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Surgery Insight: advances in endovascular repair of abdominal aortic aneurysms

Nature Clinical Practice Cardiovascular Medicine volume 4, pages 206–213 (2007)Cite this article

Abstract

Despite improvements in diagnostic and therapeutic methods and an increased awareness of their clinical significance, abdominal aortic aneurysms (AAAs) continue to be a major source of morbidity and mortality. Endovascular repair of AAAs, initially described in 1990, offers a less-invasive alternative to conventional open repair. The technology and devices used for endovascular repair of AAAs have progressed rapidly and the approach has proven to be safe and effective in short to midterm investigations. Furthermore, several large trials have demonstrated that elective endovascular repair is associated with lower perioperative morbidity and mortality than open repair. The long-term benefits of endovascular repair relative to open repair, however, continue to be studied. In addition to elective repair, the use of endovascular repair for ruptured AAAs has been increasing, and has been shown to be associated with reduced perioperative morbidity and mortality. Advances in endovascular repair of AAAs, including the development of branched and fenestrated grafts and the use of implantable devices to measure aneurysm-sac pressures following stent-graft deployment, have further broadened the application of the technique and have enhanced postoperative monitoring. Despite these advances, endovascular repair of AAAs remains a relatively novel technique, and further long-term data need to be collected.

Key Points

  • Endovascular stent graft repair is a less-invasive technique than open surgery for the treatment of abdominal aortic aneurysms, involving relining of the diseased aorta instead of replacement, circumventing the need for major abdominal surgery and associated morbidity and mortality

  • Endovascular stent grafts have developed rapidly to include a variety of different devices and adjunctive technologies, which have broadened the spectrum of patients who are candidates for endovascular repair

  • The early results of the DREAM and EVAR 1 trials confirmed the benefits of endovascular repair compared with open repair; however, longer-term data are required as the durability of endovascular repair is a concern

  • Studies have shown that there is a correlation between lower sac pressures in patients with complete aneurysm exclusion and sac shrinkage over time, however, it is unclear whether measuring sac pressures will have a role in postoperative surveillance for patients who undergo endovascular aortic repair

  • The use of branched and fenestrated endovascular stent grafts might allow more patients to undergo endovascular repair; however, there are complications specific to the use of these devices

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Figure 1: A physician-made aorto-uniiliac device
Figure 2: FDA-approved endovascular stent graft devices in use
Figure 3: Commercially developed devices currently under investigation
Figure 4: Fenestrated Zenith® device with Palmaz stents designed for the treatment of juxtarenal abdominal aortic aneurysms
Figure 5: Model of an aorto-iliac aneurysm repair with a bifurcated aortobiiliac stent and a branched iliac extension device

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References

  1. National Center for Health Statistics (1991) Vital Statistics of the United States, 1988. Volume 2: Mortality. Part A. Washington, DC: Government Printing Office

  2. Dubost C et al. (1952) Resection of aneurysm of abdominal aortic aorta: reestablishment of continuity by preserved human arterial graft, with result after five months. AMA Arch Surg 64: 405–408

    Article  CAS  Google Scholar 

  3. Ernst CB (1993) Abdominal aortic aneurysm. N Engl J Med 328: 1167–1172

    Article  CAS  Google Scholar 

  4. Parodi JC et al. (1991) Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg 5: 491–499

    Article  CAS  Google Scholar 

  5. D'Ayala M et al. (1998) Endovascular grafting for abdominal aortic aneurysms. Surg Clin North Am 78: 845–862

    Article  CAS  Google Scholar 

  6. Chuter TAM et al. (1993) Transfemoral endovascular aortic graft placement. J Vasc Surg 18: 185–197

    Article  CAS  Google Scholar 

  7. Criado FJ et al. (2000) Historical evolution of endovascular grafts for the treatment of aortic aneurysms. In Endovascular Grafting: Advanced Treatment for Vascular Disease, 1–6 (Eds Marin ML and Hollier LH) Armonk: Futura Publishing Company, Inc.

