this study was to examine bifurcated stent-graft implantation for abdominal aortic aneurysm. Fifty-seven patients were treated and followed with serial computed tomography scans for up to 3 years. Patients were allocated to three groups (first 20, second 20, last 17) according to when the repair was performed. Successful treatment is defined as exclusion of the aneurysm from the circulation, based on contrast computed tomography. Success rates in the three groups were 55%, 70% and 100%. Perigraft leak (endoleak) was present on initial assessment in 4/20, 2/20 and 1/17. Two of these aneurysms ruptured early in the postoperative period. Thereafter, leaks were sought and treated aggressively. Kinking and thrombosis occurred in six of the first 20 patients, but did not occur in any of the last 37 patients, in whom the graft limbs were routinely stent-supported throughout. Infrarenal implantation in very a short neck (< 10 mm), or a thrombus-lined neck was associated with proximal stent migration. In conclusion, changes in patient selection and technique have led to a steady rise in the short-term success rate of the stent-grafted implantation.

Aim: The purpose of this study was to analyse the technical problems associated with conversion from endoluminal repair of abdominal aortic aneurysms (AAA) to open repair and document the outcome in patients with this clinical course., Methods: Between May 1992 and May 1996 endoluminal repair of AAA was undertaken in 113 patients. Forty-eight of these had medical co-morbidities which led to them being rejected for open repair at other medical centres. Conversion from endoluminal to open repair was required in 18 patients. Thirteen of these occurred at the original operation (primary conversion) and five occurred at a later operation (secondary conversion). Seven of the 18 patients undergoing conversion had serious medical co-morbidities. Three different methods of open repair were used. The technique selected was determined by the cause of failure leading to conversion. Standard open AAA repair was used in patients requiring conversion for access problems (n = 2) and balloon malfunction, where the device ended up entirely within the aneurysmal sac (n = 1). Modifications to the standard technique were required in patients in which the endograft was correctly positioned immediately below the renal arteries and/or where part of the endograft was within one or both common iliac arteries (n = 11). Supra-coeliac control was required for patients with aortic rupture (n = 1), renal arteries covered by the endograft (n = 2) and situations where the delivery catheter was trapped within the aorta above a twisted bifurcated graft (n = 1). The mean volume of contrast used was 225 ml and the mean operative time was 5.25 h in patients undergoing primary conversion., Results: Conversion to open repair was achieved in all 18 patients. Renal impairment requiring dialysis occurred in three patients. There were three perioperative deaths, all of which were procedure-related (17%), and one late death. All four deaths occurred from among the group of seven patients with preoperative co-morbidities., Conclusions: Converting an endoluminal to an open AAA repair may require modifications to the standard open technique and result in a much higher than generally accepted morbidity and mortality rate. Patients rejected for open repair because of co-morbidities ran the same chance of requiring conversion as those without co-morbidities (15-17%). If conversion was required, however, they stood a 3 in 7 or 43% chance of dying.

Unlabelled: Endoluminal repair of abdominal aortic aneurysms (AAA) requires the aneurysm to have a proximal neck of at least 1.5 cm between the renal arteries and the aneurysm. Therefore, there may be advantages in performing endoluminal repair in the early stages of aneurysm development. However, the results of endoluminal repair performed in patients with small aneurysms with favourable morphology are not known. The aim of this study was to determine whether a randomised trial of endoluminal repair vs. no treatment for small aneurysms would be justified by using a concurrent comparison of endoluminal repair vs. no treatment for AAA 5 cm or less in diameter in patients presenting to the same centre during a 4-year period., Methods: Data on 117 patients presenting with AAA 5 cm or less in diameter were entered into a registry. The decision to perform endoluminal repair vs. no treatment was based on the patient's preference following surgical consultation and investigation by computed tomography. This study reports the mortality, morbidity and survival of patients presenting between June 1992 and August 1996. During this time 43 patients had endoluminal repair and 67 patients had no treatment for small AAA. Seven patients were unfit for any intervention. Despite patient selection for different management in each group, close analysis revealed that the groups were similar with regard to co-morbidities and risk factors, as well as age, sex, and size of aneurysm. Follow-up was by progress CT scanning and ranged from 1 to 51 months (mean 18 months (NT) and 22 months (ER))., Results: Endoluminal repair failed in six of 43 patients (14%) and resulted in 11 (25%) local vascular complications. There were two perioperative deaths and one late death in this group. Twenty-one of 67 AAA (31%) patients in the no treatment group enlarged beyond 5 cm in diameter during the study period. There was one death from aneurysm rupture and one death from myocardial infarction in this group., Conclusions: The patients in the endoluminal repair group have gained an asset in having their aneurysms repaired at a cost of early morbidity following operation. These results suggest that a randomised trial of endoluminal repair vs. no treatment will become justified in the subset of patients with small AAA 5 cm or less, if the incidence of complications can be reduced by further improvements in endoluminal technology.

