What Is Being Done Where

Endovascular Treatment of Infrarenal Abdominal Aortic Aneurysm with Short and Angulated Neck

in High-Risk Patient-Greece-

E. Rose, M.D., 7/27/2013

Introduction

Endovascular treatment of Abdominal Aortic Aneurysms (AAA) associated with lower operative risk, shorter OR time

Aortic morphology may affect choice of open vs. closed treatment

Short or angulated proximal neck also makes open repair more difficult

Very sick patient with multiple comorbidities much more likely to die on the table

Case Report

77 year-old male, sudden onset abdominal pain radiating to back.

CT abdomen revealed infrarenal AAA, maximum diameter 9 cm.

Multiple comorbidities, including CABG, subsequent removal of sternum for infection, subsequent MI X 2

Too high risk for open repair

Koutsias S, Antoniou G, Karathanos C, et al. Case Report: Endovascular Treatment of Infrarenal Abdominal Aortic Aneurysm with Short and Angulated Neck in High-RiskPatient. Case Reports in Vascular Medicine 2013, http://dx.doi.org/10/1155/2013/898024.

DSA Arteriography

DSA arteriography that shows the short and angulated neck of the AAA.

CT Angiography

Procedure

30 mm diameter free flow thoracic tube endograft (Valiant) implanted in proximal neck

Bifurcated Talent device inserted inside Valiant graft with overlapping

Two sequential iliac extensions in left external iliac artery, one to the right

Patient survived the procedure

Sequence of Graft Insertion

Follow-up Treatment

CT angiogram 1 month showed exclusion of AAA

Patent 3-component stent graft, no endoleak CT angiogram at 2 months showed occlusion of

left limb of graft Endovascular repair unsuccessful; required fem-

fem bypass 9 months later no endoleak, good functioning

CT Angiogram Month 1

Complete exclusion ofaneurysm

CT Angiogram Month 9

No endoleak detected

Left limb of graft occluded,Fem-fem bypass patent

Long Term Outcome

1 year later presented with abdominal pain Type I endoleak with mild graft migration Abdominal pain resolved; no treatment needed Another year later admitted with abdominal

pain, severe hypotension, renal shutdown CT showed large retroperitoneal hematoma Taken to OR for open repair Died the next day

Discussion

3-year mortality in high-risk patient with large AAA is 55%

Nonintervention for AAA with high surgical risk only an option for patients with short life expectancy

Laparoscopic proximal aortic banding or fenestrated endograft are other options

More invasive More time-consuming Can take months to get fenestrated and branched endografts

The Authors' Conclusions

Insertion of thoracic endograft followed by placement of bifurcated aortic endograft proved feasible

Offered acceptable duration of aneurysm exclusion

Gives another alternative for treatment of high risk patients with difficult anatomy in an emergency situation