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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3710_Библиотеки_им_академика_М_И_Перельмана.pdf
Procedure
321
Fig. 72.2 Operative aortogram showing Type III endoleak
Fig. 72.3 Postoperative CTA 2weeks later with resolution of endoleak and smaller retroperitoneal hematoma
72 Endovascular Repair forRuptured Abdominal Aortic Aneurysm inaPatient withAntecedent Endograft
322
2018, along with repair of type IA endoleak by
ZFEN device (Cook Medical, Bloomington, IN)
using 20F sheath from the right groin. The device
was oriented in a manner that the fenestrations
were opposite to the previously placed covered
stents. From the right groin sheath, main body
device was cannulated by two 7F OSCOR steerable guiding sheaths. There was difculty in cannulating the right fenestration. ZFEN device was
deployed releasing the nal constraint, and a
coda balloon was used for angioplasty. A
6× 22mm iCAST stent in the left renal artery
was ballooned with a 7mm artery balloon catheter in order to are its origin. Completion arteriogram did not show any endoleak and ProGlide
closure (Abbott) was deployed. However, patient
had no Doppler ow (posterior tibial or dorsalis
pedis artery) in the left foot. Left common femoral artery was exposed, and femoral endarterectomy was performed because of a thick
atheromatous plaque in the posterior wall. A
bovine pericardial patch was applied, a 5F sheath
was placed in the middle of the left femoral artery
patch, and arteriogram showed evidence of dissection in the left external iliac artery; therefore
an 11-mm × 10-cm-long GORE®VIABAHN®
Endoprosthesis stent (W.L. Gore, Newark, DE)
was performed. Patient regained pulse in his left
foot. At last follow-up in October 2018, CTA of
the abdomen and pelvis showed 9.0 cm (from
8.5cm) aneurysm sac with small Type I endoleak.
EUROSTAR data registry, 39% had no complication prior to the diagnosis of rupture.
EVAR is complicated by endoleaks in
20–25% of patients. Approximately 10% of
patients following EVAR will develop Type I
endoleak which occurs more commonly in
patients with hostile neck anatomy (short, angulated neck, conical neck, heavily calcied neck,
and neck with circumferential thrombus). Type
IA endoleak may occur by a result of a graft
migration or neck dilatation. We did not have
access to the neck anatomy of AAA in this
patient when the index procedure was performed
in 2006 at out of state hospital. Therefore, exact
mechanism of Type IA endoleak in this patient
cannot be determined with certainty. Recurrent
endoleaks following repair of aortic cuff and
Palmaz stent was treated with fenestrated graft.
AbuRahma etal. reported 71 (12.6%) immediate
Type IA endoleak among 565 patients who
underwent EVAR on completion aortography
during a 10-year study interval [2]. Early intervention (proximal aortic cuff and/or stenting)
was used in 56 of 71% of patients. Late Type IA
endoleak was noted among nine patients. Late
sac expansion and reintervention rate was 9%
with early Type IA endoleaks. Detection of early
Type IA endoleak may predict a more troublesome situation requiring follow-up with frequent
imaging modalities (CTA scan of the abdomen
and pelvis, abdominal aortic ultrasound).
Discussion
Fransen et al. collected EUROSTAR data from
113 European centers which included 4901
patients. In 4, 231 postoperative EVAR patients,
they found a rupture rate of 4.7% for the rst year
and 0.6% for the second year [1]. The common
features of ruptured AAA following EVAR with
poor compliance with follow-up, stent graft
migration, and endoleaks. In 34 patients with
References
1. Fransen GAJ, Vallabhaneni SR, VanMarrewijk
CJ, Laheij RJF. Rupture of infrarenal aortic aneurysm after endovascular aneurysm repair: a series
from Eurostar Registry. Eur J Vasc Endovasc Surg.
2003;26(5):487–93.
2. AbuRahma AF, Hass SM, AbuRahma ZT, Yacoub M,
et al. Management of immediate post endovascular
aortic aneurysm type IA endoleaks and late outcomes.
J Am Coll Surg. 2017;224:740–8.