Purpose: To detail a methodology for evaluation of endovascular abdominal aortic aneurysm (AAA) repair that has been achieved through consensus of an international multidisciplinary team of investigators., Methods: This schema features an anatomical classification for AAAs, a definition of procedural success, and a procedure for clinical assessment, as well as the necessary data collection forms. Patient data include demographics, procedural and clinical success, complications, and follow-up. Procedural details can be related to anatomic situations, comorbid processes, devices, and effective aneurysmal exclusion., Results: These data would allow assessment of the procedures, physician learning curves, procedural indications, techniques, methodologies, the relationship of indications to success and complications, devices and subsequent graft patency, and aneurysmal exclusion., Conclusions: The use of this standardized data collection system could enable physicians and industry to better understand endovascular AAA repair and ultimately improve patient care.

Purpose: To report a > 3-year experience with a modular, balloon-expandable endovascular graft used for aneurysm exclusion in the aorta and other arteries., Methods: The customized White-Yu Endovascular GAD Graft, a woven polyester prosthesis with an intrinsic Elgiloy wire graft attachment system along the body of the graft, is a flexible endograft design available in straight, tapered, and bifurcated versions that can be delivered transluminally through 18F to 24F sheaths., Results: Since July 1993, 93 patients have received the White-Yu endograft for treatment of 76 abdominal aortic, 3 thoracic aortic, 13 iliac, and 1 popliteal aneurysms. Of the 79 aortic procedures, 39 involved straight tube grafts, 20 were tapered aortoiliac models, and 20 were bifurcated devices. Success rates for tube grafts were 81% in the abdominal aorta and 100% for the thoracic aorta; 5 primary endoleaks (14%) and 2 conversions to surgery (5.6%) occurred with this graft type. Aortoiliac grafts were deployed successfully in 95% (19/20) of cases with 1 conversion (5%) due to thrombosis. Seventy-five percent of the bifurcated endograft procedures were successful, with 4 conversions (20%) for technical failures and 1 graft thrombosis. Four additional endografts were deployed to treat two primary and two secondary endoleaks in tube graft patients. Two access-related arterial injuries were treated surgically. There was one case of embolus to the distal femoral artery but no microembolization. Overall perioperative (30-day) mortality was 3.1%. Over a mean 18-month follow-up (range 2 to 39), no late graft thrombosis, stenosis, or graft migration has been seen on CT scans or X ray. Endoleak has not been detected in any aortoiliac or bifurcated graft. Aneurysm size has diminished consistently in successfully treated cases., Conclusions: The White-Yu endograft appears to offer a safe, efficacious, and minimally invasive means of excluding aneurysms from the circulation. Improvements in patient selection, surgical techniques, and equipment have reduced the incidence of endoleak and conversion to open repair over the course of the evaluation.

The inability to obtain or maintain a secure seal between a vessel wall and a transluminally implanted intra-aneurysmal graft is a complication unique to the evolving technique of endovascular aneurysm exclusion. Because the term "leak" has long been associated with aneurysm rupture, the term "endoleak" is proposed as a more definitive description of this phenomenon. Embracing both persistent blood flow into the aneurysmal sac from within or around the graft (graft related) and from patent collateral arteries (nongraft related), endoleak can be classified as primary or secondary depending on the time of occurrence (within 30 days of implantation or following apparent initial seal, respectively). Diagnostic techniques to detect endoleak include arteriography, intraprocedural pressure monitoring, contrast-enhanced computed tomography, abdominal X ray, and duplex scanning. Management strategies for endoleak range from observation with periodic imaging surveillance to correction by additional endoluminal or surgical procedures. Standardization of the terminology describing this important sequela to endovascular aneurysm exclusion should facilitate uniform reporting of clinical trial data vital to the evaluation of this emerging technique.