    Google Scholar 

  8. Marin ML et al. (1998) Impact of transrenal aortic endograft placement on endovascular graft repair of abdominal aortic aneurysms. J Vasc Surg 28: 638–646

    Article  CAS  Google Scholar 

  9. Burks JA Jr et al. (2002) Endovascular repair of abdominal aortic aneurysms: stent-graft fixation across the visceral arteries. J Vasc Surg 35: 109–113

    Article  Google Scholar 

  10. Parmer SS and Carpenter JP ; Endologix Investigators (2006) Endovascular aneurysm repair with suprarenal vs infrarenal fixation: a study of renal effects. J Vasc Surg 43: 19–25

    Article  Google Scholar 

  11. Cayne NS et al. (2003) Does transrenal fixation of aortic endografts impair renal function? J Vasc Surg 38: 639–644

    Article  Google Scholar 

  12. Matsumura JS et al. (2003) A multicenter controlled clinical trial of open versus endovascular treatment of abdominal aortic aneurysm. J Vasc Surg 37: 262–271

    Article  Google Scholar 

  13. Moore WS et al. EVT/Guidant Investigators (2003) Five-year interim comparison of the Guidant bifurcated endograft with open repair of abdominal aortic aneurysm. J Vasc Surg 38: 46–55

    Article  Google Scholar 

  14. Zarins CK et al. (1999) AneuRx stent graft versus open surgical repair of abdominal aortic aneurysms: multicenter prospective clinical trial. J Vasc Surg 29: 292–305

    Article  CAS  Google Scholar 

  15. Hua HT et al. (2005) Early outcomes of endovascular versus open abdominal aortic aneurysm repair in the National Surgial Quality Improvement Program-Private Sector (NSQIP-PS). J Vasc Surg 41: 382–389

    Article  Google Scholar 

  16. Bush RL et al. (2006) Open versus endovascular abdominal aortic aneurysm repair in VA hospitals. J Am Coll Surg 202: 577–587

    Article  Google Scholar 

  17. Lee WA et al. (2004) Perioperative outcomes after open and endovascular repair of intact abdominal aortic aneurysms in the United States during 2001. J Vasc Surg 39: 491–496

    Article  Google Scholar 

  18. Greenhalgh RM et al. EVAR trial participants (2004) Comparison of endovascular aneurysm repair with open repair in patients with abdominal aortic aneurysm (EVAR trial 1), 30-day operative mortality results: randomised controlled trial. Lancet 364: 843–848

    Article  CAS  Google Scholar 

  19. Prinssen M et al. Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group (2004) A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med 351: 1607–1618

    Article  CAS  Google Scholar 

  20. Blankensteijn JD et al. Dutch Randomized Endovascular Aneurysm Management (DREAM) Trial Group (2005) Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med 352: 2398–2405

    Article  CAS  Google Scholar 

  21. EVAR trial participants (2005) Endovascular aneurysm repair versus open repair in patients with abdominal aortic aneurysm (EVAR trial 1): randomised controlled trial. Lancet 365: 2179–2186

  22. Yusuf SW et al. (1994) Emergency endovascular repair of leaking aortic aneurysm. Lancet 344: 1645

    Article  CAS  Google Scholar 

  23. Hinchliffe RJ et al. (2001) Endovascular repair of ruptured abdominal aortic aneurysm—a challenge to open repair? Results of a single centre experience in 20 patients. Eur J Vasc Endovasc Surg 22: 528–534

    Article  CAS  Google Scholar 

  24. Ohki T et al. (1999) Endovascular graft repair of ruptured aortoiliac aneurysms. J Am Coll Surg 189: 102–112

    Article  CAS  Google Scholar 

  25. Yilmaz N et al. (2002) Emergency treatment of symptomatic or ruptured abdominal aortic aneurysms: the role of endovascular repair. J Endovasc Ther 9: 448–457

    Article  Google Scholar 

  26. Lee WA et al. (2004) Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg 40: 211–215

    Article  Google Scholar 

  27. Alsac JM et al. (2005) Emergency endovascular repair for ruptured abdominal aortic aneurysms: feasibility and comparison of early results with conventional open repair. Eur J Vasc Endovasc Surg 30: 632–639

    Article  Google Scholar 

  28. Larzon T et al. (2005) Endovascular treatment of ruptured abdominal aortic aneurysms: a shift of the paradigm? J Endovasc Ther 12: 548–555

    Article  Google Scholar 

  29. Dillavou ED et al. (2006) Improving aneurysm-related outcomes: nationwide benefits of endovascular repair. J Vasc Surg 43: 446–451

    Article  Google Scholar 

  30. Greco G et al. (2006) Outcomes of endovascular treatment of ruptured abdominal aortic aneurysms. J Vasc Surg 43: 453–459