Part XVIII
Endovascular Repair for Large Iliac
and Hypogastric Aneurysms Following
Open Abdominal Aortic Aneurysm Repair
Endovascular Repair ofLarge Left
Iliac Anastomotic Aneurysm
Following Open Abdominal Aortic
Aneurysm Repair
Physical Examination andHistory
An 82-year-old male presented to the emergency
room with left lower quadrant abdominal pain of
3weeks duration on October 6, 2005. Patient had
undergone open abdominal aortic aneurysm
(AAA) repair in 1984 with aortobiiliac graft. On
the right side, iliac anastomosis was done end-toend near the common iliac artery bifurcation, and
on the left side, common iliac artery in its distal
portion was closed shut, and an end-to-side anastomosis was performed to the proximal external
iliac artery. Patient was found to have 5.5cm left
iliac anastomotic aneurysm in April 2005, but the
repair was deferred as patient underwent emergent coronary artery bypass graft for unstable
angina with triple vessel coronary artery disease.
CTA of the abdomen and pelvis on October 4,
2005, showed 8cm transverse diameter left iliac
anastomotic aneurysm with hydronephrosis with
diminished function of the left kidney. Patient
underwent left ureteral stenting by urology for
hydronephrosis.
Procedure
The patient underwent urgent endovascular repair
of the left iliac anastomotic aneurysm using
16× 16× 115 AneuRx iliac extension limb via
left femoral artery approach (Fig.73.1). However,
despite repeated attempts to advance the glide-
73
Fig. 73.1 Showing large left iliac anastomotic aneurysm
with redundancy of left limb of Dacron graft
wire through the left iliac limb of the Dacron graft
was unsuccessful as the wire would curl up in the
saccular aneurysm sac. In addition, patient was
found to have a kink at the origin of the left iliac
limb resulting from cephalad migration of the left
limb of the Dacron graft. Using left brachial
approach and with the help of a 7 F vertebral
guiding catheter (Cordis, Johnson and Johnson,
Cincinnati, OH), a 26 cm angle stiff glidewire
(Boston Scientic, Miami, FL) was engaged in the
left iliac limb with some difculty because of aforementioned, a kink in the Dacron graft. However,
angle stiff glidewire could not be advanced into the
native iliac artery due to large anastomotic aneurysm sac. Therefore, a gooseneck snare (EV3
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_73
325
326
Fig. 73.2 Completion arteriogram following endovascu-
lar repair of left iliac anastomotic aneurysm
73 Endovascular Repair ofLarge Left Iliac Anastomotic Aneurysm Following Open Abdominal Aortic…
Plymouth MN) was used to retrieve the wire from
the left femoral artery approach. The glidewire
was then replaced with a Lunderquist® wire (Cook
Medical, Bloomington, IN) using a Kumpe catheter. The guiding catheter was left in the left iliac
limb of the Dacron graft to obtain contrast studies
during the procedure. A 16× 16×115 mm left
iliac limb (AneuRx) was deployed from the mid
segment of the left iliac limb (Dacron) to the middle of the left external iliac artery with complete
exclusion of the aneurysm (Fig.73.2). The patient
was discharge on the third postoperative day in
satisfactory condition. Postoperative CT scan of
the abdomen and pelvis showed complete exclusion of the aneurysm. Patient died 3 years later
from unrelated cause.
Discussion
a graft related complication. They reported nine
para-anastomotic false aneurysms (3.0%)
developed at a mean follow-up of 6.1 years,
three at the proximal aortic anastomosis, and
the remaining six at the iliac and femoral anastomosis [1]. Femoral anastomotic aneurysms
are far more common than iliac anastomotic
aneurysms.
Endografting of aortic and iliac anastomotic
aneurysm is preferable to open repair in patients
with suitable anatomy and who are otherwise
high risk for open repair [2, 3]. Iliac anastomotic aneurysms may be saccular and may have
associated redundancy of the limb of the synthetic graft. But once glidewire is crossed proximal and distal to the aneurysm, deployment of
the endograft is relatively straightforward.
Good long- term outcomes can be expected following endovascular repair with much less
morbidity and mortality as compared to open
repair. Following endovascular repair, left
hydronephrosis resolved in 3–4 weeks in this
patient.