Purpose: To summarize the results of endovascular abdominal aortic aneurysm (AAA) treatment using several endograft designs over a 4.5-year experience and offer comparisons on the various devices., Methods: From May 1992 to August 1996, 121 AAA patients meeting the criteria for an endoluminal repair were treated with 1 of 5 endograft designs in three configurations. The endografts were implanted in the operating room under fluoroscopic control. Follow-up included contrast-enhanced computed tomography within 10 days of operation, 6 months postoperatively, and annually thereafter., Results: Endografts were successfully deployed in 106 patients (88%). Fifteen cases were converted to open repair. Six procedure-related deaths occurred within 30 days owing to myocardial infarction (3), combined renal failure and septicemia (2), and multisystem failure (1). There were 36 local/vascular complications (30%) and 18 systemic/remote complications (15%). Of the 121 patients undergoing endoluminal AAA repair, 93 (77%) are currently alive and well with their AAAs excluded from the circulation., Conclusions: Trends in endoluminal AAA repair and prosthetic design point toward simpler devices and earlier treatment of smaller aneurysms once the long-term outcome of aortic endografting has been determined.

Objective: To report the outcome in our first 100 patients with abdominal aortic aneurysms repaired by the endoluminal method., Design: Analysis of concurrently collected data of patients undergoing repair of an aortic aneurysm. The technique involves the delivery of an endograft into the abdominal aorta by means of a sheath inserted through the femoral or iliac artery. Clinical examination and contrast-enhanced computed tomography (CT) were performed within 10 days, at six months and then annually after operation., Setting: Royal Prince Alfred Hospital, Sydney, a tertiary referral teaching hospital., Patients: 100 patients, seven women and 93 men, with a mean age of 70 years (range, 46-87), treated between May 1992 and December 1995. Because of comorbidities, 43 of the patients had been considered unsuitable for conventional open repair at other medical centres. Our criteria for inclusion were the presence of a 1.5-cm or greater segment of thrombus-free aorta between the lowermost renal artery and the commencement of the aneurysm, and iliac arteries allowing access to the aorta from the groin., Outcome Measures: (i) Need to convert to open repair; (ii) damage to the arteries from sheath insertion; (iii) communication between the aneurysmal sac and the circulation; (iv) death within 30 days; (v) effect on aneurysmal diameter., Results: Endografts were successfully deployed in 88 patients. In the remaining 12 patients endoluminal repair was converted to open repair. There were five deaths within 30 days of the operation, including three in the failed group. Damage to the femoral or iliac arteries from sheath insertion occurred in five patients. These were repaired without the need to convert to open repair. No patients were lost to follow-up (62 patients have been followed up for at least six months). Contrast-enhanced computed tomography shows progressive diminution in maximal transverse diameter of the aneurysms with time, after successful exclusion of the aneurysmal sac from the general circulation., Conclusion: Endoluminal repair of abdominal aortic aneurysms is feasible and this method of repair is durable in mid-term follow-up.

Purpose: The purpose of this study was to test a transfemoral system of bifurcated endovascular graft insertion for aortic aneurysm repair., Methods: Bifurcated endovascular grafts were inserted through bilateral femoral artery cutdowns in 41 patients. The results were assessed by completion angiography and follow-up computed tomography., Results: The second half of the study included more aneurysms 6 cm or larger (p < 0.05) and more instances of short proximal neck (p < 0.05), proximal neck angulation (p < 0.05), and iliac angulation (p < 0.05). Despite the increasingly challenging anatomy, the results were better in the second half of the study as illustrated by the lower overall combined morbidity/mortality rate (15% vs 50%) and higher overall success rate (85% versus 65%). The mortality rate for the series as a whole was 7.5%. Mean follow-up was 18.8 months for the first 20 patients and 10.9 months for the second 20. The commonest complication in the first half of the study was graft thrombosis (n = 5). This complication was absent from the second half of the study because of routine adjunctive stenting. Two patients died of complications of endovascular repair. In both cases aneurysm rupture on the third postoperative day was associated with coagulopathy and angiographic signs of perigraft leak., Conclusion: Aneurysm exclusion with a bifurcated endovascular graft was feasible in a wide range of patients, but when the aneurysm was not entirely excluded from the circulation, the risk of rupture persisted.

