Thrombus distribution and changes in aneurysm size following endovascular aortic aneurysm repair

Objectives:to determine (a) changes in aneurysm size following endovascular repair, (b) the significance of collateral lumbar artery blood flow and (c) the relationship between thrombus distribution within the aneurysm sac and the development of a “lumbar endoleak”.Materials and Methods:72 patients treated with endovascular stent-grafts were followed up with spiral computed tomography for a median of 11 (range 3–27) months. The cross-sectional area of the aneurysm was measured at the point of maximum diameter pre- and post-operatively. The distribution and quantity of thrombus was recorded pre-operatively and this was related to changes in aneurysm size and the development of lumbar endoleaks post-operatively.Results:an increase in aneurysm size occurred in 22 patients, of whom 10 had endoleaks. Fifteen aneurysms did not change in size, including four with endoleak, and 35 aneurysms decreased in size with no endoleaks. There was a significant difference between the endoleak and no endoleak groups (Chi-squared test = 17.1 with 2 degrees of freedom (d.f.), p<0.001). Nine endoleaks were from patent lumbar arteries. No patients with thick circumferential or posteriorly placed thrombus developed an endoleak arising from lumbar vessels (0/23 cases) compared to those with minimal or anteriorly placed thrombus (9/49 cases) (Chi-squared test with Yate's correction = 3.17 with 1 d.f., p<0.1).Conclusions:aneurysms do not decrease in size in the presence of a lumbar endoleak, and some expand significantly. A number of aneurysms increase in size despite no evidence of an endoleak on computed tomography (CT). Patterns of thrombus distribution may be able to predict patients at risk from persistent endoleak via lumbar vessels

Transfemoral insertion of a bifurcated endovascular graft for aortic aneurysm repair: The first 22 patients

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