Hanyang Med Rev.  2011 Feb;31(1):1-9. 10.7599/hmr.2011.31.1.1.

Endovascular Treatment of Abdominal Aortic Aneurysm

• Kim HC

• KMID: 2053745
• DOI: http://doi.org/10.7599/hmr.2011.31.1.1

Abstract

Endovascular aneurysm repair (EVAR) has been a revolutionary development in the treatment of abdominal aortic aneurysms (AAAs) since its introduction in the early 1990s. The result of the two randomized controlled trials comparing EVAR versus open repair for the treatment of AAAs has provided some insight to the advantages and limitations of EVAR technology. Endoleaks continue to be a challenge for EVAR and most endoleaks can now be successfully managed by endovascular techniques. Fenestrated and branched stent-graft technology is increasingly applied to patients with complex AAA anatomies. This paper outlines some of the concepts and discusses the controversies and challenges facing clinicians involved in EVAR today and in the future.

Keyword

Endovascular aneurysm repair; Stent-graft; Abdominal aortic aneurysm

MeSH Terms

Aneurysm
Aortic Aneurysm, Abdominal
Endoleak
Endovascular Procedures
Humans

Figure

• 

  Fig. 1 A 74-year-old man with abdominal aortic aneurysm. A) CT angiography with maximal intensity projection shows an infrarenal abdominal aortic aneurysm. B) Aortography after endovascular aneurysm repair shows exclusion of abdominal aortic aneurysm.

• 

  Fig. 2 A 63-year-old man with abdominal aortic aneurysm. A) CT angiography with maximal intensity projection shows an infrarenal abdominal aneurysm with wall calcification (arrowhead). Note two left renal arteries. B) Aortography after stent-graft deployment shows type I endoleak (arrowhead). C) Spot image obtained after deployment of proximal extender cuff (arrow). Left lower renal artery (arrowhead) was embolized by using multiple coils to prevent type II endoleak before deployment of extender cuff. D) Aortography after deployment of extender cuff reveals disappearance of type I endoleak.

• 

  Fig. 3 A 54-year-old man who received endovascular aneurysm repair for abdominal aortic aneurysm. A) Axial CT image of arterial phase shows small enhancing lesion (arrow) within abdominal aortic aneurysm suggesting type II endoleak. B) Right internal iliac angiography shows small sac filled with contrast media which is supplied by the iliolumbar artery (white arrowhead) connected with the lumbar artery (black arrowhead). C) Spot image obtained during the procedure of embolization shows coils (arrow) within the sac. Microcatheter (arrowhead) within the lumbar artery is noted. D) Axial CT iamge of arterial phase shows coils within endoleak sac.

Reference

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

2. Parodi JC, Palmaz JC, Barone HD. Transfemoral intraluminal graft implantation for abdominal aortic aneurysms. Ann Vasc Surg. 1991. 5:491–499.

3. Armon MP, Yusuf SW, Whitaker SC, Gregson RH, Wenham PW, Hopkinson BR. The anatomy of abdominal aortic aneurysms: implications for sizing of endovascular grafts. Eur J Vasc Endovasc Surg. 1997. 13:398–402.

4. Greenberg R, Fairman R, Srivastava S, Criado F, Green R. Endovascular grafting in patients with short proximal necks: an analysis of short-term results. Cardiovasc Surg. 2000. 8:350–354.

5. Choke E, Munneke G, Morgan R, Belli AM, Loftus I, McFarland R, Loosemore T, Thompson MM. Outcomes of endovascular abdominal aortic aneurysm repair in patients with hostile neck anatomy. Cardiovasc Intervent Radiol. 2006. 29:975–980.

6. Haulon S, Greenberg RK, Pfaff K, Francis C, Koussa M, West K. Branched grafting for aortoiliac aneurysms. Eur J Vasc Endovasc Surg. 2007. 33:567–574.

7. Henretta JP, Hodgson KJ, Mattos MA, Karch LA, Hurlbert SN, Sternbach Y, Ramsey DE, Sumner DS. Feasibility of endovascular repair of abdominal aortic aneurysms with local anesthesia with intravenous sedation. J Vasc Surg. 1999. 29:793–798.