Aim: The aim of this prospective study was to analyse early anatomico-pathological changes in abdominal aortic aneurysms (AAA) following endoluminal repair to determine if the natural history of continued expansion of AAA is reversed., Materials and Methods: Sixty-seven of 85 patients undergoing endoluminal AAA repair between May 1992 and August 1995 had their operations prior to the end of February 1995 and were potentially available for follow up at 6 months or longer after operation. Excluded were: patients with failed endoluminal repairs (n = 14), patients who died within 6 months of operation (n = 5), patients with anastomotic AAA (n = 1), leaving 47 patients in the study group. Based on contrast enhanced CT performed preoperatively, within 10 days of operation and 6, 12 and 18 months after operation patients were divided into two groups: those in whom the AAA maximum transverse diameter (MTD) decreased Group I (n = 39) and those in which it increased Group II (n = 8). The following parameters were analysed: diameter of the supra coeliac aorta, MTD and the dimensions of the proximal and distal necks of the AAA plus extravasation ("leak") of contrast into the aneurysmal sac., Results: Leak of contrast was seen in 0 of 39 patients in Gp I and 5 of 8 patients in Gp II. Patients in Group I experienced a progressive diminution in AAA mean MTD. The diameters of the proximal and distal necks increased but there was no shortening of the length of the necks in this group. In Group II the AAA MTD was dependent on whether or not the aneurysmal sac was isolated from the circulation. The diameter of the proximal and distal necks increased irrespective of this fact., Conclusion: We conclude that in early follow up AAA which diminish in diameter following endoluminal repair remain isolated from the general circulation. Co-incident with this decrease in AAA diameter, the proximal and distal necks increase in diameter but do not undergo any shortening in length. This paradoxical increase in neck diameter, was not progressive in the period of follow-up.

The aim of this prospective study was to analyze the outcome of elective endoluminal grafting in patients with various morphologies of abdominal aortic aneurysms (AAA). Between May 1992 and May 1994, endoluminal repair of AAA was undertaken in 40 patients. After detailed imaging by means of CT scanning and arteriography, aneurysms were classified into one of two types according to the following criteria: type I (suitable for transfemoral implantation of a straight tube graft), AAA with a proximal neck (2 cm or longer), a distal neck (1.5 cm or longer), and an iliac artery diameter of 8 mm or greater (N = 19); or type II (requiring tapered aortoiliac or bifurcated grafts or access through an iliac approach), AAA that did not fit the type I criteria (N = 21). Radiographic guidance was used to pass the aortic endografts (38 Dacron and 2 PTFE) via a delivery sheath introduced through the femoral or iliac arteries into the aorta. The configuration of the aortic endografts was tubular in 26 patients, tapered aortoiliac in 11, and bifurcated in three. Successful endoluminal repair was achieved in 17 (89%) of 19 patients with type I AAA and in 15 (71%) of 21 patients with type II AAA. All failed endoluminal repairs proceeded to successful open repair, and there were no deaths during the period of hospitalization for the operation. The mean operative time and mean hospital stay were shorter in patients with type I AAA compared to patients with type II AAA. The incidence of postoperative complications was 37% in type I endoluminal repairs compared to 71% in type II endoluminal repairs. There was one cardiac death (procedure related) within 30 days, and there were three late deaths (one cardiac, one from liver failure in a type II AAA repair, and one from a ruptured esophagus in a type I repair). These preliminary results suggest that there is a better outcome in transfemoral endoluminal tube graft repair of aneurysms conforming to type I criteria compared to endoluminal repair of the more complex type II AAA.

