BACKGROUND: The management of aortic aneurysm, type A and complicated type B aortic dissections is open surgical repair. However, open repair is associated with significant mortality and morbidity given the average patients' age and co-morbidities. Advances in the field of vascular therapy, have allowed the successful repair of major vascular disorders utilizing minimally invasive techniques while minimizing morbidity, mortality and post operative recovery time.
OBJECTIVE: To assess the feasibility, efficacy, reliability and safety of endoluminal repair in the treatment of aortic aneurysms and aortic dissections.
METHODS: All patients who underwent endovascular aortic repair for aortic aneurysms and dissections at the Cardiac Catheterization Laboratory of St. Luke's Medical Center from 1999 to March 2005 were included in the study. Pre-procedural imaging studies, demographics, clinical presentation, procedural details, adverse events and length of hospital stay were recorded in standardized data collection forms. Follow up was done via phone calls and review of outpatient records. Follow up CT scans and x-ray films were reviewed, measured and recorded.
RESULTS: A total of 30 patients with a mean age of 66 years (range 39 to 87 years) underwent 34 endoluminal repair procedures. There were 27 men and 3 women. There were 31 primary and 3 secondary repair procedures. Of the primary repair procedures, 15 (48 percent) were infrarenal aneurysms, 7 (23 percent) thoracic aneurysms and 9 (29 percent) Stanford type B dissections. Of the 3 secondary procedures, 2 had endografts
to repair endoleaks and another had a bare stent implanted at the infrarenal aorta. All repairs were performed using Talent stent grafts (Medtronic). Sixteen (53 percent) were asymptomatic and underwent repair because of a large or a rapidly expanding aneurysm. Endograft implantation, aneurysmal exclusion and entry tear closure was successfully achieved in all patients. Thirteen (42 percent) of these patients underwent combined interventional procedures. Most had multiple co-morbidities and included
hypertension in 27 patients (90 percent), coronary artery disease in 21 (70 percent), cigarette smoking in 20 (66 percent), dyslipidemia in 19 (63 percent), family history of coronary artery disease in 14 (47 percent), cerebrovascular disease in 9 (30 percent), previous revascularization in 8 (27 percent), prior MI in 6 (20 percent), and COPD in 4 (13 percent). Post implantation fever was noted in 9 (30 percent), while a transient increase in creatinine was noted in 8 (24 percent). No patient required post-operative dialytic support. Two (6 percent) patients who underwent descending thoracic repair died. One due to a massive myocardial infarction 72 hours post implantation
and a catastrophic retrograde dissection a few days after the index procedure in another. The average length of follow-up was 27 months with a range of 3 months to 5 years. Fifteen (54 percent) patients had a decrease in size of the aneurysm, 8 (29 percent) had no significant change in size and 5 patients (17 percent) had enlargement of the aneurysm. Two of these stabilized and required no further intervention. During follow-up, 3 patients (11 percent) died. One expired following conversion to open repair 2 years after the index procedure, 1 had sudden cardiac death and 1 died due to end stage liver disease. There were no aneurysmal ruptures at mid term follow up.
CONCLUSION: Endovascular treatment of complex aortic aneurysms and dissections in patients with multiple co-morbidities is feasible, safe, and effective. The endograft repair technique is associated with high procedural success rates as well as acceptable mortality and morbidity. It represents a feasible alternative to vascular repair in complex anatomy, high risk patients or those individuals who refuse standard surgical repair. Mid term follow up suggests sustained beneficial effects and no aneurysmal ruptures.