8. Teh LG, Sieunarine K, van Schie G, Goodman MA, Lawrence-Brown M, Prendergast FJ, Hartley D. Use of the percutaneous vascular surgery device for closure of femoral access sites during endovascular aneurysm repair: lessons from our experience. Eur J Vasc Endovasc Surg. 2001. 22:418–423.

9. Abu-Ghaida AM, Clair DG, Greenberg RK, Srivastava S, O'Hara PJ, Ouriel K. Broadening the applicability of endovascular aneurysm repair: the use of iliac conduits. J Vasc Surg. 2002. 36:111–117.

10. Lee WA, Berceli SA, Huber TS, Ozaki CK, Flynn TC, Seeger JM. Morbidity with retroperitoneal procedures during endovascular abdominal aortic aneurysm repair. J Vasc Surg. 2003. 38:459–463. discussion 64-5.

11. Henretta JP, Karch LA, Hodgson KJ, Mattos MA, Ramsey DE, McLafferty R, Sumner DS. Special iliac artery considerations during aneurysm endografting. Am J Surg. 1999. 178:212–218.

12. Peterson BG, Matsumura JS. Internal endoconduit: an innovative technique to address unfavorable iliac artery anatomy encountered during thoracic endovascular aortic repair. J Vasc Surg. 2008. 47:441–445.

13. Stanley BM, Semmens JB, Mai Q, Goodman MA, Hartley DE, Wilkinson C, Lawrence-Brown MD. Evaluation of patient selection guidelines for endoluminal AAA repair with the Zenith Stent-Graft: the Australasian experience. J Endovasc Ther. 2001. 8:457–464.

14. Kato N, Semba CP, Dake MD. Embolization of perigraft leaks after endovascular stent-graft treatment of aortic aneurysms. J Vasc Interv Radiol. 1996. 7:805–811.

15. Buth J, Harris PL, van Marrewijk C, Fransen G. The significance and management of different types of endoleaks. Semin Vasc Surg. 2003. 16:95–102.

16. Jones JE, Atkins MD, Brewster DC, Chung TK, Kwolek CJ, LaMuraglia GM, Hodgman TM, Cambria RP. Persistent type 2 endoleak after endovascular repair of abdominal aortic aneurysm is associated with adverse late outcomes. J Vasc Surg. 2007. 46:1–8.

17. Bernhard VM, Mitchell RS, Matsumura JS, Brewster DC, Decker M, Lamparello P, Raithel D, Collin J. Ruptured abdominal aortic aneurysm after endovascular repair. J Vasc Surg. 2002. 35:1155–1162.

18. Gorich J, Rilinger N, Sokiranski R, Kramer S, Schutz A, Sunder-Plassmann L, Pamler R. Embolization of type II endoleaks fed by the inferior mesenteric artery: using the superior mesenteric artery approach. J Endovasc Ther. 2000. 7:297–301.

19. Stavropoulos SW, Park J, Fairman R, Carpenter J. Type 2 endoleak embolization comparison: translumbar embolization versus modified transarterial embolization. J Vasc Interv Radiol. 2009. 20:1299–1302.

20. Bonvini R, Alerci M, Antonucci F, Tutta P, Wyttenbach R, Bogen M, Pelloni A, Von Segesser L, Gallino A. Preoperative embolization of collateral side branches:a valid means to reduce type II endoleaks after endovascular AAA repair. J Endovasc Ther. 2003. 10:227–232.

21. Gould DA, McWilliams R, Edwards RD, Martin J, White D, Joekes E, Rowlands PC, Brennan J, Gilling-Smith G, Harris PL. Aortic side branch embolization before endovascular aneurysm repair: incidence of type II endoleak. J Vasc Interv Radiol. 2001. 12:337–341.

22. Heikkinen MA, Arko FR, Zarins CK. What is the significance of endoleaks and endotension. Surg Clin North Am. 2004. 84:1337–1352. vii

23. Fearn S, Lawrence-Brown MM, Semmens JB, Hartley D. Follow-up after endovascular aortic aneurysm repair: the plain radiograph has an essential role in surveillance. J Endovasc Ther. 2003. 10:894–901.