Purpose: Currently no randomized studies show the relative morbidity and mortality of the open and endoluminal methods of abdominal aortic aneurysm (AAA) repair. The aim of this study was to analyze the outcome of two matched groups of patients with AAA, one undergoing open repair and the other undergoing endoluminal repair., Methods: Two groups of patients who had undergone repair of AAA by open technique (group 1) or by endoluminal methods (group 2) were compared. A historic control cohort of 27 patients was selected from 56 consecutive patients who underwent open repair of AAA between January 1991 and February 1992. Patients considered unsuitable for the endoluminal method on the basis of computed tomography and aortography were excluded (n=29). Between May 1992 and November 1994 prospective data were recorded for 62 consecutive patients who underwent endoluminal repair by tube or bifurcated endografts. Twenty-eight patients who had been specifically referred for endoluminal AAA repairs because of preexisting severe medical comorbidities were excluded. Six of the endoluminal cases had failure, requiring conversion to open operation, and were excluded for separate analysis, leaving 28 patients in group 2. Patients in both groups were thus fit and suitable for either open or endoluminal repair and were comparable in relation to age, sex, risk factors, dimensions, and form of AAA., Results: The mean values for operation time, blood loss, intensive care stay, and hospital stay for group 1 and group 2 were 2.6 versus 3.1 hours, 1422 versus 873 ml,* 1.8 versus 0.7 days,* and 12.4 versus 11.1 days, respectively (*p<0.05). Local/vascular complications occurred in 15% of patients in group 1 compared with 25% in group 2 (p=0.55), whereas remote/systemic complications occurred in 37% and 29%, respectively (p=0.3). Five of 28 patients in the endoluminal group had complications requiring early operative repair (n=3) or late revision (n=2). When comparison was made on an intention-to-treat basis (with failed procedures included), the incidence of local/vascular complications was significantly greater for endoluminal repair (p=0.047)., Conclusions: The incidence of systemic/remote complications was similar for the two groups in spite of significantly less blood loss and shorter intensive care unit stay with endoluminal repair. The incidence of local/vascular complications had a tendency to be higher for endoluminal compared with standard open method (and was significantly greater if failed procedures were included). In this early experience with prototype devices, patients who were medically suitable for open surgical procedures did not derive benefit from the less invasive endoluminal technique with respect to duration of operation, length of hospital stay, or perioperative morbidity and mortality. On the other hand, because they also did not have worse outcome, a randomized study is now justified in this group.

Purpose: The aim of this prospective study was to analyze early changes in morphology and dimensions of abdominal aortic aneurysms (AAA) following endoluminal repair., Methods: Forty-two of 62 patients undergoing endoluminal repair of AAAs between May 1992 and November 1994 were potentially available for follow-up at 6 months or longer after operation. After excluding patients with failed endoluminal repairs, patients who died within 6 months of operation, and patients with anastomotic aneurysms, a study group of 30 patients remained. Contrast-enhanced computed tomography (CE-CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure. Based on the postoperative CE-CT findings, patients were divided into two groups: those with no extravasation of contrast into the aneurysmal sac (group I; n = 26), and those in which there was contrast extravasation ("leak") into the aneurysmal sac (group II; n = 4)., Results: The mean maximum diameters of AAAs in group I diminished progressively at 6 and 12 months, while those in group II increased. Twenty-three (88%) patients in group I had decreased diameter of AAA, while all patients in group II had progressive increase in AAA diameter. Patients who had an increase in AAA diameter had a significantly higher incidence of leak compared with those who had a decrease in diameter (p = 0.001)., Conclusions: The majority of AAAs in which the sac has been excluded from the general circulation diminish in size following successful endoluminal repair. An increase in size occurs in those AAAs in which a communication exists between the aortic lumen and the sac. These results suggest that successfully excluded AAAs that continue to increase in size should be suspected of having an undetected leak.