References
1. Hallet JW, Marshall DM, Peterson TM, Gray DT,
et al. Graft related complications after abdominal aortic aneurysm repair: reassurance from a
36-year population- based experience. J Vasc Surg.
1997;25:271–86.
2. Yuan JG, Marin ML, Veith FJ, Ohk IT, et al.
Endovascular grafts for non-infected aortoiliac aneurysms. J Vasc Surg. 1997;26:210–22.
3. Curti LA, Stella A, Rossi C, Gelaverni
L. Endovascular repair as rst choice treatment for
anastomotic and true iliac aneurysms. J Endovasc
Ther. 2001;8:139–43.
Hallet etal. reported from a 36-year populationbased study (1959–1990), and 307 patients who
underwent open AAA repair, and 29 (9.4%) had
Endovascular Repair ofaLarge
Hypogastric Aneurysm Following
Open Repair ofAbdominal Aortic
Aneurysm
Physical Examination andHistory
A 77-year-old male presented with right hip and
thigh pain of 2months duration in May of 2000.
He had a history of open abdominal aortic aneurysm (AAA) repair with aortobiiliac graft in
1982. Contrast-enhanced CT scan of the abdomen and pelvis showed 7cm transverse diameter
right hypogastric artery aneurysm with slight
dilatation of the distal common iliac artery
(Fig.74.1).
74
Procedure
Patient underwent endovascular repair of right
hypogastric artery aneurysm in July 2000 via a
right femoral artery cutdown. After insertion of
7F sheath in the right common femoral artery an
internal mammary artery catheter (5F) with soft
angled glidewire (0.35–180 cm) was used to
cannulate the right hypogastric artery. Internal
mammary artery catheter was exchanged for a
straight 5 F angiographic catheter which was
passed into the right hypogastric aneurysm. An
Amplatz Super Stiff™ (Boston Scientic,
Marlborough, MA) 180-cm-long wire was
exchanged for the glidewire, and a Raabe sheath
(Cook Medical, Bloomington, IN) was placed in
the large hypogastric aneurysm. Raabe sheath
was advanced to gain control of both anterior
and posterior branches of the hypogastric artery,
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_74
Fig. 74.1 CTA showing large hypogastric artery
aneurysm
and Tornado® coils (Cook Medical, Bloomington
IN) were deployed in the branches of the hypogastric artery. Amplatz Super Stiff wire was then
advanced into the main body of the aortobiiliac
graft, and the 7 F sheath in the right femoral
artery was replaced by a 16 F sheath. An iliac
extension (AneuRx) limb 16 × 15.5 mm was
deployed from the mid right iliac limb of the
Dacron graft to mid external iliac artery followed by balloon angioplasty. Completion arteriogram showed absent lling of the right
hypogastric aneurysm. Follow-up CT angiography in September 2005 showed patent aortobiiliac graft with extension of the endograft into the
mid external iliac artery with complete exclusion of the aneurysm (Fig. 74.2). Patient was
327
74 Endovascular Repair ofaLarge Hypogastric Aneurysm Following Open Repair ofAbdominal Aortic…
328
Fig. 74.2 Postoperative CTA showing successful endovascular repair of large hypogastric aneurysm
followed for another 3 years till his death in
2008 from unrelated cause.
of hypogastric aneurysm was 68.4 ± 20.5 mm.
One rupture occurred at less than 3cm and four
at less than 4 cm (6.3% of all ruptures). Open
repair was performed in 73% of patients and
Discussion
endovascular repair in 27% with a 30-day mortal-
ity of 12.7%. From their large experience, the
Most common iliac and hypogastric artery aneurysms occur in conjunction with AAA.In patients
with AAA, 10–20% have associated common
iliac artery aneurysm. Isolated hypogastric aneurysms are unusual with an incidence of 0.4% and
are six times more common in men than women.
Most hypogastric artery aneurysms are degenerative though mycotic etiology in an isolated hypogastric artery aneurysm should be excluded.
Laine etal. reported a retrospective review of 63
authors concluded that hypogastric aneurysms
rarely rupture under 4cm in transverse/ap diam-
eter [1].