24. Sprouse LR 2nd, Meier GH 3rd, Parent FN, DeMasi RJ, Glickman MH, Barber GA. Is ultrasound more accurate than axial computed tomography for determination of maximal abdominal aortic aneurysm diameter? Eur J Vasc Endovasc Surg. 2004. 28:28–35.

25. Ashoke R, Brown LC, Rodway A, Choke E, Thompson MM, Greenhalgh RM, Powell JT. Color duplex ultrasonography is insensitive for the detection of endoleak after aortic endografting: a systematic review. J Endovasc Ther. 2005. 12:297–305.

26. van der Laan MJ, Bartels LW, Viergever MA, Blankensteijn JD. Computed tomography versus magnetic resonance imaging of endoleaks after EVAR. Eur J Vasc Endovasc Surg. 2006. 32:361–365.

27. Prinssen M, Buskens E, Blankensteijn JD. The Dutch Randomised Endovascular Aneurysm Management (DREAM) trial. Background, design and methods. J Cardiovasc Surg (Torino). 2002. 43:379–384.

28. Prinssen M, Verhoeven EL, Buth J, Cuypers PW, van Sambeek MR, Balm R, Buskens E, Grobbee DE, Blankensteijn JD. A randomized trial comparing conventional and endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2004. 351:1607–1618.

29. Blankensteijn JD, de Jong SE, Prinssen M, van der Ham AC, Buth J, van Sterkenburg SM, Verhagen HJ, Buskens E, Grobbee DE. Two-year outcomes after conventional or endovascular repair of abdominal aortic aneurysms. N Engl J Med. 2005. 352:2398–2405.

30. Greenhalgh RM, Brown LC, Kwong GP, Powell JT, Thompson SG. 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. 2004. 364:843–848.

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

32. Endovascular aneurysm. Endovascular aneurysm repair and outcome in patients unfit for open repair of abdominal aortic aneurysm (EVAR trial 2): randomised controlled trial. Lancet. 2005. 365:2187–2192.

33. Lee WA, Hirneise CM, Tayyarah M, Huber TS, Seeger JM. Impact of endovascular repair on early outcomes of ruptured abdominal aortic aneurysms. J Vasc Surg. 2004. 40:211–215.

34. Resch T, Malina M, Lindblad B, Dias NV, Sonesson B, Ivancev K. Endovascular repair of ruptured abdominal aortic aneurysms: logistics and short-term results. J Endovasc Ther. 2003. 10:440–446.

35. Peppelenbosch N, Yilmaz N, van Marrewijk C, Buth J, Cuypers P, Duijm L, Tielbeek A. Emergency treatment of acute symptomatic or ruptured abdominal aortic aneurysm. Outcome of a prospective intent-to-treat by EVAR protocol. Eur J Vasc Endovasc Surg. 2003. 26:303–310.

36. Ivatury RR, Diebel L, Porter JM, Simon RJ. Intra-abdominal hypertension and the abdominal compartment syndrome. Surg Clin North Am. 1997. 77:783–800.

37. Park JH, Chung JW, Choo IW, Kim SJ, Lee JY, Han MC. Fenestrated stent-grafts for preserving visceral arterial branches in the treatment of abdominal aortic aneurysms: preliminary experience. J Vasc Interv Radiol. 1996. 7:819–823.

38. O'Neill S, Greenberg RK, Haddad F, Resch T, Sereika J, Katz E. A prospective analysis of fenestrated endovascular grafting: intermediate-term outcomes. Eur J Vasc Endovasc Surg. 2006. 32:115–123.

39. Weigang E, Hartert M, Siegenthaler MP, Beckmann NA, Sircar R, Szabo G, Etz CD, Luehr M, von Samson P, Beyersdorf F. Perioperative management to improve neurologic outcome in thoracic or thoracoabdominal aortic stent-grafting. Ann Thorac Surg. 2006. 82:1679–1687.