Purpose: To report the results of a postmortem examination in a patient who died of unrelated causes 7 months following endoluminal treatment of an infrarenal abdominal aortic aneurysm (AAA)., Methods: As part of an FDA Phase I pilot study, a 73-year-old man underwent successful endoluminal exclusion of an infrarenal AAA using a 9-cm-long endograft (Endovascular Grafting System). Seven months later, he succumbed to complications of a spontaneous esophageal rupture. At autopsy, the aorta was dissected in situ by a vascular surgeon and pathologist before being explanted in order to examine the wound healing characteristics at the aorta-endograft interface. Particular attention was also directed to the hooks composing the attachment system at each end of the endograft., Results: Macroscopic and microscopic examination revealed that the graft had completely excluded the aneurysm sac from the circulation and was incorporated into the aortic wall at the proximal neck and distal cuff. A smooth pannus of endothelial cells covered the proximal end of the endograft at the areas of contact with the aorta, while microscopic examination of the distal end of the graft revealed poorly formed, fibrinous pannus. The neointima deep to the endothelium consisted of a collagenous matrix containing myofibroblasts and histiocytes, providing evidence of healing between the endograft and aorta. Both renal arteries were clear of the proximal end of the endograft, but a previously unrecognized right lower pole renal artery with an extremely caudal origin was excluded from the aortic lumen. Each hook of the attachment system was seen protruding through the adventitia of the aorta. There was no evidence of trauma to the aortic wall or the surrounding tissues caused by these hooks., Conclusion: There appears to be evidence that an endoluminally placed aortic graft may be incorporated by the host aortic tissue.

A 62-year-old male patient was admitted with acute dissociation of the descending thoracic aorta and an infrarenal abdominal aortic aneurysm (AAA). Investigation revealed that the thoracic dissection probably had arisen retrogradely in the posterior wall of the AAA and extended superiorly to the left subclavian artery as a blind sac. Implantation of an endoluminal graft device below the renal arteries enabled simultaneous treatment of the AAA and the thoracic aortic dissection. The patient had an uncomplicated recovery. Postoperative aortography and computed tomography demonstrated normal flow through the aorta and endograft without leak of contrast into the AAA sac or the false lumen of the dissection. Contrast computed tomography 6 months after operation demonstrated that the false lumen was no longer evident.

Purpose: The aim of this study was to report early experiences with the Sydney and Endovascular Technologies (EVT) prostheses for the treatment of abdominal aortic aneurysms (AAA) deemed suitable for endoluminal tube graft repair., Methods: Consecutive endoluminal tube graft repairs were analyzed over the first 12 months in which the Sydney and EVT prostheses were used. Patients eligible for the EVT prosthesis had type I AAAs: a proximal neck length > or = 2 cm, a distal cuff length > or = 1.5 cm, and nontortuous iliac arteries > or = 8 mm. Selection criteria for the Sydney device were more liberal and included AAAs that had distal cuffs < 1.5 cm. During the study period, 28 of 91 patients evaluated for AAA repair were thus selected for endoluminal grafting: 18 patients received the Sydney endograft and 10 the EVT device. Medical comorbidities were present in slightly less than one third of patients in both groups. Contrast-enhanced computerized tomography (CT) was performed preoperatively, within 10 days of operation, and at 6 and 12 months postprocedure., Results: All endografts were successfully deployed in both groups. Postprocedural CT scans revealed incomplete aneurysm exclusion in four patients with the Sydney endograft. Subsequent deployment of a second endograft sealed these "leaks" in two cases; the other two were converted to open repair (89% clinical success). No leaks were seen with the EVT device. Local/vascular complications occurred in 33% of the Sydney group compared with 20% for the EVT device (p = 0.001); systemic sequelae were more common in the EVT group (30% versus 17% in the Sydney cohort, p = 0.002). There were no deaths within 30 days; three late deaths were not procedure related., Conclusion: AAAs that are suitable for endoluminal tube graft repair may be treated with a high rate of initial success with either the Sydney or EVT prostheses. More liberal selection criteria may increase the likelihood of local/vascular complications.