Hypogastric artery aneurysm rupture may be
the rst presentation with hypotension associated
with abdominal and thigh pain. Retroperitoneal
rupture may be contained for many hours, but
intraperitoneal rupture leads to rapid exsanguination. Ruptures into rectum, ureter, and bladder
have been reported.
patients (55 men and 8 women) with ruptured
hypogastric artery aneurysms [1]. A concomitant
iliac artery was present in 65% and an AAA in
41.7%, and 36.7% of patients had both AAA and
common iliac artery aneurysm. Isolated hypogastric aneurysm was present in 30% of their
patients. The mean maximal diameter of rupture
Reference
1. Laine MT, Bjorck M, Beiles TB, Szeberin Z. Few
internal iliac artery aneurysm rupture under 4 cm. J
Vasc Surg. 2017;65(1):76–81.
Part XIX
Endovascular Repair for Hypogastric
Aneurysm Following EVAR
Endovascular Repair
ofHypogastric Artery Aneurysm
inaPatient withPrior
Endovascular Aneurysm Repair
75
Physical Examination
A 78-year-old female was admitted to the hospital with abdominal pain associated with low back
discomfort. She underwent upper GI endoscopy
which was negative for acute gastroduodenal
pathology. CTA of the abdomen and pelvis
showed 6.2 cm abdominal aortic aneurysm
(AAA) and 1.4cm right hypogastric artery aneurysm (Fig.75.1).
Procedure
She underwent endovascular aneurysm repair
(EVAR) with Endurant® graft (Medtronic,
Dublin, Ireland) on January 28, 2013. Main body
was deployed from the right side (25×13×124),
contralateral limb (16×16×124), and an ipsilateral extension limb 13×13×82mm. Following
balloon angioplasty, completion aortogram was
performed which showed satisfactory exclusion
of the AAA without any endoleak. Patient was
followed by ultrasound of the abdomen and CTA
of the abdomen and pelvis which showed stable
aneurysm sac with no endoleak but with gradually increasing right hypogastric artery aneurysm
(Fig.75.2).
Patient developed symptoms of intestinal
angina (loss of weight) associated with postprandial pain and food fear. Extensive GI workup was
negative for inammatory or malignancy in the
GI tract. Patient underwent CTA which showed
celiac artery stenosis of 80% with a patent superior mesenteric artery and inferior mesenteric
artery occlusion following endograft placement.
Patient underwent celiac artery angioplasty as
one could visualize enlarged collaterals in the
distribution of gastroduodenal artery. Angioplasty
was performed with a 7mm×2cm angioplasty
catheter on November 27, 2017, with improvement in symptoms in intestinal angina.
Patient underwent CTA of the abdomen and
pelvis in January 2018 which showed satisfactory
exclusion of the AAA, 10% residual stenosis of
the celiac artery; there was no evidence of
endoleak, but right hypogastric aneurysm had
enlarged to 4.2 cm ap/transverse diameter
(Fig. 75.3). Attempt to coil the aneurysm was
unsuccessful as there was signicant stenosis at
the origin of the hypogastric artery. Therefore,
using right femoral artery approach, a 12F sheath
was inserted and a 16×10×124 Endurant iliac
limb was deployed, and distal to that a selfexpanding iliac stent 8mm×4cm was deployed
as external iliac artery was stenotic (60%) at its
origin. Completion arteriography showed complete exclusion of the aneurysm with no crosslling of right hypogastric artery branches from
the branches of left hypogastric artery (Fig.75.3).
CTA of the abdomen and pelvis in June 2019
showed satisfactory exclusion of the AAA and of
the hypogastric aneurysm (Fig.75.4). Patient had
duplex imaging of abdomen (November 2019)
© Springer Nature Switzerland AG 2020
S. S. Hans, Challenging Arterial Reconstructions, https://doi.org/10.1007/978-3-030-44135-7_75
331
75 Endovascular Repair ofHypogastric Artery Aneurysm inaPatient withPrior Endovascular Aneurysm…
332
Fig. 75.1 CTA of the abdomen and pelvis showing AAA with small hypogastric aneurysm
Fig. 75.2 Postoperative CTA showing satisfactory exclusion of AAA with small hypogastric aneurysm