    Article  Google Scholar 

  31. Hechelhammer L et al. (2005) Midterm outcome of endovascular repair of ruptured abdominal aortic aneurysms. J Vasc Surg 41: 752–757

    Article  Google Scholar 

  32. Inoue K et al. (1999) Aortic arch reconstruction by transluminally placed endovascular branched stent graft. Circulation 100 (Suppl II): II316–II321

    CAS  PubMed  Google Scholar 

  33. Chuter TAM et al. (2003) Modular branched stent graft for endovascular repair of aortic arch aneurysm and dissection. J Vasc Surg 38: 859–863

    Article  Google Scholar 

  34. Chuter TAM et al. (2001) Multi-branched stent-graft for type III thoracoabdominal aortic aneurysm. J Vasc Interv Radiol 12: 391–392

    Article  CAS  Google Scholar 

  35. Bleyn J et al. (2002) Side-branched modular endograft system for thoracoabdominal aortic aneurysm repair. J Endovasc Ther 9: 838–841

    PubMed  Google Scholar 

  36. Anderson JL et al. (2001) Endoluminal aortic grafting with renal and superior mesenteric artery incorporation by graft fenestration. J Endovasc Ther 8: 3–15

    Article  CAS  Google Scholar 

  37. Greenberg RK et al. (2004) Endovascular management of juxtarenal aneurysms with fenestrated endovascular grafting. J Vasc Surg 39: 279–287

    Article  Google Scholar 

  38. Abraham CZ et al. (2003) A modular multi-branched system for endovascular repair of bilateral common iliac artery aneurysms. J Endovasc Ther 10: 203–207

    PubMed  Google Scholar 

  39. Iwase T et al. (1999) Transluminal repair of an infrarenal aortoiliac aneurysm by a combination of bifurcated and branched stent grafts. Cathet Cardiovasc Intervent 47: 491–494

    Article  CAS  Google Scholar 

  40. Marin ML (2002) Covered stents: are they ready for prime time? Presented at Advanced Endovascular Therapies and All That Jazz: 2002 New Orleans, LA, USA

  41. Haddad F et al. (2005) Fenestrated endovascular grafting: the renal side of the story. J Vasc Surg 41: 181–190

    Article  Google Scholar 

  42. Baum RA et al. (2001) Aneurysm sac pressure measurements after endovascular repair of abdominal aortic aneurysms. J Vasc Surg 33: 32–41

    Article  CAS  Google Scholar 

  43. Dias NV et al. (2004) Intra-aneurysm sac pressure measurements after endovascular aneurysm repair: differences between shrinking, unchanged, and expanding aneurysms with and without endoleaks. J Vasc Surg 39: 1229–1235

    Article  Google Scholar 

  44. Ellozy SH et al. (2004) First experience in human beings with a permanently implantable intrasac pressure transducer for monitoring endovascular repair of abdominal aortic aneurysms. J Vasc Surg 40: 405–412

    Article  Google Scholar 

  45. Ellozy SH et al. (2006) Abdominal aortic aneurysm sac shrinkage after endovascular aneurysm repair: correlation with chronic sac pressure measurement. J Vasc Surg 43: 2–7

    Article  Google Scholar 

  46. Ohki T et al. (2005) Preliminary Outcome Of Wireless Pressure Sensing For EVAR (the Apex Trial). Presented at the Society for Vascular Surgery Annual Meeting: 2005 June 16–19, Chicago, IL, USA

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Authors and Affiliations

  1. DT Baril is a Resident in general surgery, TS Jacobs is Assistant Professor of Surgery and Radiology, and ML Marin is Professor and Chairman of Surgery at Mount Sinai School of Medicine, New York, NY, USA.,

    Donald T Baril, Tikva S Jacobs & Michael L Marin

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  1. Donald T Baril
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  2. Tikva S Jacobs
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  3. Michael L Marin
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Correspondence to Michael L Marin.

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Competing interests

ML Marin is a scientific advisory board member for Remon Medical. The other authors declared they have no competing interests.

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Baril, D., Jacobs, T. & Marin, M. Surgery Insight: advances in endovascular repair of abdominal aortic aneurysms. Nat Rev Cardiol 4, 206–213 (2007). https://doi.org/10.1038/ncpcardio0849

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