Objective: The aim of this study was to report the outcome of endoluminal grafting of abdominal aortic aneurysms (AAA) with special reference to complications., Methods: Between May 1992 and August 1994 endoluminal repair of aneurysms was undertaken in 61 patients. In 53 the aneurysm was aortic and these are the basis of this report. In patients with AAA all procedures were elective and were performed in the operating room with the patient draped for an open repair in the event of failed endoluminal repair. The configuration of the endografts was tubular 36, tapered aortoiliac/aortofemoral 12 and bifurcated 5. Radiographic guidance was used to pass the endografts into the aorta via a delivery sheath introduced through the femoral or iliac arteries., Results: Successful endoluminal repair of AAA was achieved in 43 of 53(81%) patients. In the remaining 10 patients, endoluminal repair was abandoned in favour of an open repair. There were 17(32%) local/vascular and 13(25%) systemic/remote remote complications. The sum of these complications occurring in successful endoluminal repairs and those complications leading to failure of endoluminal repair was 40(75%). There were two cardiac deaths within 30 days in patients undergoing endoluminal repair (both procedure related) and four late deaths (unrelated to aneurysm repair). Three of the late deaths were in patients undergoing endoluminal repair and one endoluminal converted to open repair., Conclusion: Endoluminal repair of AAA in our experience has a low perioperative (< 30 days) mortality rate (3.7%) but a high morbidity rate (75%). It is recommended that complications be classified into three groups: systemic/remote and local/vascular (following successful endoluminal repair) plus those complications leading to failure of endoluminal repair. The first group is composed of medical complications while the latter two groups comprise those surgical complications directly related to the endoluminal technique.

The purpose of this study was to evaluate and optimize a system of transfemoral bifurcated graft insertion for endovascular repair of infrarenal aortic aneurysm. Grafts were inserted through bilateral femoral arteriotomies in 22 patients. Placement was guided by fluoroscopy. Results were assessed by completion angiography, with computed tomography scanning or duplex ultrasonography at 1, 3 and 6 months. The first 11 insertions were complicated by failed insertion in two cases, proximal leakage in one, graft limb thrombosis in five and wound infection in one. The second 11 insertions were complicated by retrograde leakage around the distal graft orifice in two patients. One of these was associated with aneurysm rupture, leading to the sole mortality of the series. There were no instances of graft migration or embolism. In conclusion, the lessons learned during the first 11 insertions were responsible for the improved results apparent in the second 11 insertions. When applied in properly selected patients, transfemoral insertion of a bifurcated graft is a reliable method of isolating an aortic aneurysm from the circulation.

Objective: To review the outcome of endoluminal repair of abdominal aortic aneurysm., Patients: Twelve patients with abdominal aortic aneurysms (mean diameter, 5 cm; range, 4.4-7.8 cm) were selected according to strict criteria relating to the morphology of the aneurysm and iliac arteries. The aneurysms all had a proximal neck between the renal arteries and the aneurysm and a distal neck between the aneurysm and the bifurcation of the aorta. The iliac arteries were not tortuous and were 8 mm or greater in diameter., Intervention: The aneurysm was repaired with a graft stent device introduced into the aorta via a sheath in the femoral artery., Results: Successful endoluminal repair was achieved in 10 of 12 patients (83%). The two patients in whom the endoluminal repair was abandoned were treated by standard open repair. All patients have since had an aortogram and duplex ultrasound examination to confirm exclusion of the aneurysm from the general circulation (mean period of follow-up, seven months). There have been no deaths., Conclusion: Abdominal aortic aneurysms conforming to strict morphological criteria can be treated safely and successfully by this minimally invasive endoluminal method.

Purpose: The aim of this study was to analyze the causes of failure of endoluminal grafting for abdominal aortic aneurysms (AAA) and to put forward proposals for preventing these failures., Methods: Since May 1992, endoluminal repair of aneurysms was undertaken in 47 patients. Forty-three of these patients had AAAs and are the basis of this study. All procedures were nonurgent and were performed in the operating room with the patient draped for an open repair in the event of failed endoluminal repair. Radiographic guidance was used to pass the endografts into the aorta via a delivery sheath introduced through the femoral or iliac arteries. The configuration of the endografts was tubular (n = 28), tapered aortoiliac/aortofemoral (n = 11), and bifurcated (n = 4)., Results: Successful endoluminal repair was achieved in 34 of 43 (79%) patients. The remaining nine were terminated in favor of an open repair. The causes of failure were problems with access (2), balloon malfunction (1), stent dislodgment (3), graft thrombosis (1), and inability to deploy the contralateral limb of a bifurcated graft (2). All failed endoluminal repairs proceeded to successful open repair. There was no perioperative mortality in patients undergoing endoluminal repair or in those whose endoluminal repair was converted to open operation., Conclusions: The failures of endoluminal grafting have been analyzed. Methods of avoiding access problems, balloon malfunction, and stent dislodgment have been defined and recommendations made.